Balloon mitral commissurotomy for mitral restenosis after surgical commissurotomy

doi:10.1016/0002-9149(93)90546-O

The American Journal of Cardiology

Volume 71, Issue 15, 1 June 1993, Pages 1311-1315

https://doi.org/10.1016/0002-9149(93)90546-O Get rights and content

Abstract

Balloon mitral commissurotomy (BMC) was performed in 113 patients. Of these patients, 27 (24%) (25 women and 2 men, aged 49 ± 13 years) had recurrent mitral stenosis 13 ± 6 years (range 5 to 29) after surgical Commissurotomy. Eleven patients (41%) were considered at high risk for surgery. BMC resulted in an increase in mitral valve area from 1.1 ± 0.3 to 1.9 ± 0.7 cm² (p < 0.0001), and a decrease in mean mitral gradient from 16 ± 7 to 6 ± 3 mm Hg (p < 0.0001). An optimal result of BMC (increase in valve area ≥25% with a post-BMC valve area ≥1.5 cm²) was obtained in 18 patients (67%). The results did not differ from those observed in the 86 patients of our entire series without prior surgical Commissurotomy. Patients with an optimal result of BMC had a more recent surgical Commissurotomy and lesser morphologic alterations of the mitral valve than did those with a nonoptimal result. Patients with echocardiographic scores <10 had an 80% success rate of BMC; however, this rate decreased to 29% for those with scores ≥10. One patient (4%) died from a cerebrovascular accident. Clinical follow-up at 1 year showed persistent clinical improvement in 89% of patients with an optimal result of BMC; 72% were in New York Heart Association class I and 17% in class II. Thus, BMC is a safe and effective short- and long-term procedure for patients with mitral restenosis after surgical commissurotomy; because of its percutaneous approach, avoiding the risks associated with a second thoracotomy, BMC can be considered the treatment of choice in these patients.

References (24)

JR Belcher
Restenosis of the mitral valve. An account of fifty second operations
Lancet
(1960)
A Logan et al.
Reoperation for mitral stenosis
Lancet
(1962)
S John et al.
Restenosis of the mitral valve: surgical considerations and results of operation
Ann Thorac Surg
(1978)
A Vahanian et al.
Results of percutaneous mitral commissurotomy in 200 patients
Am J Cardiol
(1989)
RD Sellers et al.
Left retrograde cardioangiography in acquired cardiac disease. Technic, indications, and interpretations in 700 cases
Am J Cardiol
(1964)
LM Higgs et al.
Mitral restenosis: an uncommon cause of recurrent symptoms following mitral commissurotomy
Am J Cardiol
(1970)
DE Rediker et al.
Mitral balloon valvuloplasty for mitral restenosis after surgical commissurotomy
J Am Coll Cardiol
(1988)
TA Salerno et al.
A 25-year experience with the closed method of treatment in 139 patients with mitral stenosis
Ann Thorac Surg
(1981)
DS Mary et al.
Analysis of risk factors involves in reoperation for mitral and Bicuspid valve disease
J Thorac Cardiovasc Surg
(1974)
JJ Heger et al.
Long-term changes in mitral valve area after successful mitral commissurotomy
Circulation
(1979)

WA Peper et al.

Repeat mitral commissurotomy: long-term results

Circulation

(1987)

I Palacios et al.

Percutaneous balloon valvotomy for patients with severe mitral stenosis

Circulation

(1987)

Cited by (27)

Mitral balloon valvuloplasty
2010, Journal of the Saudi Heart Association
Percutaneous mitral balloon valvuloplasty (MBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, MBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of MBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0–0.5%), cerebral accident (1–2%), mitral regurgitation (MR) requiring surgery (1.6–3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with MBV and surgical commissurotomy. Restenosis after MBV ranges from 4% to 70% depending on the patient selection, valve morphology, and duration of follow-up. Restenosis was encountered in 31% of the author’s series at mean follow-up 9 ± 5.2 years (range 1.5–19 years) and the 10, 15, and 19 years restenosis-free survival rates were (78 ± 2%) (52 ± 3%) and (26 ± 4%), respectively, and were significantly higher for patients with favorable mitral morphology (MES ⩽ 8) at 88 ± 2%, 67 ± 4% and 40 ± 6%), respectively (P < 0.0001). The 10, 15, and 19 years event-free survival rates were (88 ± 2%, 60 ± 4% and 28 ± 7%, respectively, and were significantly higher for patients with favorable mitral morphology (92 ± 2%, 70 ± 4% and 42 ± 7%, respectively (P < 0.0001). The effect of MBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of MBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.
Immediate and long-term results of mitral balloon valvotomy for restenosis following previous surgical or balloon mitral commissurotomy
2005, American Journal of Cardiology
Citation Excerpt :
Long-term outcome after this procedure can be predicted from patient and valvular characteristics. Pericardial tamponade, cerebral embolization, and significant MR are recognized complications of MBV; the rate of these complications in the 2 groups was not significantly different and was lower in our series than in those of reports by other investigators.3,4,7,8,17 The immediate outcome of MBV in patients who had restenosis was satisfactory, with a 93% success rate compared with 96% in patients who underwent MBV as an initial procedure (p = NS).
This study compared immediate with long-term results of mitral balloon valvotomy (MBV) in patients who underwent MBV as an initial procedure versus those who underwent repeat MBV. Fifty-six patients who were a mean age of 28 ± 8.8 years (group A) and had mitral restenosis after surgical or balloon commissurotomy underwent MBV and were compared with 524 patients who were a mean age of 31 ± 11 years (group B) and underwent MBV as an initial procedure. Prospective data obtained included demographic, hemodynamic, echocardiographic, and clinical follow-up for 0.5 to 15 years after MBV. No deaths or technical failure were encountered after MBV. Mitral regurgitation >2/4 occurred in 1 patient (2%) in group A and in 9 patients (2%) in group B (p = 0.24). Fifty-two of 56 patients (93%) in group A had good immediate results (mitral valve area ≥1.5 cm², mitral regurgitation <2/4), as did 504 of 524 patients (96%) in group B (p = 0.4). Actuarial values for freedom from restenosis at 10 years were 58 ± 7% for group A versus 69 ± 3% for group B (p = 0.18). Ten-year event-free survival rate was 54 ± 7% for group A versus 80 ± 3% for group B (p <0.005). The predictors of event-free survival were age (p = 0.003), echocardiographic score (p <0.0001), and baseline atrial fibrillation (p = 0.01). In conclusion, MBV is safe and provides good immediate results in patients who have restenosis. Long-term results are inferior compared with de novo mitral stenosis but is still satisfactory. More than 50% of patients remained improved at 10 years, thus enabling the operation or reoperation to be deferred.
Effectiveness of percutaneous mechanical mitral commissurotomy using the metallic commissurotome in patients with restenosis after balloon or previous surgical commissurotomy
2003, American Journal of Cardiology
Citation Excerpt :
PMMC in patients who had prior commissurotomy was not associated in this series with an increased complication rate, which was comparably low in the 2 groups. In previous series, severe complication rates, including death, tamponade, and severe mitral regurgitation varied between 7% and 10% of patients who underwent balloon valvotomy for restenosis.10–16 Characteristics of our patients who had previous commissurotomy were less favorable because of older age, more frequent atrial fibrillation, more distorted valves, and echographic scores that were significantly higher.
Balloon mitral valvuloplasty has been reported to give equal or less positive results after previous commissurotomy than after a first procedure. Percutaneous mechanical mitral commissurotomy (PMMC) is a new technique that has not yet been evaluated in this subset of patients. Of 1,175 PMMC procedures (1,175 patients), 173 patients (14.7%) had previous commissurotomy; patients were older (40 vs 35 years of age, p <0.0001) and more often in atrial fibrillation (34% vs 21%, p = 0.0016) than were patients who had not undergone previous commissurotomy. The baseline transmitral gradient was lower (17 ± 8 vs 19 ± 8 mm Hg, p <0.002) and the echocardiographic Wilkins score was higher (8.7 ± 1.9 vs 7.6 ± 1.8, p <0.0001) for patients who underwent previous commissurotomy. Baseline mitral valve area was comparable between the 2 groups (0.96 ± 0.21 vs 0.93 ± 0.24 cm²). Immediate results were satisfactory, although slightly less favorable after previous commissurotomy, with a final mitral valve area of 2.01 ± 0.30 versus 2.12 ± 0.36 cm² (p <0.0001), and a residual transvalvular gradient of 5.0 ± 3.6 versus 4.2 ± 4.1 mm Hg (p = 0.003). The rates of procedural success (93%) and severe complications (4.7%) were comparable between the 2 groups. Thus, PMMC is an effective and safe technique for the treatment of mitral restenosis after previous commissurotomy.
Percutaneous mitral commissurotomy for restenosis after surgical commissurotomy
2000, Journal of the American College of Cardiology
Citation Excerpt :
The frequency of severe traumatic mitral regurgitation was 4% in the present series, which is close to the 3.4% observed in our global experience of PMC (3). Series of PMC generally do not report higher rates of severe mitral regurgitation in patients with prior commissurotomy as compared with first procedure (7–13). The composite end point of good immediate results used in this study associates a mitral valve area ≥1.5 cm2 and no regurgitation >2/4, such conditions generally providing normal hemodynamics (3,14,24).
OBJECTIVES
The results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy.
BACKGROUND
Balloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy.
METHODS
We studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 ± 8 years after surgical commissurotomy. Mean age was 47 ± 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121.
RESULTS
Complications were death in 1 patient (0.4%) and mitral regurgitation >2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve area ≥1.5 cm² without regurgitation >2/4). Predictors of poor immediate results in multivariate analysis were older age (p < 0.001), lower initial valve area (p = 0.01) and the use of the double-balloon technique (p = 0.015). In the 175 patients who underwent follow-up, 8-year survival without operation and in New York Heart Association class I or II was 48 ± 5%, and 58 ± 6% after good immediate results. In this latter group, poor late functional results were predicted by higher cardiothoracic index (p < 0.0001), previous open-heart commissurotomy (p = 0.05) and lower final valve area (p < 0.0001) in a multivariate Cox model.
CONCLUSIONS
Percutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.
Percutaneous balloon mitral valvuloplasty
1997, Progress in Cardiovascular Diseases
Percutaneous balloon mitral valvuloplasty, first performed by Inoue in 1982, was a rational progression from 4 decades of experience with the blunt surgical dilatation technique of closed mitral commissurotomy. As with surgical commissurotomy, balloon valvuloplasty relieves mitral stenosis by the splitting of fused commissures. A series of studies have shown that balloon valvuloplasty achieves excellent acute hemodynamic results in close to 90% of patients, with a typical 100% increase in mitral valve area. Over the past 15 years since Inoue's first patient, a number of other techniques have been introduced and largely discarded in favor of the original approach. Advances have occurred along the lines of improved noninvasive assessment of mitral valve disease, which have allowed better case selection and prediction of outcome. Follow-up series have shown sustained improvement, with modest rates of complications and restenosis. Comparative studies have shown that balloon valvuloplasty is as effective and safe as surgical commissurotomy, and is a cost-effective procedure of first choice in ideal patients.
Balloon mitral commissurotomy in patients with previous annuloplasty. Our experience
1995, International Journal of Cardiology
Balloon mitral commissurotomy is an alternative to surgical commissurotomy in the treatment of mitral stenosis and different studies have shown its usefulness for restenosis following surgical commissurotomy. We describe our experience in balloon mitral commissurotomy in five patients with previous commissurotomy and annuloplasty. Among 360 balloon commissurotomies performed in our hospital up to December 1993, 29 procedures were performed on patients with restenosis after surgical commissurotomy, five of whom also had an annuloplasty (flexible ring in four and rigid in one). The balloon commissurotomy was performed without complications using the Inoue single balloon technique. Mitral valve area increased from 0.9 ± 0.1 cm² to 1.0 ± 0.1 cm² by pressure half-time, and from 1.0 ± 0.2 cm² to 1.3 ± 0.1 cm² by Gorlin formula. Two patients in functional class III underwent mitral valve replacement, 32 and 11 months later; the other three patients were in class II 38, 10 and 7 months later. The presence of a mitral ring should not constitute a contraindication to balloon commissurotomy. However, the haemodynamic results are not favourable in our patients, probably due to the practical absence of commissural fusion and the ring's restrictive effect on valvular stretching.

View all citing articles on Scopus

View full text

Balloon mitral commissurotomy for mitral restenosis after surgical commissurotomy

Abstract

Lancet

Lancet

Ann Thorac Surg

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Long-term changes in mitral valve area after successful mitral commissurotomy

Circulation

Repeat mitral commissurotomy: long-term results

Circulation

Percutaneous balloon valvotomy for patients with severe mitral stenosis

Circulation