Is redo percutaneous mitral balloon valvuloplasty (PMV) indicated in patients with post-PMV mitral restenosis?

Re-intervention percutaneous balloon mitral valvuloplasty in a patient with left atrial appendage thrombus: a case report

Background

Percutaneous balloon mitral valvuloplasty (PBMV) using an Accura balloon is an effective method for management of rheumatic mitral stenosis.

Case summary

Herein, we present a case of a 43-year-old female, who had undergone a previous PBMV, who presented with very severe mitral re-stenosis with Type Ia left atrial (LA) clot, in atrial fibrillation and New York Heart Association functional Class III. We used the modified septal puncture and over-the-wire technique, avoiding inadvertent manipulation of the LA clot for PBMV. The mitral valve was successfully dilated from 0.9 to 1.5 cm2, and the patient had an uneventful post-procedure recovery.

Discussion

The presence of LA clot and mitral re-stenosis in a previously intervened valve are considered unfavourable characteristics for a PBMV procedure, and patients are usually advised surgical intervention. These patients are also high-risk candidates for surgery due to late presentation with advanced disease and poor functional capacity. Our patient underwent successful re-intervention with PBMV despite having suboptimal characteristics.

The role of three dimensional transesophageal echocardiography novel-score in the success of redo percutaneous balloon mitral valvuloplasty

Mitral valve commissure evaluation is known to be important in the success of percutaneous balloon mitral valvuloplasty (PBMV) and Wilkins score (WS) is used in clinical practice. In our study, we aimed to determine whether WS in redo PBMV is sufficient in the success of procedure and additionally we have evaluated a novel scoring system including three dimensional (3D) transesophageal echocardiography (TEE) of the mitral valve structure before redo PBMV in terms of success of the procedure. Fifty patients who underwent redo PBMV were included in the study. The patients were divided into two groups according to the success of the Redo PBMV procedure which was defined as post-procedural MVA ≥ 1.5 cm² and post-procedural mitral regurgitation less than moderate by echocardiographic evaluation after PBMV. A novel score based on 3D TEE findings was created by analyzing the images recorded before Redo PBMV and by evaluating the mitral commissure and calcification. The role of traditional WS and novel score in the success of the procedure were investigated. In the study group, 36 patients (72%) had successful redo PBMV procedure. WS was 8 (IQR 7-9) and novel 3D TEE score was found 4 (IQR 3-4) in the whole study group. While no statistically significant relationship was found between WS and procedural success (p = 0.187), a statistically significant relationship was found between novel 3D TEE score and procedural success (p = 0.042). Specifically, the procedural successes rate was > 90% when novel 3D TEE score was < 4. The novel 3D TEE score might be an informative scoring system in the selection of suitable patients for successful redo PBMV, especially in patients who are considered for surgery due to the high WS.

Immediate and late clinical outcomes of balloon mitral valvotomy based on immediate postballoon mitral valvotomy mitral valve area & percentage gain in mitral valve area-A tertiary centre study

AIM

The aim of the study was to compare the immediate and late clinical outcomes of balloon mitral valvotomy (BMV), based on the immediate post-BMV valve area and percentage gain in mitral valve area (MVA).

METHODS

Clinical data of 818 consecutive patients who underwent BMV in our institute from 2000 to 2008 were analyzed retrospectively. They were categorized into three groups based on the postprocedural MVA and percentage gain in valve area-(1) 50% gain with final MVA <1.5 cm², group 1 (fair result); (2) final MVA of ≥1.5 cm², group 2 (good result); and (3) <50% gain with final MVA <1.5 cm², group 3 (suboptimal result).

RESULTS

The baseline characteristics of the three patient groups were clearly distinct. Those who had <50% gain with final MVA <1.5 cm² were older and had higher incidence of atrial fibrillation (17 [22.4%]), heart failure (32 [42.1%]), pulmonary artery hypertension (45 [59.2%]), and significantly deformed valves (39 [51.3%]) at baseline. At a mean follow-up period of 5.64 ± 3.84 years, incidence of redo BMV (23 [4.6%]) and mitral valve replacement (17 [3.4%]) was higher in them than those with immediate MVA ≥1.5 cm². Among those with MVA <1.5 cm², events on follow-up were similar irrespective of the percentage gain in MVA.

CONCLUSIONS

Immediate postprocedural MVA of ≥1.5 cm², and not percentage gain, predicts better long-term clinical outcomes after BMV. Patients who had less than 50% gain with final MVA <1.5 cm² represent high-risk population with advanced mitral valve disease and comorbidities.

Electrocardiographic P-wave Indices as a Useful Tool to Predict Successful Percutaneous Balloon Mitral Valvotomy in Patients with Mitral Stenosis

Introduction : Patients with hemodynamically significant mitral stenosis (MS) have prolonged P-wave duration and increased P-wave dispersion (PWD) that decrease after successful percutaneous balloon mitral valvotomy (PBMV). The purpose of this study was to investigate if the changes in these indices may predict a successful procedure. Methods : Fifty two patients with MS in sinus rhythm underwent PBMV (90.4% female; mean age 38±10 years). Mitral valve area (MVA), valve score, mean diastolic mitral gradient (mMVG), mitral regurgitation severity, and systolic pulmonary artery pressure (sPAP) were evaluated by echocardiography before PBMV and repeated after one month. P-wave duration (Pmax /Pmin) and PWD were measured before and immediately after PBMV, at discharge, and at the end of the first month after discharge. Results : Among all procedures, 38 (73.1%) were defined as successful. Mean age, valve score, mMVG, and MVA before PBMV were similar for both groups. MVA was significantly greater in the successful PBMV group (1.65±0.27 vs. 1.41±0.22; P= 0.003). sPAP was reduced after PBMV in all patients and there were no significant differences in the mean sPAP before and after PBMV in both successful and unsuccessful groups. Pmax and PWD were significantly decreased immediately after the procedure (P= 0.035), the next day (P= 0.005) and at one month (P= 0.002) only in patients with successful PBMV. Pmin did not change significantly in either group. Conclusion : Only is successful PBMV associated with a decrease in Pmax and PWD. These simple electrocardiographic indices may predict the success of the procedure immediately after PBMV.

Patient profile and results of percutaneous transvenous mitral commissurotomy in mitral restenosis following prior percutaneous transvenous mitral commissurotomy vs surgical commissurotomy

BACKGROUND

Patients with mitral restenosis who have undergone prior PTMC or surgical commissurotomy have increased. Predictors of outcome of repeat PTMC in either subgroup of patients may be different.

AIMS AND OBJECTIVES

Aim was to assess and compare the immediate results of PTMC in patients who had undergone a prior PTMC or surgical commissurotomy.

METHODS AND RESULTS

This is a single center, prospective, open label study. Of 70 patients in study, 44 (62.85%) patients had prior history of PTMC and 26 (37.15%) had prior surgical commissurotomy (closed/open). Average time from the initial procedure was 8.88 ± 5.36 years overall, 6.75 ± 3.38 for patients with prior PTMC and 16.73 ± 3.67 for patients with prior surgical commissurotomy. Prior PTMC group had 75% female, patients with prior surgical commissurotomy were older (44 ± 7 vs 33.57 ± 9.1 years, p = 0.001), had higher NYHA class (III/IV in100% vs 86.36%, p = 0.006.), higher atrial fibrillation (73.1% vs 25% p < 0.0001) and higher Wilkins' score (>8 in 88.46% vs 68.18%, p = 0.05). Successful PTMC was lower (65.4% vs 84.1%) in patients with prior surgical commissurotomy, though statistically not significant (p = 0.07). After PTMC, mitral valve area, PA systolic pressure, LA mean pressure and trans-mitral gradient were similar. Post procedure complications were not different in both the groups.

CONCLUSION

PTMC for mitral restenosis in patients with prior surgical valvotomy is as effective as in patients with prior PTMC despite older age, higher NYHA class, higher Wilkins score and atrial fibrillation and can be considered in all patients with restenosis irrespective of the type of past procedures done.

[Immediate results of repeat percutaneous mitral valvuloplasty]

Percutaneous mitral valvuloplasty (PMV) has emerged as the procedure of choice in treatment of mitral stenosis and has proved effectiveness in cases of mitral restenosis after surgical commissurotomy. However, this technique is costly, is not devoid of complication and success is not guaranteed. Indications of an attempted redo percutaneous mitral valvuloplasty (redo-PMV) are not well established. Hence the idea to study the immediate results of (re-PMV).

PURPOSE OF WORK

The purpose of this study is to evaluate the immediate results of the re-PMV in patients with mitral restenosis and analyze the different clinical and laboratory findings to determine predictors of success of re-PMV to better selection of candidates for a new attempt PMV.

METHODS

Retrospective study from a series of 40 procedures of re-PMV with the Inoue balloon succeeding a successful initial procedure, collected in the cardiology department of Habib Thameur hospital of Tunis between 1996 and 2011, in which we identified the data of clinical and paraclinical examinations.

RESULTS

The mean age of patients was 43 ± 11 years [23; 63]. Of the population, 87.5% were female (five men and 35 women). The average time between the two procedures was 8 ± 4 years [1; 15]. The immediate procedural success defined by a mitral valve area greater or equal to 1.5 cm(2) and a grade less than or equal to 2 mitral regurgitation was obtained in 31 patients (77.5%). A severe mitral regurgitation (MR) was observed in three patients (7.5%). A cerebrovascular stroke occurred in one patient (2.5%). No death or cardiac tamponade were noted. Class III or IV of NYHA, a pre-procedural MR, pulmonary hypertension and an overall score of Padial greater than 10 were retained as predictors of failure. More the overall score of Wilkins is high (>8), more it is predictive of failure. The two components of the Wilkins score: valvular mobility and subvalvular apparatus (SVA) and the parameter of the redesign of the SVA score of Padial considered separately are also predictive of failure. Only a left atrial area less than or equal to 25 cm(2) was linked to high risk of severe MR.

CONCLUSION

Redo percutaneous mitral valvuloplasty is a therapeutic alternative to surgery that is effective and promising interesting immediate results. Analysis of clinical and mainly echographic parameters is useful for predicting the success of the gesture, which will allow a better selection of candidates for re-PMV.

Repeat percutaneous balloon mitral valvotomy vs. mitral valve replacement in patients with restenosis after previous balloon mitral valvotomy and unfavorable valve characteristics

BACKGROUND

Symptomatic mitral restenosis develops in up to 21% of patients after percutaneous balloon mitral valvotomy (PBMV), and most of these patients undergo mitral valve replacement (MVR).

HYPOTHESIS

Repeating PBMV (re-PBMV) might be an effective and less-invasive treatment for these patients.

METHODS

Forty-seven patients with post-PBMV mitral restenosis and unfavorable valve characteristics were assigned either to re-PBMV (25 cases; mean age 40.7 ± 11 y, 76% female) or MVR (22 cases; mean age 47 ± 10 y, 69% female) at 51 ± 33 months after the prior PBMV. The mean follow-up was 41 ± 32 months and 63 ± 30 months for the re-PBMV and MVR groups, respectively.

RESULTS

The 2 groups were homogenous in preoperative variables such as gender, echocardiographic findings, and valve characteristics. Patients in the MVR group were older, with a higher mean New York Heart Association functional class, mean mitral valve area, mitral regurgitation grade, and right ventricular systolic pressure (P = 0.03), and more commonly were in AF. There were 3 in-hospital deaths (all in the MVR group) and 4 during follow-up (3 in the MVR group and 1 in the re-PBMV group). Ten-year survival was significantly higher in re-PBMV vs MVR (96% vs. 72.7%, P<0.05), but event-free survival was similar (52% vs. 50%, P = 1.0) due to high reintervention in the re-PBMV group (48% vs. 18.1%, P = 0.02).

CONCLUSIONS

In a population with predominantly unfavorable characteristics for PBMV, short- and long-term outcomes are both reasonable after re-PBMV with less mortality but requiring more reinterventions compared with MVR.

Immediate and long-term outcome of redo percutaneous mitral valvuloplasty: comparison with initial procedure in patients with rheumatic mitral restenosis

AIMS

We explored the immediate and long-term outcome of redo percutaneous mitral valvuloplasty (PMV) in a series of patients with mitral restenosis in comparison with initial PMV in the same series.

METHODS

We enrolled 40 consecutive patients presenting with mitral restenosis after successful initial PMV. Redo PMV was performed by the antegrade transseptal approach using either the Inoue technique or the multitrack technique. Reassessment by transthoracic echocardiography was repeated 48 hours later, and annually thereafter. Procedural success was defined as 50% or more increase of mitral valve area (MVA) with a final MVA >or=1.5 cm(2), without major complications. Restenosis was defined as loss of >50% of the initial gain of MVA by the preceding PMV with a final MVA <1.5 cm(2).

RESULTS

Procedural success was achieved in 37 (92.5%) patients. Both the initial and redo procedures were similar concerning the final MVA and mean transmitral pressure gradient (P > 0.05 for all). The gain of MVA was higher in the initial as compared to the redo procedure (P < 0.001). The initial mitral valve score correlated negatively with the final MVA in both the initial and redo procedures, and was the only independent predictor of the time to redo procedure, by multivariate regression analysis. At long-term follow-up (61 +/- 2.8 months), the mean MVA was 1.6 +/- 0.3 cm(2). Three patients--out of 12 available for follow-up--developed restenosis.

CONCLUSION

Redo PMV for mitral restenosis is feasible, safe, and achieves immediate and long-term outcome comparable to initial PMV.

Comparison of long-term outcome after mitral valve replacement or repeated balloon mitral valvotomy in patients with restenosis after previous balloon valvotomy

Symptomatic mitral stenosis (MS) develops in 7% to 21% of patients after percutaneous mitral balloon valvotomy (PMV). Treatment options for these patients are surgical mitral valve replacement (MVR) or repeated PMV. However, no comparisons were made between these 2 procedures regarding long-term outcome. This retrospective study compares the long-term outcome of 888 patients with symptomatic MS after MVR or repeated PMV who underwent PMV from April 1988 to December 2003. Thirty-two patients subsequently underwent repeated PMV, and 59 patients underwent MVR for symptomatic MS. Mean follow-up was 85 +/- 43 months with a maximum follow-up of 15 years. Patients with MVR have more unfavorable clinical characteristics, including a higher incidence of atrial fibrillation and severe mitral regurgitation. Event-free survival was similar between the 2 groups up to 40 months after the procedure; 3-year event-free survival rates were 96.6% for MVR patients and 90.0% for repeated PMV patients (p = 0.215). However, after 40 months, the outcome was more favorable for MVR. Comparing MVR versus PMV, 6-year event-free survival rates were 93.0% versus 75.9% (p = 0.036), and 9-year event-free survival rates were 90.4% versus 36.0% (p <0.001). In conclusion, the long-term outcome of patients with symptomatic MS after previous PMV was more favorable after MVR than after repeated PMV. These data suggest that MVR may be the preferred mode of therapy in patients with unfavorable valve morphologic characteristics and no co-morbid disease.

Feasibility, safety, and morphologic predictors of outcome of repeat percutaneous balloon mitral commissurotomy

Early and mid-term results of repeat percutaneous balloon mitral commissurotomy (PBMC) were analyzed in 35 patients with symptomatic valvular restenosis: 12 patients (34%) after first successful PBMC and 23 patients (66%) after successful surgical closed mitral commissurotomy. Twenty-one patients had bilateral fused commissures, and 14 patients had unilateral or bilateral split commissures. Mitral valve area gain was significantly greater in the group with fused commissures compared with the group with split commissures (0.6 +/- 0.2 vs 0.3 +/- 0.2 cm(2), respectively, p = 0.04).

Pathologic analysis of restenosis following percutaneous transluminal mitral commissurotomy

To clarify mechanisms of restenosis following percutaneous transluminal mitral commissurotomy (PTMC), we studied 253 patients (25% male) with PTMC using an Inoue balloon. Initial success (defined as either a mitral valve area >or= 1.5 cm(2) or more than twice the pre-PTMC valve area) was achieved in 95% of patients. During a mean follow-up period of 8 +/- 3 years, 12 patients underwent mitral valve replacement due to mitral valve restenosis. Visual inspection of the 12 resected valves with restenosis did not reveal fusion of the commissures. Histologically, all the resected mitral valves had evidence of end-stage rheumatic valvular disease, such as severe fibrosis and calcification. Deterioration of Wilkins echo score supported rheumatic disease progression in the leaflets and subvalvular region. Therefore, restenosis is not due to recurrence of fusion in commissures in these Japanese patients. Histologic and echocardiographic findings suggest that restenosis is based on end-stage valvular disease.