Percutaneous transvenous mitral commissurotomy for restenosis after surgical mitral valvotomy

Percutaneous transvenous mitral commissurotomy (PTMC) was performed in 350 patients. Of these patients, 51 (15%) (30 women and 21 men, aged 32 ± 11 years) had restenosis 11 ± 4 years following surgical valvotomy. Forty (79%) patients were in New York Heart Association (NYHA) class III and 11 (21 %) were in class IV. PTMC resulted in an increase in mitral valve area from 0.82 ± 0.3 to 1.9 ± 0.2 cm² (p < 0.001), an increase in cardiac index from 1.9 ± 0.4 to 2.8 ± 0.51/min/m² (p < 0.001), and a decrease in mean transmitral gradients from 29 ± 4 to 6 ± 4 mmHg (p < 0.001). The results did not differ from those observed in 299 patients without prior surgical valvotomy. On univariate analysis, the subvalvular fibrosis, assessed angiographically, and the duration from prior surgery were not found to influence the overall outcome. At 24 weeks, 46 of 48 (96%) patients in whom clinical follow-up was available, were found to be in NYHA class I and 2 (4%) patients were in class II. Thus, PTMC is a safe and effective procedure for patients with mitral restenosis following surgical valvotomy.     

N-terminal-pro-brain natriuretic peptide,a surrogate biomarker of combined clinical and hemodynamic outcomes following percutaneous transvenous mitral commissurotomy

Aim

To examine the relationship between plasma levels of N-terminal-proB type natriuretic peptide (NT-proBNP) and various echocardiographic and hemodynamic parameters in patients with mitral stenosis undergoing percutaneous transvenous mitral commissurotomy (PTMC).

Materials and methods

The study population consisted of 100 patients with rheumatic mitral stenosis who underwent PTMC. NT-proBNP levels in these patients were measured before PTMC and 48 hours after PTMC. These levels were then correlated with various echocardiographic and hemodynamic parameters measured before and after PTMC.

Results

Eighty-one percent of the study population were women, and the most common presenting symptom was dyspnea which was present in 94% of the patients. Dyspnea New York Heart Association class correlated significantly with baseline NT-proBNP levels (r = 0.63; p < 0.01). The plasma NT-proBNP levels in these patients increased as echocardiogram signs of left atrial enlargement and right ventricular hypertrophy developed (r = 0.59, p < 0.01). Patients in atrial fibrillation had significantly higher NT-proBNP levels than patients in sinus rhythm. Baseline NT-proBNP levels correlated significantly with left atrial volume (r = 0.38; p < 0.01), left atrial volume index (r = 0.45; p < 0.01), systolic pulmonary artery pressures (r = 0.42; p < 0.01), and mean pulmonary artery pressures (r = 0.41; p < 0.01). All patients who underwent successful PTMC showed a significant decrease in NT-proBNP (decreased from a mean 763.8 pg/mL to 348.6 pg/mL) along with a significant improvement in all echocardiographic and hemodynamic parameters (p < 0.01). The percent change in NT-proBNP correlated significantly with the percent improvement noted with left atrial volume (r = 0.39; p < 0.01), left atrial volume index (r = 0.41; p < 0.01), systolic (r = 0.32, p < 0.01), and mean pulmonary artery pressures (r = 0.31, p < 0.01).

Conclusions

The decrease in NT-proBNP levels following PTMC reflects an improvement in clinical and hemodynamic status; hence, it is reasonable to suggest that NT-proBNP is helpful in evaluating the response to PTMC.     

重度二尖瓣狭窄球囊分离术42例分析

目的 探索重度二尖瓣狭窄球囊分离术治疗的新方法.方法 房间隔穿刺点定位,采用吞钡食管左心房压迹定位法,以压迹上下缘的中下1/4水平线为房间隔穿刺高度,与脊柱中右1/4垂线的交点为房间隔穿刺点,穿刺成功率100%.穿刺成功后于右前斜位25°下行直接左心房造影,根据二尖瓣口位置调整二尖瓣探条(stylet),引导Inoue球囊过二尖瓣口,必要时在超声心动图指导下进左心室,选用直径23～28mm球囊扩张.结果 全部患者均成功,跨二尖瓣压差自18～51(34±11)mmHg降至4～9(7±3)mmHg(t=2.623,P<0.01).左心房平均压自20～60(38±13)mmHg,降至6～13(8±3)mmHg,二尖瓣听诊区雷鸣样舒张期杂音明显减轻或消失,效果显著(t=2.714,P<0.01).结论 对于风湿性心脏病重度二尖瓣狭窄,食管左心房压迹定房间隔穿刺点,安全而方便.右前斜位25°下,直接左心房造影显示二尖瓣口,指导Inoue球囊导管进左心室成功率高.     

Influence of intraballoon pressure on development of severe mitral regurgitation after percutaneous transvenous mitral commissurotomy

To evaluate the influence of intra-balloon pressure on the development of severe mitral regurgitation (≥grade 3 + ), we measured intraballoon pressure during percutaneous transvenous mitral commissurotomy (PTMC) in 62 patients using the Inoue balloon catheter. The peak intraballoon pressure was 2.29 ± 0.55 kg/cm². Severe mitral regurgitation as a result of leaflet tear occurred in 7 patients (11%). Patients were divided into two groups those with (n = 7) and those without (n = 55) severe mitral regurgitation. Intraballoon pressure had been significantly higher in those with vs. those without severe mitral regurgitation (2.76 ± 0.31 kg/cm² vs. 2.23 ± 0.55 kg/cm², P < 0.01). Multiple logistic regression analysis revealed that the occurrence of severe mitral regurgitation was related to only the peak intraballoon pressure. These data suggest that a high intraballoon pressure is a risk factor for severe mitral regurgitation as a result of leaflet tear.     

二尖瓣球囊扩张术和机械分离术的临床评价

目的探讨二尖瓣球囊扩张术和机械扩张术治疗二尖瓣狭窄的特点和治疗效果。方法2001年2月～2002年8月,采用二尖瓣球囊扩张术(percutaneous balloon mitral valvuloplasty,PBMV)治疗二尖瓣狭窄52例,评分(7±1);采用机械扩张术(percutaneous mechanical mitral commissurotomy,PMMC)治疗二尖瓣狭窄36例,评分(10±2)。对术后24h、1年的心脏超声检查随访结果进行对比分析。结果PBMV成功率94%(49/52);PMMC成功率92%(33/36)。PBMV后二尖瓣面积(mitral valve area,MVA)(1.7±0.2)cm2,PMMC后MVA(2.1±0.5)cm2,差异有统计学意义(P<0.01)。心包填塞并发症:PBMV发生率5.7%;PMMC5.5%。PBMV和PMMC增加二尖瓣反流面积大于3cm2例数分别占14%(7/52)和10%(3/33),差异有统计学意义(P<0.01)。术后1年,PBMV组需外科换瓣手术3例,PMMC组无手术换瓣病例。结论PBMV和PMMC都是治疗二尖瓣狭窄有效的方法,P...     

Percutaneous transvenous mitral commissurotomy versus surgical commissurotomy in the treatment of mitral stenosis

There is no doubt that percutaneous transvenous mitral commissurotomy (PTMC) in experienced centers is associated with a low risk of major complications and yields excellent immediate and long-term outcome. Although previous observational studies on both PTMC and surgical commissurotomy have indicated similar outcome between the two treatment strategies in terms of valve area improvement and risk of major complication (death, thromboembolism and significant resultant mitral regurgitation), it was not until recently that several prospective randomized trials comparing the two procedures and involving >470 patients with favorable valve characteristics (pliable, noncalcified valve with mild sub-valvular disease and no or mild mitral regurgitation), have confirmed that PTMC is indeed just as, if not more, effective as surgical commissurotomy. The late restenosis rate at up to 3-year follow-up appears comparable. Furthermore, PTMC has other additional benefits. It is nontraumatic, may be repeated without additional risk, and has been shown to be an extremely useful and efficacious palliative tool in those with end-stage mitral stenosis or with unfavorable valve anatomy who refuse surgery, and in certain subset of patients at high surgical risk because of medical comorbidities.     

Plasma noradrenaline as an indicator of functional state in hearts with mitral stenosis: The influence of acutely reduced left atrial pressure by balloon mitral commissurotomy

Summary To investigate the mechanism in which plasma noradrenaline concentration (pNA) is elevated in heart failure, the effect of balloon mitral valvulo-plasty was used as a model of acute manipulation of the left atrial pressure reduction in ten patients with mitral stenosis. Gorlin mitral valve area and pNA were correlated with New York Heart Association functional class and found to have a significant exponential inverse relationship with each other ([pNA, pg/ml] = 198.9 × [mitral valve area, cm²]^–0.696;P = 0.003). Elevated pNA could be partially explained by a reduced cardiac index (CI) ([pNA, pg/ml] = 403.4 × [CI, l/min/m²]^–0.889;P = 0.027;r = 0.495), especially in severely failed hearts, but not by pulmonary capillary wedge pressure (PCWP). However, the percent changes (%) of variables early after balloon valvulo-plasty exhibited aparadoxical contrast; % pNA showing a clear negative exponential correlation with % PCWP ([% pNA] = 436.0 × [% PCWP + 80]^–0.679 – 80;P = 0.021), but not with % CI. These results suggest that pNA should be considered an indicator of cardiac functional class in mitral stenosis. PNA is modulated by both cardiac index and pulmonary capillary pressure, but in different ways.     

Intermediate-term results of percutaneous transvenous mitral commissurotomy in children less than 12 years of age.

The objectives of this study were to review the efficacy of percutaneous transvenous mitral commissurotomy (PTMC) in young children less than 12 years of age and to provide intermediate-term follow-up data. There is a paucity of information regarding the long-term efficacy of PTMC done in children less than 12 years of age. The data of 100 consecutive children less than 12 years of age (mean, 11.1 +/- 1.2 years) who underwent PTMC using Inoue balloon were analyzed retrospectively. Serial clinical and echocardiographic follow-up information of more than 6 months was available in 94 patients. The procedure was successful in 94 patients. The mean calculated mitral valve area (MVA) increased from 0.72 0.14 to 1.7 0.35 cm(2) (P 0.0001). Echocardiographic restenosis (MVA < or = 1 cm(2) or > 50% gain loss) occurred in 14 of 94 patients (16%) over a mean follow-up of 34.4 25.9 (range, 2-115) months. The improvement in New York Heart Association (NYHA) functional class was maintained in most patients (from a mean of 2.87 0.5 pre-PTMC to 1.42 0.6 at follow-up). Seven out of 14 patients with restenosis underwent a re-PTMC. The actuarial rate of good functional status (survival, no repeat interventions, and NYHA class 1 or 2) at 100 months was 75.4% 8.7%. PTMC provides excellent intermediate-term palliation even in young children with rheumatic mitral stenosis.     

Percutaneous balloon mitral valvuloplasty in patients with mitral restenosis after previous surgical commissurotomy: A matched comparative study

Background Although the efficacy of percutaneous balloon mitralvalvuloplasty in patients with unoperated mitral stenosis hasbeen well documented, there exists less clear-cut data on itseffectiveness in patients with mitral restenosis after previoussurgical commissurotomy. Accordingly, the purpose of this studywas to evaluate our immediate and midterm results of balloonmitral valvuloplasty in this subset of patients with previousmitral surgery. Methods Between October 1991 and August 1995, 29 consecutivepatients with mitral restenosis after prior surgical commissurotomy(group 1) underwent Inoue balloon mitral valvuloplasty. Theywere matched on a patient-to-patient basis with regards to baselinemitral echocardiographic score, mitral valve area, seventy ofangiographic mitral regurgitation and follow-up duration with29 other patients with unoperated mitral stenosis (group 2)who underwent balloon mitral valvuloplasty during the same studyperiod. Results Balloon mitral valvuloplasty yielded identical improvementsin transmitral gradient and mitral valve area (from 0.8 to 1.6cm² determined echocardiographically, and similar changes inthe severity of mitral regurgitation in both groups of patients.All procedures were successfully completed without major cardiaccomplications. Follow-up echocardiographic assessment in 73%of patients revealed equal mitral valve area (1.6 cm²) and arestenosis rate of 17%, with no difference in the restenosisrate between the two groups. Conclusion Balloon mitral valvuloplasty in selected patientswith mitral restenosis after past surgical commissurotomy canbe performed safely and with similar immediate and midterm efficacyas in patients with de novo mitral stenosis.     

Urgent/Emergent percutaneous transvenous mitral commissurotomy

Urgent/emergent percutaneous transvenous mitral commissurotomy (PTMC) was performed in 10 patients (two men and eight women, aged 21 to 60 yr). All patients had arterial hypoxemia and four required mechanical respirators. PTMC was performed in the semi-recumbent position in four patients. The seven patients with pliable valves (group 1) achieved good hemodynamic and echocardiographic results after PTMC, but one died 2 wk later because of sepsis complicating preexisting pneumonitis. The two pregnant patients uneventfully delivered normal babies at term. There was continued clinical improvement in the six surviving patients at last follow-up at 11 to 39 mon (median 26). Of the three patients with calcified valves and severe subvalvular lesions (group 2), the premoribund patient in whom last-resort PTMC created severe mitral regurgitation died 3 days later of multiple organ failure. The other two patients underwent mitral valve replacement 1–6 days later because of lack of clinical improvement due to creation of severe mitral regurgitation and ineffective mitral valve dilation, respectively. In conclusion, urgent/emergent PTMC is feasible and safe. However, its outcomes are dictated by the status of diseased mitral valve and coexisting illness.     

Unsuccessful deflation of a bifoil balloon during percutaneous mitral valvuloplasty

A middle-aged woman was subjected to balloon mitral valvuloplasty using a bifoil balloon catheter. After inflation the balloon failed to deflate inspite of negative suction, probably due to a kink. The balloon was perforated with a transseptal puncture needle in order to deflate it and save open heart surgery. © 1996 Wiley-Liss, Inc.     

Successful percutaneous mitral balloon commissurotomy in a patient with a previous mitral valve repair

A case of successful percutaneous mitral balloon commissurotomy (PMBC) in a patient who had undergone mitral valve repair with a Carpentier ring 6 years earlier is described. © 1993 Wiley-Liss, Inc.     

再次经皮球囊二尖瓣成形术治疗成形术后再狭窄的疗效观察

目的　评价再次经皮球囊二尖瓣成形术 (PBMV)治疗二尖瓣狭窄PBMV术后再狭窄的临床疗效。方法　采用Inoue法对 2 9例PBMV术后再狭窄患者进行再次PBMV ,并与 2 5 8例首次接受PBMV的患者进行疗效比较。结果　再次PBMV后二尖瓣口面积由 ( 0 98± 0 13)cm2 增至 ( 1 6 5±0 2 4)cm2 (P <0 0 0 1) ,二尖瓣跨瓣压差由 ( 2 6 5± 1 44 )kPa( 1kPa =7 5mmHg)降至 ( 0 79± 0 2 3)kPa(P<0 0 0 1) ,左房平均压由 ( 3 37± 0 6 2 )kPa降至 ( 1 6 6± 0 93)kPa(P <0 0 0 1) ,左房内径由 ( 4 5 2± 0 5 7)cm降至 ( 4 17± 0 5 0 )cm(P <0 0 5 )。再次PBMV组二尖瓣口面积增加值与左房平均压下降值小于首次PBMV组 [分别为 ( 0 6 7± 0 11)cm2 vs( 0 88± 0 32 )cm2 (P <0 0 5 )与 ( 1 71± 0 88)kPavs( 1 94± 0 5 6 )kPa(P <0 0 5 ) ]。再次PBMV组无心包填塞、死亡发生 ,主要并发症为重度二尖瓣反流 2例。结论只要选择合适病例 ,再次PBMV术仍可取得显著的即刻血流动力学改善 ,是PBMV术后再狭窄患者的一种安全而有效的治疗方法。     

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.     

Transvenous mitral commissurotomy examined with transesophageal echocardiography

Summary Transvenous mitral commissurotomy (TMC) was conducted with transesophageal echocardiography (TEE) in two patients with mitral stenosis. It was possible to see clearly not only the intracardiac structures to be examined by TMC, such as the right and left atria, interatrial septum, and mitral valve, but also the instruments used in TMC, such as the catheter, guidewire, and balloon. It was possible to determine the positional relation between the intracardiac structures and instruments. We could observe all procedures other than Brockenbrough's procedure by both TEE and fluoroscopy at the same time. Although safety and reliability cannot be confirmed from just the two present cases, TEE appears to be applicable to TMC.     

A simple balloon-sizing method in Inoue-balloon percutaneous transvenous mitral commissurotomy

This study was carried out to examine whether the previously determined balloon sizing method based on patient height was valid for percutaneous transvenous mitral commissurotomy using the current second-generation Inoue balloon catheter. The study consisted of 70 patients with pliable noncalcified mitral valves (group 1) and 85 patients with calcified mitral valves and/or severe subvalvular lesions (group 2). The mitral valve area was increased more in group 1 than in group 2 (1.0 ± 0.3 to 1.9 ± 0.5 cm² versus 1.0 ± 0.3 to 1.6 ± 0.5 cm², P = 0.002). Using the stepwise dilatation technique, none of the group 1 patients developed severe mitral regurgitation. Severe mitral regurgitation occurred in 4 patients (4.7%) in group 2. In conclusion, a simple balloon sizing method based on body height for selection of an appropriate-sized balloon catheter, as well as an initial inflated balloon diameter for the stepwise dilatation technique is useful for optimal acute outcomes in mitral commissurotomy. © Wiley-Liss, Inc.     

Specifics of technique in percutaneous mitral commissurotomy in a case of dextrocardia and situs inversus with mitral stenosis

Percutaneous mitral commissurotomy (PMC) was successfully performed in a 48-year-old woman with dextrocardia and situs inversus and a severe mitral stenosis. After PMC, the valve area increased from 0.97 to 1.89 cm², and no complication occurred. This case shows that PMC is practicable in a case of dextrocardia with situs inversus. The procedure appears to be safer and easier when carried out with the Inoue balloon, image inversion on the screen, and under transesophageal echocardiographic monitoring. © 1996 Wiley-Liss, Inc.     

Immediate and mid-term results of repeat percutaneous mitral commissurotomy for restenosis following earlier percutaneous mitral commissurotomy.

AIMS: This study assessed the results of repeat percutaneous mitral commissurotomy for mitral restenosis following a first procedure. METHODS AND RESULTS: Repeat balloon commissurotomy was performed in 53 patients who had symptomatic restenosis a mean of 6+/-2 years (2-11) after a successful first procedure; seven patients had mildly calcified valves. All patients had restenosis with a fusion of both commissures as assessed by echocardiography. A double-balloon was used in one case and the Inoue technique in 52. Complications were stroke in one patient and severe mitral regurgitation (Sellers grade 3) in two. Valve area increased from 1.03+/-0.22 to 1.82+/-0.21 cm(2)(P<0.0001) as assessed by planimetry. Good immediate results, defined as valve area >/=1.5 cm(2)with no regurgitation >2/4, were obtained in 48 patients (91%). The 5-year survival rate without operation and in NYHA class I or II was 69+/-11% in the whole population, and 76+/-11% in the 48 patients who had had good immediate results. CONCLUSION: This study suggests that repeat balloon commissurotomy is a valid treatment for symptomatic restenosis after a first successful procedure. It gives good results in patients selected on the basis of favourable characteristics and the echocardiographic analysis of the mechanism of restenosis.     

Intra-arterial thrombolysis for left middle cerebral artery embolic stroke during percutaneous mitral commissurotomy.

Cerebral thromboembolism is a serious complication. Early recognition and rapid reperfusion can prevent long-term neurological morbidity. We report a case of successful intra-arterial thrombolysis for middle cerebral artery embolic stroke during percutaneous mitral commissurotomy, which resulted in complete neurological recovery.