Long-term (9 to 33 months) echocardiographic follow-up after successful percutaneous mitral commissurotomy

doi:10.1016/0002-9149(92)90711-7

The American Journal of Cardiology

Volume 69, Issue 19, 15 June 1992, Pages 1602-1606

https://doi.org/10.1016/0002-9149(92)90711-7 Get rights and content

Abstract

Late results after successful percutaneous mitral commissurotomy were assessed by prospective clinical and echocardiographic follow-up. Fiftyseven patients were followed for a mean of 19 ± 6 months (range 9 to 33) after the procedure. Mitral valve area (measured by Doppler half-time method) increased from 1.0 ± 0.2 to 2.2 ± 0.5 cm² immediately after commissurotomy, and then decreased to 1.9 ± 0.5 cm² at follow-up (p < 0.05), whereas gradient did not change after its immediate postcommissurotomy reduction. Echocardiographic restenosis (mitral valve area ≤1.5 cm² with >50% reduction of initial gain) was seen in 12 of 57 patients (21%). Atrial shunting, detected by transthoracic color Doppler in 61% of patients immediately after the procedure (color flow jet through atrial septum), persisted in 30% at follow-up.

Restenosis by univariate analysis correlated with age, smaller valve area after the procedure, and higher echocardiographic score. Multivariate analysis identified leaflet mobility and calcifications as the components of a score that was predictive for restenosis. Magnitude of shunt (pulmonary-to-systemic flow ratio >1.5), use of a Bifoil balloon (2 balloons on 1 shaft), and smaller valve area after the procedure were predictors by multivariate analysis of the persistence of atrial shunting. Clinical improvement persisted at long-term follow-up (mean New York Heart Association class 1.6 ± 0.6 vs 2.6 ± 0.6 before commissurotomy). Improvement of ≥1 functional class was seen in 75% of patients (80% of those without and 58% of those with restenosis); patients with a shunt did not differ from the entire group.

Thus, percutaneous mitral commissurotomy provides excellent late (9 to 33 months) clinical results. Echocardiographic restenosis was identified in 20% of patients, and was related to age, valve morphology and a suboptimal result. Atrial shunting (small and clinically well-tolerated) was absent after long-term follow-up in 50% of patients; its persistence was related to the magnitude of the shunt, the size of the deflated balloon, and a suboptimal result.

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Cited by (81)

Very Long Term Follow-Up After Percutaneous Balloon Mitral Valvuloplasty
2018, JACC: Cardiovascular Interventions
The aim of this study was to assess very long term outcomes after successful percutaneous balloon mitral valvuloplasty (PBMV).
PBMV remains the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis and suitable anatomy.
All consecutive patients who underwent successful PBMV between 1987 and 2010 were included. The primary endpoint was the composite of all-cause mortality, need for mitral surgery, or repeat PBMV up to 23 years.
Among all 1,582 consecutive patients undergoing PBMV, acute success was achieved in 90.9% (n = 1,438). Independent predictors of acute success included left atrial size (odds ratio: 0.96; 95% confidence interval [CI]: 0.93 to 0.99; p = 0.045), Wilkins score ≤8 (odds ratio: 1.66; 95% CI: 0.48 to 0.93; p = 0.02) and age (odds ratio: 0.97; 95% CI: 0.96 to 0.99; p = 0.006). Very long term follow-up (median 8.3 years, mean 15.6 years) was obtained in 79.1% of successful cases. The incidence of the primary endpoint was 19.1% (95% CI: 17.0% to 21.1%). The rates of overall mortality, need for mitral valve surgery, or repeat PBMV were 0.6% (95% CI: 0.3% to 1.2%), 8.3% (95% CI: 7.0% to 9.9%), and 10.0% (95% CI: 8.5% to 11.7%), respectively. On multivariate analysis, New York Heart Association functional class III or IV (hazard ratio: 1.62; 95% CI: 1.26 to 2.09; p < 0.001), higher age (hazard ratio: 0.97; 95% CI: 0.96 to 0.98; p = 0.028), and mitral valve area ≤1.75 cm² after the procedure (hazard ratio: 1.67; 95% CI: 1.28 to 2.11; p = 0.028) were independent predictors of the primary endpoint.
In very long term follow-up, more than 75% of patients exhibited sustained results. Prediction of late favorable results is multifactorial and strongly determined by age, previous symptoms and post-procedural mitral valve area.
Late outcome of percutaneous mitral commissurotomy: Randomized comparison of Inoue versus double-balloon technique
2017, American Heart Journal
Late prognosis after successful percutaneous mitral commissurotomy (PMC) is unclear. We compared late results of PMC using Inoue versus double-balloon techniques up to 25 years in a randomized trial.
Between 1989 and 1995, 302 patients (77 men, 41 ± 11 years) with severe mitral stenosis were randomly assigned to undergo PMC using Inoue (n = 152; group I) or double-balloon technique (n = 150; group D). The end points were the composite events of death, mitral surgery, repeat PMC, or deterioration of New York Heart Association (NYHA) class ≥3.
During median follow-up of 20.7 years (maximum, 25.6), clinical events occurred in 82 (53.9%) patients in group I (37 deaths, 44 mitral surgeries, 9 repeat PMCs, 3 NYHA class ≥3) and in 79 (52.7%) patients in group D (34 deaths, 51 mitral surgeries, 5 repeat PMCs, 4 NYHA class ≥3). Event-free survival rates at 24 years were not significantly different between group I and group D (40.8% and 42.6%, respectively; hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.65–1.20; P = .423). On multivariate analysis, absence of post-PMC commissural mitral regurgitation (MR) (HR, 1.84; 95% CI, 1.28–2.63; P = .001) and immediate post-PMC mitral valve area (MVA) <1.8 cm² (HR, 1.53; 95% CI, 1.04–2.25; P = .031) were independently correlated with clinical events after successful PMC.
The Inoue and double-balloon methods showed similar good clinical outcomes up to 25 years, and the achievement of effective commissurotomy to develop post-PMC commissural MR or immediate post-PMC MVA ≥1.8 cm² is important in optimizing the late results of PMC.
Patient profile and results of percutaneous transvenous mitral commissurotomy in mitral restenosis following prior percutaneous transvenous mitral commissurotomy vs surgical commissurotomy
2014, Indian Heart Journal
Citation Excerpt :
Restenosis is time dependent and found to be associated with poor long term functional results after good immediate results and adverse clinical events 5 years after PTMC.11–15 The incidence has been reported to range from 4 to 39% within 6 years of follow up and progressive decrease of MVA overtime has been well documented.16–23 Chen et al24 reported a decrease in MVA of 0.2 cm2 at 5 years and Trevino et al25 reported a decrease of 0.25 cm2 at 3 years.
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.
Aim was to assess and compare the immediate results of PTMC in patients who had undergone a prior PTMC or surgical commissurotomy.
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.
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 redo percutaneous mitral valvuloplasty
2013, Annales de Cardiologie et d'Angeiologie
La dilatation mitrale percutanée (DMPC) est devenue le traitement de choix du rétrécissement mitral et a prouvé son efficacité en cas de resténose mitrale après commissurotomie chirurgicale. Cependant, cette technique, coûteuse, n’est pas dénuée de complication et sa réussite n’est pas garantie. Les indications d’une tentative de redilatation mitrale percutanée (re-DMPC) ne sont pas bien établies. D’où l’idée d’étudier les résultats immédiats de la re-DMPC.
Le but de ce travail est d’évaluer les résultats immédiats de la re-DMPC chez des patients présentant une resténose mitrale et d’analyser les différents éléments cliniques et paracliniques permettant de déterminer les facteurs prédictifs de succès de la re-DMPC afin de mieux sélectionner les candidats à une nouvelle tentative de DMPC.
Étude rétrospective à partir d’une série de 40 procédures de re-DMPC par ballon d’Inoué succédant à une procédure antérieure initialement réussie, colligées dans le service de cardiologie de l’hôpital Habib Thameur de Tunis entre 1996 et 2011 chez qui nous avons recensé les données des examens cliniques et paracliniques.
L’âge moyen de nos patients était de 43 ± 11 ans [23 ; 63]. De la population, 87,5 % étaient de sexe féminin (cinq hommes et 35 femmes). Le délai moyen entre deux procédures était de 8 ± 4 ans [1 ; 15]. Le succès procédural immédiat défini par une surface mitrale supérieure ou égale à 1,5 cm² et une fuite mitrale inférieure ou égale à grade 2 a été obtenu chez 31 patients (77,5 %). Une insuffisance mitrale (IM) sévère a été observée chez trois patients (7,5 %). Un accident vasculaire cérébral ischémique est survenu chez un patient (2,5 %). Aucun cas de décès ni de tamponnade n’a été noté. Le stade III ou IV de NYHA, une IM pré-procédurale, une hypertension artérielle pulmonaire et un score global de Padial supérieur à 10 ont été retenus comme facteurs prédictifs d’échec. Plus le score global de Wilkins est élevé (> 8), plus il est prédictif d’échec. Les deux composantes du score de Wilkins : la mobilité valvulaire et l’appareil sous-valvulaire (ASV) ainsi que le paramètre remaniement de l’ASV du score de Padial considérés séparément sont également prédictifs d’échec. Seul une surface auriculaire gauche inférieure ou égale à 25 cm² était liée à un risque élevé d’IM sévère.
La redilatation mitrale percutanée est une alternative thérapeutique à la chirurgie qui est efficace et promettant des résultats immédiats intéressants. L’analyse des paramètres cliniques et surtout échographiques aident à prédire le succès du geste, ce qui permettra une meilleure sélection des candidats à la re-DMPC.
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).
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.
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.
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 cm² 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 cm² was linked to high risk of severe MR.
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.
Mean pulmonary arterial pressure after percutaneous mitral valvuloplasty predicts long-term adverse outcomes
2012, Revista Portuguesa de Cardiologia
Percutaneous mitral valvuloplasty (PMV) is an effective treatment option for mitral stenosis (MS), but its success is assessed on the basis of clinical and echocardiographic outcomes in studies with relatively short follow-up. We aimed to characterize a cohort of patients undergoing PMV with long-term follow-up and to determine independent predictors of post-PMV mitral re-intervention and event-free survival.
We studied 91 consecutive patients with MS who underwent PMV with a median clinical follow-up duration of 99 months. Two endpoints were considered: post-PMV mitral re-intervention (PMV or mitral surgery) and a composite clinical events endpoint including cardiovascular death, mitral valve re-intervention and hospital admission due to decompensated heart failure. We compared patients who required post-PMV mitral re-intervention with those who did not during follow-up.
The study population included 83.5% females and mean age was 48.9 ± 13.9 years. The 1-, 3-, 5-, 7- and 9-year rates of clinical event-free survival were 93.0 ± 2.8%, 86.0 ± 3.9%, 81.0 ± 4.4%, 70.6 ± 5.6%, and 68.4 ± 5.8%, respectively. The 1-, 3-, 5-, 7- and 9-year rates of mitral re-intervention-free survival were 98.8 ± 1.2%, 97.5 ± 1.7%, 92.1 ± 3.1%, 85.5 ± 4.5%, and 85.5 ± 4.5%, respectively. The median time to mitral re-intervention was 6.2 years. Patients who required mitral re-intervention during follow-up were younger (43.3 vs. 51.2 years, p=0.04) and had higher pre- and post-PMV mitral gradient (14.9 vs. 11.5 mmHg, p=0.02 and 6.4 vs. 2.1 mmHg, p<0.001) and higher post-PMV mean pulmonary artery pressure (mPAP) (30.0 vs. 23.2 mmHg, p=0.01). In a Cox proportional hazards model, mPAP ≥25 mmHg was the sole predictor of both mitral re-intervention (HR 5.639 [1.246–25.528], p=0.025) and clinical events (HR 3.622 [1.070–12.260], p=0.039).
In our population, immediate post-PMV mPAP was the sole predictor of post-PMV mitral intervention. These findings may help identify patients in need of closer post-PMV follow-up.
A valvuloplastia mitral percutânea (PMV) é uma opção eficaz para o tratamento da estenose mitral. Contudo, os resultados deste procedimento são baseados em estudos clínicos e ecocardiográficos com tempos de seguimento relativamente curtos. Os objetivos deste estudo são caracterizar uma população de doentes submetidos a PMV, realizar um seguimento clínico de longa duração e determinar os preditores independentes de reintervenção mitral após PMV e de sobrevida livre de eventos.
Foi estudada uma população de 91 doentes com estenose mitral tratada por PMV e realizou-se um seguimento clínico com a duração média de 99 meses. Foram pré-definidos dois endpoints: reintervenção mitral pós-PMV (PMV ou cirurgia mitral) e um endpoint clínico combinado que incluiu morte de causa cardiovascular, reintervenção mitral e internamento hospitalar por insuficiência cardíaca descompensada. Foi realizado um estudo comparativo entre os doentes que necessitaram de reintervenção mitral após PMV e os que não foram reintervencionados durante o tempo de seguimento clínico.
A população estudada incluiu 83,5% de mulheres e a idade média foi de 48,9 ± 13,9 anos. As taxas de sobrevida livre de eventos aos 1, 3, 5, 7 e 9 anos foram de 93,0 ± 2,8%; 86,0 ± 3,9%; 81,0 ± 4,4%; 70,6 ± 5,6% e 68,4 ± 5,8%, respetivamente. As taxas de sobrevida sem reintervenção mitral aos 1, 3, 5, 7 e 9 anos foram de 98,8 ± 1,2%; 97,5 ± 1,7%; 92,1 ± 3,1%; 85,5 ± 4,5% e 85,5 ± 4,5%, respectivamente. O tempo mediano até à reintervenção mitral foi de 6,2 anos. Os doentes que necessitaram de reintervenção mitral durante o seguimento clínico eram mais novos (43,3 vs. 51,2 anos, p = 0,04), tinham gradientes transmitrais pré e pós-PMV mais elevados (14,9 vs. 11,5 mmHg, p = 0,02 e 6,4 vs. 2,1 mmHg, p < 0,001) e uma pressão média na artéria pulmonar (mPAP) pós-PMV mais elevada (30,0 vs. 23,2 mmHg, p = 0,01). No modelo de regressão logística de Cox a mPAP ≥ 25 mmHg foi o único preditor de reintervenção mitral (HR 5,639 [1,2-25,5], p = 0,025) e de eventos clínicos (HR 3,6 [1,1-12,3], p = 0,039).
Na população estudada, a mPAP medida imediatamente após a valvuloplastia mitral foi o único preditor de reintervenção mitral. Os resultados deste estudo podem contribuir para a identificação dos doentes que beneficiam de um seguimento pós-PMV mais frequente.
Percutaneous Mitral Balloon Valvuloplasty for Patients with Rheumatic Mitral Stenosis
2012, Interventional Cardiology Clinics
Citation Excerpt :
More than 90% of young patients with pliable valves, in sinus rhythm and with no evidence of calcium under fluoroscopy, remain free of cardiovascular events at an approximately follow-up of 5 years.21,23,40 Functional deterioration at follow-up is late and related primarily to mitral restenosis.23,40 The incidence of restenosis, as assessed by sequential echocardiography, is approximately 40% after 7 years.25

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Long-term (9 to 33 months) echocardiographic follow-up after successful percutaneous mitral commissurotomy

Abstract

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

Percutaneous balloon mitral valvotomy for patients with severe mitral stenosis

Circulation

Percutaneous catheter commissurotomy in rheumatic mitral stenosis

N Engl J Med

Assessment of left to right atrial shunting after percutaneous mitral valvuloplasty by transesophageal color Doppler flow mapping

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Left-to-right atrial shunting after percutaneous mitral valvuloplasty

Circulation

Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves and central circulatory shunts

Am Heart J

Noninvasive assessment of pressure half time by Doppler ultrasound

Circulation

Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation

Br Heart J