Predictors of event-free survival after percutaneous mitral commissurotomy

Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement vs Percutaneous Mitral Valvuloplasty

BACKGROUND

This study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm2).

METHODS

From the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm2 < MVA ≤ 1.5 cm2 and MVA ≤ 1.0 cm2, respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention.

RESULTS

Among 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012).

CONCLUSIONS

PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

Left atrial size predicts long-term outcome after balloon mitral valvuloplasty

BACKGROUND

The treatment of choice for severe rheumatic mitral stenosis is balloon mitral valvuloplasty (BMV). Numerous predictors of immediate and long-term procedural success have been described. The aims of this study were to describe our experience with BMV over the last decade and to evaluate predictors of long-term event-free survival.

METHODS

Medical records were retrospectively analyzed of patients who underwent BMV between 2009 and 2021. The primary outcome was a composite endpoint of all-cause mortality, mitral valve replacement (MVR), and repeat BMV. Long-term event-free survival was estimated using Kaplan-Meier curves. Logistic regression was used to create a multivariate model to assess pre-procedural predictors of the primary outcome.

RESULTS

A total of 96 patients underwent BMV during the study period. The primary outcome occurred in 36 patients during 12-year follow-up: one (1%) patient underwent re-BMV, 28 (29%) underwent MVR, and eight (8%) died. Overall, event-free survival was 62% at 12 years. On multivariate analysis, pre-procedural left atrial volume index (LAVI) > 80 mL/m2 had a significant independent influence on event-free survival, as did previous mitral valve procedure and systolic pulmonary arterial pressure above 50 mmHg.

CONCLUSIONS

Despite being a relatively low-volume center, excellent short and long-term results were demonstrated, with event-free survival rates consistent with previous studies from high-volume centers. LAVI independently predicted long-term event-free survival.

Immediate and long-term results of percutaneous mitral commissurotomy: up to 15 years

PURPOSE

To evaluate immediate and long-term clinical results of percutaneous mitral commissurotomy (PMC) in patients with severe mitral stenosis.

METHODS

In a retrospective study, data were included from 317 patients over 18 years of age (mean age 45) who had been treated for mitral stenosis between January 1993 and March 2015 with PMC using the Inoue balloon technique. Immediate results: Valvular function improved as evidenced by an increase in mitral valve area from 1.01 ± 0.24 cm² to 2 ± 0.31 cm² (P < 0.001) and a decrease in mean mitral gradient from 13.64 ± 6.03 mm Hg to 5.40 ± 2.49 mm Hg. Long-term follow-up: At 5-15 years (mean 10.2 years, Inter-quartile range 8.25), 105 (33.1%) of the 317 patients were available for follow-up, 95 living patients and 10 deceased. Of the deceased, average time from PMC to death was 8 years. Results were strongly significant showing that age at the time of PMC and surface area before the procedure were the best predictors of survival at 15 years follow-up, showing significance values of P = 0.022 and P = 0.001, respectively.

CONCLUSIONS

PMC using the Inoue balloon technique improves morbidity and long-term mortality rates in patients with severe mitral stenosis. Lower Wilkins score and NYHA class at baseline were not found to be significant predictors of mortality in older patients (age > 45). Overall, 65 (61.9%) had survived at 5-15 years follow-up without further cardiac intervention.

Rheumatic Mitral Valve Stenosis: Diagnosis and Treatment Options

PURPOSE OF REVIEW

This review provides an update on rheumatic mitral stenosis. Acute rheumatic fever (RF), the sequela of group A β-hemolytic streptococcal infection, is the major etiology for mitral stenosis (MS).

RECENT FINDINGS

While the incidence of acute RF in the Western world had substantially declined over the past five decades, this trend is reversing due to immigration from non-industrialized countries where rheumatic heart disease (RHD) is higher. Pre-procedural evaluation for treatment of MS using a multimodality approach with 2D and 3D transthoracic and transesophageal echo, stress echo, cardiac CT scanning, and cardiac MRI as well as hemodynamic assessment by cardiac catheterization is discussed. The current methods of percutaneous mitral balloon commissurotomy (PMBC) and surgery are also discussed. New data on long-term follow-up after PMBC is also presented. For severe rheumatic MS, medical therapy is ineffective and definitive therapy entails PMBC in patients with suitable morphological mitral valve (MV) characteristics, or surgery. As procedural outcomes depend heavily on appropriate case selection, definitive imaging and interpretation are crucial. It is also important to understand the indications as well as morphological MV characteristics to identify the appropriate treatment with PMBC or surgery.

Predictors of Long-Term Outcomes of Percutaneous Mitral Valvuloplasty in Patients with Rheumatic Mitral Stenosis

PURPOSE

We determined factors associated with long-term outcomes of patients who underwent successful percutaneous mitral balloon valvuloplasty (PMV).

MATERIALS AND METHODS

Between August 1980 and May 2013, 1187 patients underwent PMV at Severance Hospital, Seoul, Korea. A total of 742 patients who underwent regular clinic visits for more than 10 years were retrospectively analyzed. The endpoints consisted of repeated PMV, mitral valve (MV) surgery, and cardiovascular-related death.

RESULTS

The optimal result, defined as a post-PMV mitral valve area (MVA) >1.5 cm² and mitral regurgitation ≤Grade II, was obtained in 631 (85%) patients. Over a mean follow up duration of 214±50 months, 54 (7.3%) patients underwent repeat PMV, 4 (0.5%) underwent trido-PMV, and 248 (33.4%) underwent MV surgery. A total of 33 patients (4.4%) had stroke, and 35 (4.7%) patients died from cardiovascular-related reasons. In a multivariate analysis, echocardiographic score [p=0.003, hazard ratio=1.56, 95% confidence interval (CI): 1.01-2.41] and post-MVA cut-off (p<0.001, relative risk=0.39, 95% CI: 0.37-0.69) were the only significant predictors of long-term clinical outcomes after adjusting for confounding variables. A post-MVA cut-off value of 1.76 cm² showed satisfactory predictive power for poor long-term clinical outcomes.

CONCLUSION

In this long-term follow up study (up to 20 years), an echocardiographic score >8 and post-MVA ≤1.76 cm² were independent predictors of poor long-term clinical outcomes after PMV, including MV reintervention, stroke, and cardiovascular-related death.

Management of atrial fibrillation in patients with rheumatic mitral stenosis

Atrial fibrillation (AF) is frequent in patients with rheumatic mitral stenosis (MS). Pressure overload leads to marked structural and electrical remodelling of left atrium. The frequency of persistent AF increases with age and paroxysmal, asymptomatic, AF seems even more frequent. The occurrence of AF worsens the haemodynamic tolerance of MS and markedly increases the risk of thromboembolic events. AF has a negative impact on the natural history of MS and on its outcome after commissurotomy. The respective indications of rhythm and rate control should be adapted to patient characteristics, particularly the consequences of MS, and take into account the high risk of recurrence of AF. Oral anticoagulant therapy is mandatory when AF complicates MS, regardless of its severity and CHA2DS2-VASc score. Non-vitamin K antagonists oral anticoagulants are not recommended in moderate-to-severe MS due to the lack of data. Percutaneous mitral commissurotomy does not appear to prevent the occurrence of AF in MS but should be considered as the first-line therapy when AF is associated with severe symptomatic MS, followed by the discussion of cardioversion or ablation. AF ablation should be considered in patients with mitral disease requiring intervention, but the ideal timing and techniques are difficult to determine due to the lack of appropriate specific randomised trials in patients with MS.

Late results of percutaneous mitral commissurotomy up to 20 years: development and validation of a risk score predicting late functional results from a series of 912 patients

BACKGROUND

Long-term follow-up after percutaneous mitral commissurotomy enables predictive factors of late results to be identified.

METHODS AND RESULTS

Late results of percutaneous mitral commissurotomy were assessed in 1024 consecutive patients. Good immediate results, defined as valve area ≥1.5 cm(2) without mitral regurgitation >2/4, were obtained in 912 patients (89%). These 912 patients were randomly split into 2 cohorts comprising 609 and 303 patients that were used to develop and validate, respectively, a scoring system predicting late functional results. The 20-year rate of good functional results (survival without cardiovascular death, mitral surgery, or repeat percutaneous mitral commissurotomy and in New York Heart Association class I or II) was 30.2 ± 2.0%. A multivariable Cox model identified 7 predictive factors of poor late functional results: higher final mean gradient (P<0.0001), interaction between age and final mitral valve area (P<0.0001) showing that the impact of valve area decreases with age, interaction between sex and valve calcification (P<0.0001) showing that the impact of valve anatomy is stronger in men, and interaction between rhythm and New York Heart Association class showing an impact of New York Heart Association class only in patients in atrial fibrillation (P<0.0001). A 13-point score enabled 3 risk groups to be defined, corresponding to predicted good functional results of 55.1%, 29.1%, and 10.5% at 20 years in the validation cohort.

CONCLUSIONS

Twenty years after percutaneous mitral commissurotomy in a population of patients with varied characteristics, 30% still had good functional results. Prediction of late functional results is multifactorial and strongly determined by age and the quality of immediate results. A simple validated scoring system is useful for estimating individual patient outcome.

Predicting success and long-term outcomes of percutaneous mitral valvuloplasty: a multifactorial score

BACKGROUND

Percutaneous mitral valvuloplasty (PMV) success depends on appropriate patient selection. A multifactorial score derived from clinical, anatomic/echocardiographic, and hemodynamic variables would predict procedural success and clinical outcome.

METHODS

Demographic data, echocardiographic parameters (including echocardiographic score), and procedure-related variables were recorded in 1085 consecutive PMVs. Long-term clinical follow-up (death, mitral valve replacement, redo PMV) was performed. Multivariate regression analysis of the first 800 procedures was performed to identify independent predictors of procedural success. Significant variables were formulated into a risk score and validated prospectively.

RESULTS

Six independent predictors of PMV success were identified: age less than 55 years, New York Heart Association classes I and II, pre-PMV mitral area of 1 cm(2) or greater, pre-PMV mitral regurgitation grade less than 2, echocardiographic score of 8 or greater, and male sex. A score was constructed from the arithmetic sum of variables present per patient. Procedural success rates increased incrementally with increasing score (0% for 0/6, 39.7% for 1/6, 54.4% for 2/6, 77.3% for 3/6, 85.7% for 4/6, 95% for 5/6, and 100% for 6/6; P < .001). In a validation cohort (n = 285 procedures), the multifactorial score remained a significant predictor of PMV success (P < .001). Comparison between the new score and the echocardiographic score confirmed that the new index was more sensitive and specific (P < .001). This new score also predicts long-term outcomes (P < .001).

CONCLUSION

Clinical, anatomic, and hemodynamic variables predict PMV success and clinical outcome and may be formulated in a scoring system that would help to identify the best candidates for PMV.

Restenosis and adverse clinical events after successful percutaneous mitral valvuloplasty: immediate post-procedural mitral valve area as an important prognosticator

AIMS

We sought to investigate the factors associated with restenosis and its potential association with late clinical deterioration after successful percutaneous mitral valvuloplasty (PMV).

METHODS AND RESULTS

We analysed echocardiographic (median 74 months) and clinical (median 109 months) follow-up data of 329 patients who achieved procedural success, defined as mitral valve area (MVA) > or =1.5 cm(2) and mitral regurgitation (MR) < or =2/4, between 1995 and 2000. Clinical events included cardiovascular death, mitral valve surgery, and repeat PMV. The 1, 3, 5, 7, and 9 year rates of restenosis-free survival were 99 +/- 1%, 97 +/- 1%, 95 +/- 1%, 86 +/- 3%, and 72 +/- 4%, respectively. The 1, 3, 5, 7, and 9 year rates of event-free survival were 99.7 +/- 0.3%, 96.4 +/- 1.0%, 94.5 +/- 1.3%, 90.8 +/- 1.6%, and 90.0 +/- 1.7%, respectively. Immediate post-PMV MVA and commissural MR or splitting, indicators of procedural adequacy, were independent predictors of both restenosis and clinical events. The best immediate post-PMV MVA cut-off value for predicting both restenosis and clinical events within 5 years after successful PMV were 1.8 cm(2) [95% confidence interval (CI) = 1.7-1.9] and 1.9 cm(2) (95% CI = 1.7-2.0), respectively. Patients with immediate post-PMV MVA <1.8 cm(2) showed significantly lower event-free survival rate than those with post-PMV MVA > or =1.8 cm(2) (P < 0.001).

CONCLUSION

Immediate post-PMV MVA> or =1.8 cm(2) was an important predictor of both restenosis- and clinical event-free survival and this value should be considered as a component of optimal result.

Impact of concomitant aortic regurgitation on percutaneous mitral valvuloplasty: Immediate results, short-term, and long-term outcome

BACKGROUND

The aim of the study is to examine the effect of concomitant aortic regurgitation (AR) on percutaneous mitral valvuloplasty (PMV) procedural success, short-term, and long-term clinical outcome. No large-scale study has explored the impact of coexistent AR on PMV procedural success and outcome.

METHODS

Demographic, echocardiographic, and procedure-related variables were recorded in 644 consecutive patients undergoing 676 PMV at a single center. Mortality, aortic valve surgery (replacement or repair) (AVR), mitral valve surgery (MVR), and redo PMV were recorded during follow-up.

RESULTS

Of the 676 procedures performed, 361 (53.4%) had no AR, 287 (42.5%) mild AR, and 28 (4.1%) moderate AR. There were no differences between groups in the preprocedure characteristics, procedural success, or in the incidence of inhospital adverse events. At a median follow-up of 4.11 years, there was no difference in the overall survival rate (P = .22), MVR rate (P = .69), or redo PMV incidence (P = .33). The rate of AVR was higher in the moderate AR group (0.9% vs 1.9% vs 13%, P = .003). Mean time to AVR was 4.5 years and did not differ significantly between patients with no AR, mild AR, or moderate AR (2.9 +/- 2.1 vs 5.7 +/- 3.6 vs 4.1 +/- 2.5 years, P = .46).

CONCLUSIONS

Concomitant AR at the time of PMV does not influence procedural success and is not associated with inferior outcome. A minority of patients with MS and moderate AR who undergo PMV will require subsequent AVR on long-term follow-up. Thus, patients with rheumatic MS and mild to moderate AR remain good candidates for PMV.

Predictors of Surgery After Percutaneous Mitral Valvuloplasty

BACKGROUND

Percutaneous mitral valvuloplasty (PMV) is a minimally invasive treatment option for selected patients with mitral stenosis (MS). In general, the procedure is well-tolerated with a high success rate. However, relatively little is known about the predictors of surgical intervention after PMV.

METHODS

A retrospective analysis was performed on 243 patients undergoing PMV at a single institution over a 14 year period.

RESULTS

Fifty (21%) of 243 patients, comprising 44 women and 6 men and aged 55 +/- 14 years, underwent cardiac surgery at a median interval of 6 months (range, 0 to 130) after PMV. Nine (18%) underwent a procedure within 15 days, and 41 (82%) had a procedure more than 15 days after the valvuloplasty. After PMV, surgery-free survival was 85% at 1 year, 83% at 2 years, 81% at 3 years, 80% at 4 years, and 80% at 5 years.

CONCLUSIONS

The need for surgery after PMV is not uncommon. Independent predictors of surgery after PMV included severity of mitral regurgitation (p < 0.003) and a higher echo score (p < 0.039).

Balloon mitral valvuloplasty at Monash Medical Centre: follow up of 201 procedures over an 11-year period

Over a period of 11 years from 1988 to 1999, 201 patients underwent balloon mitral valvuloplasty (BMV) at Monash Medical Centre, Australia. Before BMV,133 patients (66%) were symptomatic with minimal activity or at rest. BMV increased mitral valve area and cardiac output, and reduced transmitral, left atrial and pulmonary pressures, with infrequent procedural complications (<8%). At the initial 3-month follow up after BMV, symptoms were absent or minimal in 178 patients (89%), with 85% remaining event free at 12 months. At long-term follow up (median: 30 months; range: 0-129 months), cumulative event-free survival was 73% after 5 years. After BMV, 37 patients (18%) underwent mitral valve surgery, while a repeat BMV was performed in three patients (1.5%). The results of this series provide additional data for the growing body of evidence which suggests that BMV is a relatively safe and effective procedure for producing long-term benefit in patients with symptomatic mitral stenosis.

The Impact of Age in the Immediate and Long-Term Outcomes of Percutaneous Mitral Balloon Valvuloplasty

BACKGROUND

Differences in age, clinical characteristics, and valve morphology may account for controversial results of percutaneous mitral balloon valvuloplasty (PMV).

METHODS

We have previously reported the immediate and long-term clinical follow-up (50 +/- 45 months) of 879 patients who underwent PMV at the Massachusetts General Hospital. In the present study, we used this database to determine the impact of age in the immediate and long-term outcome of PMV. For purpose of analysis, these patients were divided into four age groups: group 1 (< or =35 years), group 2 (36-55 years), group 3 (56-75 years), and group 4 (>75 years).

RESULTS

The incidence of atrial fibrillation, calcified valves under fluoroscopy, higher echocardiographic score, New York Heart Association (NYHA) class IV and pre-PMV mitral regurgitation (MR) increased with patient's age. As patients became older, a lower post-PMV mitral valve area (2.1 +/- 0.7, 2.0 +/- 0.6, 1.8 +/- 0.6, and 1.6 +/- 0.6; P < 0.0001) and progressive decrease in procedural success (81.4%, 80.5%, 65.3%, and 53%; P < 0.0001) were observed. Younger age was identified as an independent predictor of PMV success by multiple stepwise logistic regression (odds ratio [OR]: 3.33; confidence interval [CI]: 1.41-7.69, P = 0.006). Furthermore, age was identified as an independent predictor of long-term events by Cox regression analysis (risk ratio [RR]: 1.02; CI: 1.01-1.03, P < 0.00001). However, the effect of age seemed to be blunted by the morphology of the valve at follow-up, as patients with echocardiogram score >8 in groups 2, 3, and 4 presented similar combined event-free survival (death, mitral valve replacement, or redo PMV).

CONCLUSION

Age is an important predictor of immediate and long-term outcomes after PMV, particularly in patients with optimal mitral valve morphology. (

Indication and timing of percutaneous mitral balloon valvotomy and the role of atrial fibrillation

Percutaneous transvenous mitral balloon valvotomy (PTMV) has been proven to be an effective and safe method for treatment of patients with severe mitral valve stenosis. This technique has become an accepted alternative for surgical commissurotomy, not only in young patients with pliable valves, but also in selected older patients with extensive valvular pathology. This review highlights the significance of coexisting atrial fibrillation, patient selection and timing of PTMV in patients with mitral valve stenosis.

[Mitral stenosis]

The decrease in the incidence of acute rheumatic fever in western countries has led to a sharp decrease in the incidence of mitral stenosis. This decrease also modifies the clinical presentation and mitral stenosis is now encountered in older patients who have severe impairment of valve anatomy. In developing countries, mitral stenosis remains a frequent disease. The management of patients with mitral stenosis has been modified by the development of percutaneous mitral commissurotomy whose safety and efficacy have been demonstrated in a number of studies with a follow-up of up to ten years. Percutaneous mitral commissurotomy is now the reference treatment for mitral stenosis with pliable valves in young patients and its efficacy has been validated in randomised trials versus surgery. Mitral stenosis in older patients, as it is encountered in western countries, is a more heterogeneous group. Predictive analysis has shown that the predictions of immediate and late results are multifactorial. This has led to consider the indications for percutaneous mitral commissurotomy in patients who do not have ideal anatomic conditions, when their other characteristics are favourable. This is particularly the case in young patients who do not have a very tight mitral stenosis (1-1.5 cm2) and who do not have an advanced heart disease. When the conditions are favourable, percutaneous mitral commissurotomy can be considered in patients who have few symptoms, in particular in order to reduce the thromboembolic risk.

The long-term outcome of balloon valvuloplasty for mitral stenosis

Percutaneous mitral commissurotomy (PMC) is the treatment of choice in young patients who have favorable valve anatomy. It affords an event-free survival greater than 90% at 5 to 7 years,. Economic considerations are the main limitation of PMC in such patients, who are mainly encountered in developing countries. Mitral stenosis in older patients with less favorable valve anatomy is the most frequent presentation in Western countries. This represents a heterogeneous group, but predictive analyses are helpful in deciding who should have PMC. The main conclusion is that the prediction of immediate and late results is multifactorial. Good results can be expected in young patients with unfavorable valve anatomy who do not have a very tight stenosis, are moderately symptomatic, and in sinus rhythm. In addition, PMC may reduce the thromboembolic risk related to mitral stenosis.

Predictors of long-term event-free survival and of freedom from restenosis after percutaneous balloon mitral commissurotomy

BACKGROUND

Most long-term studies after balloon mitral commissurotomy (BMC) were from industrialized countries. Less is known about the long-term results of BMC from developing countries where patients are younger with fewer mitral valve deformities.

METHODS

Between December 1987 and December 1998, we performed BMC in 654 patients whose mean age was 33 +/- 13 years. Baseline and postprocedural variables were evaluated to identify predictors of event-free survival (survival without repeat BMC or mitral valve replacement) and of freedom from restenosis defined as a mitral valve area (MVA) >/=1.5 cm(2) after BMC and <1.5 cm(2) at follow-up.

RESULTS

The actuarial survival rates were 98%, 98%, and 97% at 5, 7, and 10 years, respectively. The 5-, 7-, and 10-year event-free survival rates were 85%, 81%, and 72%. Multivariate predictors of a higher 10-year event-free survival rate were lower echocardiographic score (79% for a score </=8, 61% for a score of 9 to 11, 62% for a score >/=12, P <.001) and cardiac sinus rhythm (P =.04) before BMC, lower mean left atrial pressure (P <.001), lower mitral valve gradient (P <.001), and less than or equal to grade 2 mitral regurgitation (P =.036) after BMC. Restenosis occurred in 16% of patients. The restenosis-free rates were 88%, 80%, and 66% at 5, 7, and 10 years, respectively. A higher freedom from restenosis at 10 years was associated with a lower score (77% for a score </=8, 45% for a score of 9-11 and 50% for a score >/=12, P =.03) and a larger MVA before BMC (P =.03), a larger MVA (P <.001), and a lower mitral valve gradient (P =.04) after BMC.

CONCLUSIONS

BMC produces excellent 10-year results in patients with pliable mitral stenosis and good results in patients with semipliable or calcified mitral stenosis. BMC is the procedure of choice in patients with pliable valves and it is a reasonable treatment option in young patients with unfavorable mitral valve anatomy.

Late results of percutaneous mitral commissurotomy for calcific mitral stenosis

The aim of this study was to assess late results of percutaneous mitral commissurotomy (PMC) in calcific mitral stenosis and to identify predictors to improve patient selection. We analyzed 422 patients who underwent PMC for calcific mitral stenosis. The extent of calcium was graded from 1 to 4 by fluoroscopy: 227 patients (53%) were graded 1, 125 (30%) graded 2, 55 graded 3 (13%), and 15 graded 4 (4%). The procedure failed in 15 patients, used a single balloon in 11, a double balloon in 126, and the Inoue balloon in 270. In-hospital mortality was 1.2%. Good immediate results (valve area >/=1.5 cm(2) without mitral regurgitation >2/4), were obtained in 321 patients (76%). Multivariate analysis identified 5 predictors of good immediate results: a younger age (p = 0.0004), a lesser degree of stenosis (p = 0.0005), a smaller extent of calcium (p = 0.04), the use of the Inoue balloon (p = 0.015), and a larger effective balloon dilating area (p = 0.006). Good functional results, defined as survival with no further intervention and in New York Heart Association class I or II, were 36 +/- 4% at 8 years. The predictors of good functional results after good immediate results were a younger age (p = 0.04), a lower pre-PMC New York Heart Association class (p <0.0001), sinus rhythm (p = 0.0006), a smaller extent of calcium (p = 0.02), and a lower gradient after PMC (p <0.0001). Despite a frequent deterioration on follow-up after PMC for calcific mitral stenosis, the predictive analysis suggests that PMC may be useful in deferring surgery in selected patients with mild to moderate calcific deposits, who have otherwise favorable characteristics.