Percutaneous mitral valvuloplasty

Thirty six adults with severe mitral stenosis underwent attempted percutaneous mitral commissurotomy. The valvuloplasty could not be performed in 6 cases; post-transseptal haemopericardium (1 case), inability to cross the mitral valve or the septum (5 cases). Therefore percutaneous commissurotomy was performed in 30 cases; the average age was 43 +/- 17 years (range 20-79 years). Eight patients had undergone previous valve surgery; 24 patients were very symptomatic (NYHA Classes III or IV). The valvuloplasty was performed with a single balloon in 22 cases and by simultaneous inflation of two balloons in 8 cases. Moderate mitral regurgitation present before the procedure was significantly aggravated in 2 cases leading to secondary surgery. In the other patients percutaneous commissurotomy led to a clear-cut haemodynamic improvement; the transvalvular pressure gradient fell from 15 +/- 4 to 6 +/- 2 mm Hg, p less than 0.01 and mitral valve surface area increased from 1.1 +/- 0.2 to 2.2 +/- 0.4 cm2, p less than .001. The best results were obtained with the double balloon technique in patients with little valve destruction. Percutaneous mitral valvuloplasty is therefore a tempting alternative to closed heart mitral commissurotomy in pure mitral stenosis with pliable valves. Larger series with a longer follow-up are needed to assess the morbidity and long-term results of this technique.     

Balloon mitral valvuloplasty: clinical experience at the Texas Heart Institute

For treatment of symptomatic mitral valve stenosis, balloon valvuloplasty has emerged as an alternative to surgery. This report describes our initial clinical experience with balloon mitral valvuloplasty in 45 patients (37 women and 8 men; age range, 34 to 79 years) treated from December 1986 through March 1991. Thirty-nine of the 45 patients (87%) underwent a complete procedure (that is, they had at least 1 balloon inflation and did not require emergency surgery). Pre- and post-procedural catheterization showed that these patients had a significant improvement in mean mitral valve area, from 1.0 +/- 0.3 cm(2) to 1.9+/-0.8 cm(2). Catheterization data revealed a decrease in transmitral gradient, from 16.3 +/- 7.6 mmHg to 7.6 +/- 3.7 mmHg, and an increase in cardiac index, from 2.5 +/- 0.7 L/min/m(2) to 2.9 +/- 0.8 L/min/m(2). These improvements were all statistically significant (p <0.0005). A clinically successful balloon mitral valvuloplasty was defined as an uncomplicated procedure yielding either a final mitral valve area > 1.5 cm(2) or a 40% increase in mitral valve area, and an immediate post-valvuloplasty mitral regurgitation grade 2+ increase in mitral regurgitation (4 patients). In 6 patients, the procedure was considered incomplete because of technical failure or complications. Two of these patients had nonfatal cardiac tamponade, and 1 had a torn mitral annulus that resulted in severe mitral regurgitation requiring emergent mitral valve replacement. In another patient, we were unable to cross the mitral valve with a 2nd valvuloplasty balloon after the 1st one proved unsatisfactory. There were 2 in-hospital deaths, only 1 of which was related to the procedure. Over time, our success rate has improved from 60% in the 1st 20 patients to 80% in the subsequent 25 patients, reflecting a learning curve. In particular, we attribute this improvement to increased operator experience, refinements in balloon technology, and, in more recent procedures, the initial use of smaller balloons. The improvement also reflects a change in demographic pattern, characterized by recent application of the procedure to younger patients with fewer concomitant illnesses. Because long-term follow-up data are available for only 23 patients, we cannot comment on the long-term efficacy of this technique. Overall, however, our short-term experience indicates that balloon mitral valvuloplasty is a safe, effective alternative for treating symptomatic mitral valve stenosis in carefully selected adults.     

Mitral regurgitation after percutaneous balloon mitral valvuloplasty in adults: evaluation by pulsed Doppler echocardiography

Percutaneous balloon mitral valvuloplasty is a new technique used in the treatment of adult patients with mitral stenosis. To evaluate the occurrence and severity of mitral regurgitation after balloon valvuloplasty, 24 patients (20 women and 4 men, mean age 57 years) were studied using two-dimensional and Doppler echocardiography before and less than 24 h after this procedure. Mitral valve area increased after valvuloplasty in all patients, from 0.89 +/- 0.07 to 1.61 +/- 0.09 cm2 (p less than 0.001). Before valvuloplasty, 10 patients had no mitral regurgitation, 4 had 1+, 4 had 2+ and 6 had 3+ mitral regurgitation. After valvuloplasty, new mitral regurgitation occurred in six patients. Regurgitation grade did not change in 13 patients (54%), increased by one grade in 8 patients (33%) and by two grades in 3 patients (13%). Left atrial volume decreased in all except one patient from 100 +/- 12 to 83 +/- 12 cm3 (p less than 0.001). Neither age, sex, cardiac rhythm, initial mitral valve area, increase in mitral valve area, morphologic characteristics of the valvular and subvalvular apparatus, previous mitral commissurotomy nor effective balloon dilating area discriminated between those patients with and without an increase in mitral regurgitation after valvuloplasty. Thus, mitral balloon valvuloplasty is frequently associated with an increase in mitral regurgitation. However, in this series, no patient developed severe mitral regurgitation, and left atrial volume decreased in nearly all patients. An increase in mitral regurgitation could not be predicted from any features of the valve or subvalvular apparatus, clinical characteristics of the patients or technical aspects of the procedure.     

Mitral balloon valvuloplasty for mitral restenosis after surgical commissurotomy

Mitral balloon valvuloplasty was performed in 14 patients with recurrent mitral stenosis 16.9 +/- 1.8 years (range 6 to 30) after surgical commissurotomy. There were 13 women and 1 man with a mean age of 55 +/- 4 years (range 23 to 73). Mitral balloon valvuloplasty resulted in an increase in mitral valve area from 0.8 +/- 0.1 to 1.7 +/- 0.2 cm2 (p = 0.001), a decrease in mean mitral diastolic pressure gradient from 15 +/- 2 to 7 +/- 1 mm Hg (p = 0.001) and an increase in cardiac output from 3.4 +/- 0.3 to 3.9 +/- 0.3 liters/min (p = 0.03). No deaths, strokes, vascular complications or conduction abnormalities were observed. Mitral regurgitation developed or increased in severity in seven patients (50%). There was no evidence of significant left to right shunt through the atrial septal puncture site after mitral balloon valvuloplasty. A good result (defined as a mitral valve area greater than 1.0 cm2, an increase in mitral valve area greater than 25% and a mean gradient less than 10 mm Hg) was achieved in 9 (64%) of the 14 patients. A subgroup of four patients who had a superior result (increase in mitral valve area of 1.7 +/- 0.2 versus 0.5 +/- 0.1 cm2 in the other 10 patients, p = 0.004) was identified. These patients had less echocardiographic evidence of rheumatic mitral valve damage and were the only patients who had sinus rhythm. They were also younger, less debilitated and had a lower grade of fluoroscopic valve calcification compared with the other patients. Thus, mitral balloon valvuloplasty is a safe and effective procedure for patients with recurrent mitral stenosis after surgical commissurotomy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Combined percutaneous mitral and aortic balloon valvuloplasty

Between August 1987 and November 1988, combined mitral and aortic balloon valvuloplasty was performed in 10 patients (mean age 42 +/- 9 years), all of whom had symptomatic mitral and aortic stenosis. The procedure was performed using a transarterial approach with a multiballoon catheter and an exteriorized intracardiac long guidewire circuit. The procedure could be considered successful in 9 patients where significant increases in the mean mitral (0.97 +/- 0.19 to 1.80 +/- 0.26 cm2) and aortic (0.63 +/- 0.18 to 1.15 +/- 0.32 cm2) areas were achieved. Severe mitral regurgitation that required surgery developed in 1 patient in the following 24 hours. Femoral vascular surgery was necessary in 1 patient. Mid-term follow-up was available in 8 patients for a period averaging 8 +/- 3 months. The 9 patients in whom the procedure was successful showed persistent clinical improvement in functional class, Doppler echocardiography showed 2 cases of aortic restenosis and none of mitral restenosis. Combined mitral and aortic balloon valvuloplasty could be a valid alternative treatment in selected patients with both mitral and aortic rheumatic stenosis. Further experience and long-term hemodynamic follow-up are necessary to define the role of this mode of treatment.     

The predictive value of mitral leaflet motion and thickness index scores on early restenosis after mitral balloon valvuloplasty

The purpose of this study was to investigate whether there is any association between mitral leaflet motion (LMI) and leaflet thickness index (LTI) scores and the rate of restenosis 3 months after successful mitral balloon valvuloplasty. The study population consisted of 46 patients with symptomatic rheumatic mitral stenosis who underwent balloon valvuloplasty (37 women, 9 men; mean age, 36 +/- 9 years). Two-dimensional and Doppler echocardiography were performed in all patients on the day before, immediately after, and 3 months after valvuloplasty. The severity of restriction of leaflet motion and the severity of leaflet thickening were classified into grades of mild (a score of 0), moderate (a score of 1), and severe (a score of 2). Subvalvular disease and commissural involvement were homogeneous in all patients. Before and immediately after mitral balloon valvuloplasty, there were no significant differences in mitral valve area among the groups with different LMI and LTI scores. However, at 3 months after valvuloplasty, reduction in mitral valve area was more significant in patients who had higher pre-procedural LMI and LTI scores (P < 0.05). The rates of early restenosis were 0 with a total score of 0, 14.2% with a total score of 1-2, and 32% with a total score of 3. In conclusion, quantitative assessment of LMI and LTI scores by 2-dimensional echocardiography may be helpful in predicting early restenosis after mitral balloon valvuloplasty. Early reduction in mitral valve area is significant in patients who have higher total LMI and LTI scores.     

Ablation of atrial fibrillation in mitral valve disease patients: five year follow-up after percutaneous pulmonary vein isolation and mitral balloon valvuloplasty.

BACKGROUND: The association between atrial fibrillation (AF) and mitral valve disease is frequent. Isolation of the pulmonary veins by radiofrequency energy applications performed intraoperatively has been proposed for patients with AF in whom mitral valve surgery has been indicated. Balloon mitral valvuloplasty is currently the preferred procedure for patients with mitral stenosis and a favorable valve anatomy. AIM: To evaluate the short- and long-term results of percutaneous pulmonary vein isolation for the treatment of AF in patients with mitral stenosis undergoing balloon mitral valvuloplasty. METHODS: Five patients (four male and one female, age 43 +/- 4 years) underwent balloon mitral valvuloplasty concomitant with pulmonary vein isolation between August 1996 and February 1997. These patients had permanent AF, diagnosed 31 +/- 12 months previously; their mitral valve area was 1.0 +/- 0.25 cm2 and their left atria measured 54 +/- 5 mm. Balloon mitral valvuloplasty was performed via a transseptal approach, and then four ablation lines were created in the left atrial posterior wall to encircle all four pulmonary veins. Radiofrequency applications lasted 45 seconds each, and aimed at a maximum preset temperature of 65 degrees C. Electrical cardioversion was performed at the end of the procedure. RESULTS: Mitral valve area increased 1.0 +/- 0.3 cm2 after valvuloplasty. The number of radiofrequency applications per patient was 37 +/- 3, and the average duration of the entire treatment was 131 +/- 28 minutes. Fluoroscopy time averaged 32 +/- 12 minutes. All patients were discharged in sinus rhythm, and mitral flow Doppler evaluation at one month showed a biphasic pattern in all cases, with the A wave measuring 70 +/- 15 cm/sec. Three patients maintained sinus rhythm at five-year follow-up. Of these patients, one had developed a left atrial flutter at four-year follow-up and underwent ablation. The remaining two patients presented AF at five year follow-up. CONCLUSIONS: Percutaneous isolation of the pulmonary veins concomitant with balloon mitral valvuloplasty had suppressed AF in 60% of patients by five-year follow-up.     

Percutaneous balloon mitral valvuloplasty using the Inoue balloon: analysis of echocardiographic and other variables related to immediate outcome

To determine whether the mitral valve morphology influences the results of percutaneous balloon mitral valvuloplasty for mitral stenosis, two-dimensional echocardiography was performed before valvuloplasty in 126 patients (mean age 25.5+/-9.4 years) and in 30 normal controls. The 2D echocardiographic features of mitral valve leaflets: thickness, length and motion; diastolic mitral valvular excursion; chordal length; mitral annular diameter; subvalvular distance ratio; distance between mid mitral annulus to left ventricular apex, base and tip of papillary muscle and effective balloon dilating area, effective balloon dilating area/body surface area and effective balloon dilating diameter/mitral annular diameter were then correlated to the immediate post-valvuloplasty mitral valve area. For the total patients population, post-valvuloplasty valve area increased from 0.67+/-0.17 to 2.1+/-0.86 cm2 (P<0.0001), mean transmitral diastolic gradient decreased from 24.5+/-9.0 to 6.0+/-3.0 mm Hg (P<0.0001), mean left atrial pressure decreased from 29.7+/-6.2 to 12.7+/-4.8 mm Hg (P<0.0001), mean pulmonary artery pressure decreased from 44.8+/-14.2 to 25.4+/-9.5 mm Hg (P<0.0001) and cardiac index increased from 2.7+/-0.38 to 3.1+/-0.55 l/min/m2 (P<0.0001). The patients were divided into three groups on the basis of post-valvuloplasty mitral valve area. Group I had valve area <1.5 cm2, group II had valve area from 1.5 to 1.9 cm2 and group III had valve area > or =2.0 cm2. On comparison, no statistically significant difference was found in any of the echocardiographic variables in the three groups. On univariate, multivariate, multiple regression and discriminate function analysis, none of the variables were found to have significant influence on immediate result of valvuloplasty. There was no significant difference in the incidence of mitral regurgitation in any of the three groups. We conclude that the extent of mitral valvular and subvalvular deformity do not have a significant effect on the immediate outcome of mitral valvuloplasty using the Inoue balloon and it can be successfully performed in patients with severe subvalvular fibrosis. Unique balloon geometry and stepwise balloon sizing may explain these acceptable immediate results in severely deformed valves.     

Serial assessment of mitral regurgitation by pulsed Doppler echocardiography in patients undergoing balloon aortic valvuloplasty

Mitral regurgitation was serially assessed by pulsed Doppler echocardiography in 144 patients undergoing balloon aortic valvuloplasty for symptomatic aortic stenosis. Regurgitant scores of 0, 1, 2 and 3 were assigned to pulsed Doppler patterns corresponding to no, mild, moderate and severe mitral regurgitation, respectively. Before balloon aortic valvuloplasty, mitral regurgitant score correlated significantly (p less than 0.005) but weakly with aortic valve area (r = -0.24), left ventricular ejection fraction (r = -0.34) and left ventricular systolic pressure (r = 0.23). There was no significant correlation between mitral regurgitation and either mean catheterization or mean Doppler aortic valve gradient. Balloon aortic valvuloplasty produced significant decreases in both catheterization and Doppler mean transvalvular aortic valve gradients (56 +/- 19 to 31 +/- 12 and 60 +/- 19 to 48 +/- 16 mm Hg, respectively; both p less than 0.0001) and a significant increase (p less than 0.0001) in aortic valve area assessed by catheterization (0.6 +/- 0.2 to 0.9 +/- 0.3 cm2). Left ventricular ejection fraction did not change, but cardiac output increased (p less than 0.001) and pulmonary capillary wedge pressure decreased (p less than 0.0001). Pulsed Doppler findings of mitral regurgitation were present in 102 of the 144 patients. Eighty-eight patients had a score compatible with mild or more severe degrees of mitral regurgitation, and 49 had a score indicative of moderate or severe valvular insufficiency. In the entire group of 144 patients, mitral regurgitant score decreased significantly from 1.1 +/- 1.0 to 1.0 +/- 1.0 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Feasibility of simplifying balloon mitral valvuloplasty by obviating left-sided cardiac catheterization using on-line guidance with transesophageal echocardiography

STUDY OBJECTIVES: The purpose of this study was to evaluate the feasibility of simplifying balloon mitral valvuloplasty through the obviation of left-sided cardiac catheterization using on-line guidance with transesophageal echocardiography in patients with mitral stenosis. SETTING: A tertiary care medical center DESIGN: Patients who were eligible for balloon mitral valvuloplasty were enrolled into the study if they had no evidence of ischemic heart disease. Sixty-six patients (50 women and 16 men) met the criteria. Balloon mitral valvuloplasty was performed through right-sided cardiac catheterization using adjunctive on-line guidance with transesophageal echocardiography. Left-sided catheterization was obviated. Measurement and results: Balloon mitral valvuloplasty was smoothly performed in all patients. Successful dilatation (postprocedural mitral orifice area, > 1.5 cm(2); or increment in mitral orifice area, >or= 50%) was achieved in 50 patients (75.8%). The mean (+/- SD) mitral orifice area increased from 1.08 +/- 0.23 cm(2) to 1.68 +/- 0.39 cm(2) (p = 0.0000). There were no in-hospital deaths, no patients with cardiac tamponade, or complications necessitating an emergency cardiac operation. The mean fluoroscopy time was 7.6 +/- 3.9 min, and the total procedure time was 50.2 +/- 15.0 min. CONCLUSION: It is feasible and safe to simplify balloon mitral valvuloplasty by obviating left-sided cardiac catheterization in selected patients with mitral stenosis using adjunctive on-line guidance with transesophageal echocardiography.     

Balloon valvuloplasty versus closed commissurotomy for pliable mitral stenosis: a prospective hemodynamic study

Closed surgical mitral valvotomy is the procedure of choice in most patients with symptomatic pliable mitral stenosis in developing countries. The procedure is efficacious and safe. Mitral valvotomy performed with a balloon has shown similar good results, with infrequent complications in selected subjects. Because there is a paucity of studies comparing the two techniques, this study was undertaken to compare the results of percutaneous balloon mitral valvuloplasty with those of closed commissurotomy as determined by catheterization studies. Forty-five patients with tight pliable mitral stenosis were randomly assigned to one of two groups: 23 patients had balloon valvuloplasty by the single catheter technique (group I) and 22 underwent closed surgical valvotomy (group II). The two groups were similar with regard to clinical and hemodynamic findings before intervention. Mitral valve area increased from 0.8 +/- 0.3 to 2.1 +/- 0.7 cm2 in group I (p less than 0.001) and from 0.7 +/- 0.2 to 1.3 +/- 0.3 cm2 in group II (p less than 0.001). Pulmonary artery pressure and pulmonary vascular resistance decreased in both groups, but these changes did not reach statistical significance in group II. Treadmill exercise time increased from 3.8 +/- 2.3 to 7.3 +/- 2.6 min in group I (p less than 0.001) and from 4 +/- 2.6 to 5.6 +/- 2.6 min in group II (p less than 0.001). There were no deaths. One patient in each group developed moderate (3+) mitral regurgitation. A small interatrial shunt (less than 1.5:1) was detected in three patients in group I immediately after the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hemodynamic effects and long-term outcome of percutaneous balloon valvuloplasty in patients with mitral stenosis and atrial fibrillation

BACKGROUND: The presence of atrial fibrillation (AF) has been identified as a predictor of a suboptimal result in some patients undergoing percutaneous balloon valvuloplasty in the treatment of symptomatic rheumatic mitral stenosis. HYPOTHESIS: Atrial fibrillation adversely affects the short- and long-term outcome of patients with mitral stenosis undergoing percutaneous balloon valvuloplasty. METHODS: A retrospective chart review of 104 consecutive patients with rheumatic mitral stenosis undergoing percutaneous balloon valvuloplasty was performed. A successful procedure was defined as a final mitral valve area > or = 1.5 cm2 and the absence of a complication. Endpoints included freedom from mitral valve replacement, death, and repeat balloon valvuloplasty at 5 years. RESULTS: A successful procedure was obtained in 89% of patients with sinus rhythm and in 78% of patients with AF (p = NS). Patients in sinus rhythm had a greater cardiac output resulting in a larger final valve area than patients in AF (1.8 vs. 1.6 cm2, p < 0.05). Freedom from valve replacement, death, and repeat balloon valvuloplasty at 5 years was 75% for patients in AF and 76% for patients in sinus rhythm (p = NS). Lower postprocedure mitral regurgitation grade and absence of prior commissurotomy were the only independent predictors of event-free survival. CONCLUSIONS: Patients with mitral stenosis and AF have lower cardiac outputs and gradients than patients with sinus rhythm, despite similar valve areas. The long-term outcome of balloon valvuloplasty is independent of the initial cardiac rhythm.     

Double-transseptal, double-balloon valvuloplasty for congenital mitral stenosis.

BACKGROUND. Eight patients with severe congenital mitral stenosis underwent double transseptal, double-balloon valvuloplasty; two had isolated congenital mitral stenosis, six had additional cardiac defects, and one had previous surgical valvotomy. Ages ranged from 0.6 to 36 years (median, 9 years). METHODS AND RESULTS. All procedures were tolerated well. After valvuloplasty, the left atrial a wave minus the left ventricular end-diastolic pressure (LVEDP) gradient was reduced from 25 +/- 6 mm Hg to 9 +/- 3 mm Hg (p less than 0.001), the mitral valve mean gradient was reduced from 18 +/- 7 mm Hg to 8 +/- 3 mm Hg (p = 0.003), and the LVEDP was unchanged. All patients had marked clinical improvement. Only one patient developed significant mitral regurgitation. Two of the first four patients underwent repeat balloon valvuloplasty 7 months later. Follow-up evaluation on six patients from 4 to 54 months revealed no recurrence of symptoms or increased mitral regurgitation. CONCLUSIONS. Double transseptal, double-balloon valvuloplasty is an effective treatment for many forms of congenital mitral stenosis. Mitral regurgitation is uncommon after this procedure. The double transseptal approach results in less trauma to the atrial septum and femoral veins and allows easy assessment of any residual postvalvuloplasty gradient.     

Mitral balloon valvuloplasty for patients aged over 70 years: an alternative to surgical treatment

We report the results and one-year follow-up of 20 elderly patients (age range 70-82 years) with severe rheumatic mitral stenosis treated by mitral balloon valvuloplasty (MBV). All 20 were breathless at rest despite treatment with diuretics and digoxin. At cardiac catheterization, successful dilatation was achieved in 17 patients: mean transvalvular mitral gradient fell by 45%, mean cardiac output rose by 24% and mean valve area increased by 76%. There was no procedure-related mortality. At one month, 15 patients had experienced an improvement in symptoms of at least one New York Heart Association class and, at one year, ten had maintained this improvement. Three patients proceeded to mitral valve replacement because of a suboptimal symptomatic result. Mitral balloon valvuloplasty can be successfully performed with significant symptomatic benefit in frail elderly patients unfit for surgery and may also be offered to other selected elderly patients as an alternative to surgical treatment.     

Immediate results in percutaneous mitral valvuloplasty with the Nucleus balloon

We present the immediate results of mitral valvuloplasty in 10 patients using Nucleus balloon. Several publications show highly successful results obtained with the Inoue balloon and double balloon technique. There are no publications of Nucleus balloon. We consider that this device could offer several advantages according to its physical and technical characteristics. We performed the procedure in 10 female patients, with severe mitral valve stenosis, with an average age of 44.8 years (23-70) and an average Wilkins score of 7.5 (6-9), using a combined technique. The increase in mitral valve area with Gorlin equation was 1.03 +/- .13 to 2.6 +/- .67 cm2, the decrease in transmitral gradient from 15 +/- 4.1 to 3.42 +/- 2.6 mm Hg, and decrease in systolic pulmonary pressure from 54.1 +/- 18.8 to 24.9 +/- 5.1 mm Hg. One patient developed grade I mitral insufficiency after the procedure, and another non significant interatrial shunt. CONCLUSIONS: Good results are obtained with this balloon, the valvuloplasty technique is more simple than with double balloon, it is much cheaper than Inoue balloon and we consider it could be useful in moderately calcified valves.     

In vitro analysis of mechanisms of balloon valvuloplasty of stenotic mitral valves

Preliminary reports indicate that percutaneous balloon valvuloplasty is efficacious for treatment of mitral stenosis. The present study was designed to evaluate whether anatomic features of stenotic mitral valves in older adults affect the efficacy of balloon valvuloplasty and to determine the mechanism by which increased orifice area is accomplished. Fifteen mitral valves excised intact at the time of mitral valve replacement from patients with no more than 2+/4+ mitral a regurgitation were selected for study. Balloon valvuloplasty was performed using a sequence of dilation catheters with balloons 18 to 25 mm in inflated diameter. Mitral valve area, measured with a conical valve sizer, increased from 0.71 +/- 0.06 cm2 (mean +/- standard error of the mean) to 1.77 +/- 0.19 cm2 (p less than 0.0001) after valvuloplasty, resulting in an increase in calculated orifice area of 185 +/- 27% (range 34 to 407%). The increase in calculated orifice area correlated inversely with orifice area before valvuloplasty (r = -0.57; p = 0.026), but was unrelated to extent of calcific deposits on the prevalvuloplasty x-ray of the excised mitral valve. Gross examination together with x-ray analysis after valvuloplasty revealed that the mechanism of balloon valvuloplasty in each case involved commissural splitting, including splits through heavily calcified commissures, without grossly apparent detachment of tissue fragments. These findings suggest that balloon valvuloplasty augments the functional mitral valve orifice area in a manner analogous to standard surgical commissurotomy, and balloon valvuloplasty is likely to be efficacious for a wide spectrum of adult mitral valvular stenosis, including severe stenosis with extensive calcific deposits.     

The double-balloon and Inoue techniques in percutaneous mitral valvuloplasty: comparative results in a series of 232 cases

Immediate hemodynamic results of percutaneous mitral valvuloplasty were compared in two consecutive series of unselected patients from the same institution undergoing valvuloplasty with the double-balloon (161 patients) or the Inoue balloon (71 patients) technique. Before valvuloplasty, the patient series were comparable with regard to average age, gender repartition and most clinical, electrocardiographic, X-ray and hemodynamic variables. Poor anatomic forms of mitral stenosis were equally distributed in both series (41% vs. 45%, p = NS). The magnitude of mitral valve area increase and of mean mitral gradient decrease during percutaneous mitral valvuloplasty did not differ significantly in the Inoue balloon and double-balloon series (mean +/- SEM 1.1 +/- 0.2 to 1.95 +/- 0.5 and 1.0 +/- 0.2 to 1.97 +/- 0.5 cm2, respectively, for mitral valve area and 12 +/- 3 to 5 +/- 2 and 13 +/- 4 to 5 +/- 2 mm Hg, respectively, for mean mitral gradient). Four cases of 3+ mitral regurgitation occurred in the Inoue balloon series and 7 in the double-balloon series (p = NS). A good immediate result--defined as mitral valve area greater than or equal to 1.5 cm2 with greater than or equal to 25% in mitral valve area gain and mitral regurgitation less than 2+ at the end of the procedure--was observed in 78% of patients in both series. Three cases of tamponade due to chamber perforation and 14 cases of transient air embolism in the right coronary system due to balloon rupture were observed in the double-balloon series.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiography can predict the development of severe mitral regurgitation after percutaneous mitral valvuloplasty by the Inoue technique

Severe mitral regurgitation (MR) following mitral balloon valvuloplasty is a major complication of this procedure. We recently described a new echocardiographic score that can predict the development of severe MR following mitral valvuloplasty with the double balloon technique. The present study was designed to test the usefulness of this score for predicting severe MR in patients undergoing the procedure using the Inoue balloon technique. From 117 consecutive patients who underwent mitral valvuloplasty using the Inoue technique, 14 (11.9%) developed severe MR after the procedure. A good quality echocardiogram before mitral valvuloplasty was available in 11 patients. These 11 patients were matched by age, sex, mitral valve area, and degree of MR before valvuloplasty with 69 randomly selected patients who did not develop severe MR after Inoue valvuloplasty. The total MR-echocardiographic (MR-echo) score was significantly greater in the severe MR group (10.5 +/- 1.4 vs 8.2 +/- 1.1; p <0.001). In addition, the component grades for the anterior leaflet (2.9 +/- 0.5 vs 2.2 +/- 0.4; p <0.001), posterior leaflet (2.6 +/- 0.7 vs 1.9 +/- 0.8), commissures (2.4 +/- 0.8 vs 2.0 +/- 0.5; p <0.05) and subvalvular apparatus (2.6 +/- 0.5 vs 1.9 +/- 0.4; p <0.001) were also higher in the MR group. Using a total score of > or = 10 as a cut-off point for predicting severe MR with the Inoue technique, a sensitivity of 82%, specificity of 91%, accuracy of 90%, and negative predictive value of 97% were obtained. Stepwise logistic regression analysis identified the MR-echo score as the only independent predictor for developing severe MR with the Inoue technique (p <0.0001). Thus, the MR-echo score can also predict the development of severe MR following mitral balloon valvuloplasty using the Inoue technique.     

Percutaneous transvenous mitral valvuloplasty: short-term effects and complications

Percutaneous transvenous mitral valvuloplasty (PTMV) using the Inoue balloon was performed in 18 patients with symptomatic mitral stenosis. They were seven men and 11 women, ranging in age from 38 to 77 years (mean 59 +/- 10 years). Among them, 13 were categorized as NYHA class II; four as class III; and one as class IV. As a result, the symptoms of 14 patients markedly improved. Survey by means of right and left heart catheterization and echocardiography before and after PTMV demonstrated significant improvement in test values; (1) a decrease in the mean mitral gradient from 8.5 +/- 3.3 to 4.8 +/- 2.0 mmHg (p less than 0.01), (2) an increase in the mean diastolic descent rate of the mitral valve from 17.6 +/- 8.3 to 25.1 +/- 8.1 mm/sec. (p less than 0.01), and (3) an increase in the mean mitral valve area from 1.3 +/- 0.5 to 1.7 +/- 0.5 cm2 (p less than 0.01). Bicycle ergometer stress test performed on the 13 patients before and after PTMV revealed a significant decrease in the mean pulmonary arterial pressure from 24 +/- 5 to 18 +/- 5 mmHg (p less than 0.01) at rest, and from 49 +/- 9 to 42 +/- 7 mmHg (p less than 0.05) after exercise. The degree of mitral regurgitation increased after PTMV in six patients, in three of whom it was severe. The severity was evidenced by a significant increase in the ratio of the mean balloon diameter to body surface area as compared with the data of the other 15 patients (20.6 +/- 2.2 to 18.0 +/- 1.4 mm/m2; p less than 0.05), the presence of a localized sclerosis of the mitral valve as demonstrated by two-dimensional echocardiography, and prolapse of the mitral valve as shown by a left atriogram. These early results indicated that PTMV using the Inoue balloon is an effective treatment for symptomatic patients with mitral stenosis unless severe mitral regurgitation develops. This complication may be partially due to the selection of an inappropriate balloon diameter, and due to co-existing myxomatous degeneration and localized sclerotic changes of the mitral valve.     

Value of two-dimensional echocardiography in selecting patients and balloon sizes for percutaneous balloon mitral valvuloplasty

The effect of valvular and subvalvular morphologic features and balloon size/mitral anulus size ratio on results of valvuloplasty were prospectively studied in 38 consecutive patients undergoing mitral valvuloplasty. The severity of valvular and subvalvular disease was graded echocardiographically from grade I to IV (mild to severe) for immobility, thickening, calcification of mitral leaflets and subvalvular thickening and fusion, yielding a maximal total score of 16. The diastolic mitral anulus diameter was measured in the apical four chamber view. After valvuloplasty, the mitral valve area increased from 0.9 +/- 0.3 to 2.2 +/- 0.5 cm2 (p less than 0.001) with increasing mitral regurgitation in 12 (32%) of the 38 patients. Multiple stepwise analysis revealed that the ratio of balloon size and annular size and the severity of subvalvular disease are two independent factors that correlated significantly with the mitral valve area after valvuloplasty (multiple r = 0.65, p less than 0.0002). One of 34 patients with mild subvalvular disease of grade III or less had an unsatisfactory increase in mitral valve area to less than or equal to 1.5 cm2, whereas 3 of 4 patients with severe (grade IV) subvalvular disease had a valve area less than or equal to 1.5 cm2 (p less than 0.002) after valvuloplasty. The increase in mitral regurgitation after valvuloplasty correlated significantly with the ratio of balloon to mitral anulus size and the severity of subvalvular disease (multiple r = 0.53, p less than 0.003). (ABSTRACT TRUNCATED AT 250 WORDS)