Introduction Mitral stenosis (MS), as a consequence of rheumatic fever (RF), carries a substantial worldwide morbidity and mortality. Despite the decrease in RF in industrialised countries due to improved antibiotic control, increasing immigration rates mean that RF still represents an important healthcare burden. Percutaneous balloon mitral valvuloplasty (PBMV) is the favoured treatment for MS. Our audit aimed to review recent PBMV practice at University Hospitals Bristol (UHB) and ensure that the results from this large tertiary centre are in line with the European Society of Cardiology (ESC) guidelines. There is no European PBMV audit data published to date.
Methods A retrospective audit of PBMV patients from the last 5 years. Data was collected from the CARRDAS database, patient notes, echocardiogram reports and raw data (for missing echocardiographic values).
Results 22 cases (and 1 repeat procedure) were analysed. A pre-operative transoesphageal echocardiogram (TOE) was performed on 100% patients. Following PBMV, the mean mitral valve area increased significantly by 50% (p < 0.05). The post-procedural peak and mean gradient across the mitral valve were significantly decreased (32% and 50% respectively, p < 0.05). The pulmonary pressure decreased by 16% however this result did not reach significance (Graph 1). The mean increase in valve area was 0.49cm2 however only 56% of post-operative valve areas measured above 1.5cm2, which falls below the ESC target of 80%.
In terms of post-operative complications, no patients exhibited severe mitral regurgitation (target <2%). However, the complication rates of pericardial effusion, endocarditis and groin haematoma were higher (Graph 2). Despite the percentage of pericardial effusions appearing high, it is important to note that this represents only 2 cases in a small study population.The Wilkins Score was poorly documented with evidence in only 4% of cases (target 100%).
Conclusion Comparing the results of this study to ESC guidelines indicates a favourable outcome in this cohort of patients. The completion of pre-operative TOEs and avoidance of severe valve regurgitation following surgery were exemplary. The increase in mean valve area and decrease in peak and mean valve gradients were significant and substantial. However, the Wilkins Score must be calculated and documented to reinforce decision making throughout the PBMV process. Furthermore, the acceptable ESC PBMV complication rates are: pericardial effusion 0.5–10%, severe regurgitation 2–10% and endocarditis 0%.
UHB is a tertiary centre with large referral catchment area yet still has a low volume of cases (<5/year on average). Therefore, in light of this limited caseload, it is important to maintain a small team of operators in order to maximise their experience and expertise. Continuous evaluation of the PBMV process is essential due to the minimal number of MS patients presenting each year.
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