Mitral valve operation after percutaneous transvenous mitral commissurotomy (PTMC): An evaluation of PTMC indications based on intraoperative findings

Six patients underwent open heart surgery for mitral valve disease after percutaneous transvenous mitral commissurotomy (PTMC) because of recurrent mitral stenosis (MS) in 4, moderate mitral regurgitation (MR) in 1, and acute severe MR in 1. These 6 patients were the only such observed cases out of a total of 86 patients who presented with PTMC in our hospital between October 1989 and May 1995. The duration of the subjective symptoms related to heart failure was 24.1±11.6 years, ranging from 3 to 30 years. Four of the six patients had had a previous surgical commissurotomy [closed mitral commissurotomy (CMC) in 2 and open mitral commissurotomy (OMC) in 2] from 24 to 30 years earlier (mean 28 years). The intraoperative findings of the 4 with residual MS included severe thickening, calcification on anterior and posterior leaflets, and bilateral commissures. Five patients were noted to have shortening and adhesion in the mitral subvalvular apparatus. Two patients with moderate to severe tears on the anterior leaflets and another two patients with tears on the posterior leaflet were also noticed; however, these leaflets were not severely thickened. It was possible to split and repair the fused commissure in one patient, but the other five required MVR due to severe subvalvular lesions. Therefore, if a patient has bilateral commissural calcification or has less thickend leaflets with severe subvalvular thickening and fusion with a small MVA measuring less than 0.8 cm² and a MS score of more than 8, the OMC procedure is considered to provide good long-term clinical results. The decision to perform either PTMC or OMC should only be made based on meticulous echo Doppler findings and a hemodynamic evaluation of the mitral valve.     

Mitral valve replacement after percutaneous transvenous mitral commissurotomy

Percutaneous transvenous mitral commissurotomy is widely performed as the first choice of the non-pharmacological treatments for mitral stenosis. Five patients have been identified who required mitral valve replacement after percutaneous transvenous mitral commissurotomy. The causes leading to mitral valve replacement were mitral regurgitation in three cases and insufficient commissurotomy in two. Massive mitral regurgitation is one of the most serious complications of percutaneous transvenous mitral commissurotomy. This report aims to elucidate the mechanism of massive mitral regurgitation occurring during percutaneous transvenous mitral commissurotomy. In every such case, there was a large tear in the posterior leaflet without any split in the commissures. The Japanese literature reports that 16 patients have undergone mitral valve replacement for massive regurgitation after percutaneous transvenous mitral commissurotomy; 14 of these cases had a tear in one of the leaflets and no evidence of splitting of the posterior commissure. These facts indicate that relative fragility of the leaflets as compared with rigidity of commissural fusion, especially in the posterior commissure, is an important factor of massive mitral regurgitation during percutaneous transvenous mitral commissurotomy. Copyright © 1996 Published by Elsevier Science Ltd.     

A case of mitral valve replacement due to mitral regurgitation after percutaneous transvenous mitral commissurotomy (PTMC)

A 58-year-old woman, who had congestive heart failure due to mitral regurgitation after percutaneous transvenous mitral commissurotomy, underwent mitral valve replacement. It is reported that mitral regurgitation more often occurs after PTMC in patients with severely calcified mitral valve or advanced subvalvular lesion than in those without. Our experience indicated that PTMC should be carefully performed in institutions which have a surgical team ready for emergency operation.     

Mitral valve replacement after percutaneous transluminal mitral commissurotomy

Objectives: We reviewed our experience of mitral valve replacement (MVR) after percutaneous transluminal mitral commissurotomy (PTMC) for mitral stenosis (MS). Methods: From December 1987 to December 2001, PTMC was conducted in 75 patients with symptomatic rheumatic MS. At mean follow-up of 8.4±3.5 years, 11 patients (14.7%) underwent MVR for mitral restenosis (9 cases) and mitral regurgitation (MR) (2 cases). The mean interval between PTMC and MVR was 5.2±3.2 years. Results: There were 2 hospital deaths (due to low output syndrome and mediastinitis) and 2 complications (prosthetic valve endocarditis and left ventricular rupture). The mitral valve area (MVA) at pre-PTMC, post-PTMC and pre-MVR was 1.02±0.48 cm²,1.55±0.59 cm²,1.04±0.23 cm², respectively. The MVA significantly increased after PTMC (p<0.01), but decreased significantly to the pre-PTMC value at pre-MVR (p<0.05). The left atrial dimension (LAD) significantly increased from 50.4±10.8 mm at pre-PTMC to 61.1±13.1 mm at pre-MVR (p<0.05). The number of significant tricuspid regurgitation (TR) cases increased from 2 at pre-PTMC to 5 at pre-MVR. The New York Heart Association class got better after PTMC (3 cases in class HI at pre-PTMC to 0 at post-PTMC), but at pre-MVR, deteriorated to the same level at pre-PTMC (4 cases in class III). Conclusions: Our results of MVR after PTMC were reasonable to be considered despite their high risk at MVR resulting in 2 hospital deaths. For the reliable relief of MS and control of TR, not PTMC but MVR combined with tricuspid annuloplasty may be preferable in such two cases suffering from congestive heart failure with significant TR at first intervention. Close follow-ups like periodic ultrasonic cardiography studies should be conducted to gain more information on the mitral restenosis, TR deterioration and dilatation of the cardiac chambers.     

Two cases of mitral restenosis occuring eight years after percutaneous balloon mitral commissurotomy (PTMC)

A 63-year-old man and a 49-year-old man who underwent PTMC eight years before were admitted in our hospital because of regurgitation and restenosis of the mitral valve. Both of them had ulcer like lesion on the anterior leaflet near the commissure of the mitral valve. These changes were made by PTMC and likely caused thrombosis. Long-term follow up data of PTMC is essential to chose the correct operative method for treating mitral stenosis.     

Plastic surgery of the mitral valve in patients undergoing closed commissurotomy

The authors report on 64 valve-preserving operations conducted under conditions of extracorporeal circulation in patients with a history of closed mitral commissurotomy (59 patients with restenosis of the mitral orifice and 5 patients with iatrogenic mitral insufficiency); hospital lethality was 14%. The peculiarities of the diagnosis and operative techniques of the second intervention in this pathological condition are discussed in detail. From study of the immediate postoperative results the authors conclude that during the second operation after closed mitral commissurotomy the patient's own valve can be preserved in 30-35% of cases. They claim that restenosis of the mitral orifice and iatrogenic mitral insufficiency are a complicated form of mitral valvular disease and should be corrected on an open heart with extracorporeal circulation.     

Two cases of mitral restenosis occurring eight years after percutaneous balloon mitral commissurotomy (PTMC)]

A 63-year-old man and a 49-year-old man who underwent PTMC eight years before were admitted in our hospital because of regurgitation and restenosis of the mitral valve. Both of them had ulcer like lesion on the anterior leaflet near the commissure of the mitral valve. These changes were made by PTMC and likely caused thrombosis. Long-term follow up data of PTMC is essential to chose the correct operative method for treating mitral stenosis.     

Interest of percutaneous transvenous mitral commissurotomy in the management of rheumatic mitral stenosis

During from April 1987 to October 1988, 13 cases of mitral stenosis (MS) were treated with percutaneous transvenous mitral commissurotomy (PTMC) among 24 cases of MS. The indications of PTMC were determined by surgeons in 4 cases with several reasons described as follows: 1. Patient, having been treated with closed mitral commissurotomy, who refused to be operated with open heart technique. 2. Patient associated with early gastric cancer. 3. Patient associated with severe hyperthyroidism and cardiac cachexia. 4. Patients suffering from acute renal failure following left heart failure due to association of aortic stenosis. Other 9 cases were determined by cardiologist because of the inherent benefit of PTMC being less invasive. After PTMC, the symptomatic improvement, assessed by means of NYHA classification, were observed in 11 cases out of 13. Hemodynamic data such as mitral valvular area, mitral valve gradient and cardiac index showed marked improvement without any inducing of significant mitral regurgitation. The authors thought with these results as follows: 1. The effect of PTMC may be appreciable for mild or moderate stenotic lesion of mitral orifice, however, severely affected valves should be treated by open heart techniques in order to perform radical procedures. Otherwise, significant MR may occur by overloading of balloon size beyond some extent. 2. On account of the appearance of PTMC, the indicational determination for the treatment of MS will be more controvertial than now.     

B-type natriuretic peptide (BNP) in patients undergoing mitral valve surgery

Abstract Background and Aim: Plasma B‐type natriuretic peptide (BNP) level may be increased in patients with valvular disease. Recent studies have suggested that in patients undergoing aortic valve replacement, an increased preoperative BNP is associated with a worse operative outcome. Little is known about the perioperative value of BNP in patients undergoing mitral valve (MV) surgery. We measured the preoperative and postoperative BNP levels in this population and analyzed the impact of the increased BNP level on surgical outcome. Methods: From March 2004 to February 2005, 42 patients (mean age 64 ± 12 years, 18 [42%] male) were enrolled in a prospective study. All patients underwent surgery for severe mitral regurgitation. The mean ejection fraction was 49 ± 13%, and 26 (62%) patients presented with atrial fibrillation (AF). Results: The median preoperative and postoperative BNP levels were 108 (9.7 to 995) and 357 (143 to 904) pg/mL, respectively (p = 0.002). Heart failure (p = 0.03), atrial fibrillation (AF) (p = 0.01), and ejection fraction (p = 0.01) were associated with an increased preoperative BNP level. In a multivariate analysis, the only independent predictor of the increased BNP level was AF (p = 0.01). In a univariate analysis, the preoperative BNP level was a significant predictor for inotropic support (p < 0.001), ventilation time (p = 0.003), intensive care unit (ICU; p = 0.01), and hospital length of stay (p = 0.02). In the multivariate analysis, BNP was not a predictor of these variables. Conclusions: Preoperative plasma BNP level presents with a high individual variability in patients with MV regurgitation. AF was the only independent predictor of an increased preoperative BNP level. The preoperative BNP level was not a predictor of surgical outcome. Further studies are required to confirm these findings and evaluate the potential role of this marker for patient selection.     

Reoperations of the mitral valve after closed commissurotomy

The authors report on 275 operations performed for the second time after closed commissurotomy. The intervention was undertaken for restenosis of the left venous ostium in 255 and iatrogenic mitral insufficiency in 20 patients. The peculiar features of the clinical picture and diagnosis of these two conditions are discussed in detail. The authors substantiate the indications for closed recommissurotomy and open interventions under conditions of extracorporeal circulation with the performance of plastic valve-preserving operations and replacement of the valve by a prosthesis. From study of the immediate results of reoperations after closed commissurotomy the authors conclude that the method of choice in repeated operations in this pathological condition should be an operation under conditions of extracorporeal circulation which provides the possibility for adequate and radical correction of the anomaly.     

Mitral valve surgery in patients with extensive calcification of the mitral annulus

OBJECTIVES: The objective of this work was to examine the clinical outcomes of mitral valve surgery in patients with extensive mitral annular calcification. METHODS: Mitral valve surgery was performed in 54 patients (28 men and 26 women, mean age 63 +/- 14 years) with mitral regurgitation and extensive mitral annular calcification. Most patients (78%) were in New York Heart Association classes III and IV, 14 had coronary artery disease, and 9 had prior mitral valve replacement in which the calcium bar was not removed. The calcium bar was excised and a new mitral annulus was created by suturing a strip of pericardium onto the endocardium of the left ventricle from lateral to medial fibrous trigones and to the endocardium of the left atrium. The mitral valve was repaired in 12 patients and replaced in 42. In 23 patients the intervalvular fibrous body was reconstructed and the aortic valve was also replaced. Mean follow-up was 4.1 +/- 3.7 years and was complete. RESULTS: There were 5 operative deaths and 11 late deaths. Five-year survival was 73 +/- 7%. Four patients needed reoperation and each survived. Freedom from reoperation at 5 years was 89 +/- 6%. Three patients had a stroke and 4 had anticoagulation-related hemorrhage, one of which was fatal. Five-year freedom from valve-related mortality or morbidity was 75 +/- 8%. Most survivors were in New York Heart Association functional classes II and III. CONCLUSIONS: Resection of the calcium bar and creation of a new annulus with pericardium provided good clinical results in patients with extensive calcification of the mitral valve.     

Effect of mitral valve calcinosis on the remote results of commissurotomy]

The results of 249 mitral commissurotomies in calcification of the mitral valve are analysed. The authors have differentiated three grades of calcification of the valve and two groups according to its functional state. Late results were followed up in 177 patients within the terms up to 10 years and longer. The persistant positive result was noted in 99 patients, in 11 cases it was regarded as poor, and in 37--unstable. Postoperatively 34 patients died. The analysis enabled the authors to state that the positive effect of closed mitral commissurotomy could be also gained in considerable calcification. Prosthetic replacement of the valve is indicated in the presence of massive calcinosis associated with the rigidity of cusps and marked regurgitation.     

Comparison of long-term outcome of closed mitral commissurotomy (CMC) versus open mitral commissurotomy (OMC) and mitral valve replacement (MVR)]

To predict the late result of percutaneous mitral balloon valvotomy (PMV), we studied long term outcome of CMC which is similar to PMV in terms of closed heart technic, comparing with those of OMC and MVR. 226 patients with mitral stenosis were studied. 117 patients had CMC, 72 had OMC and 37 had MVR. The cumulative follow up period in these groups were 1892 patient year, 632 patient year and 200 patient year respectively. Postoperative actual survival rate at 5, 10, 15 years in CMC patients were 95 +/- 2%, 91 +/- 3%, 86 +/- 3% respectively. No operative or late death was seen in OMC or MVR patients. Postoperative event free rate at 10 years in OMC or MVR patients (97 +/- 2%, 90 +/- 6%, respectively) were higher than that in CMC patients (79 +/- 4%). Thromboembolism developed in 7 (6%) CMC patients, and 4 of these patients died from cerebral embolism. No patient in OMC or MVR group had thromboembolism. Reoperation was done for mitral restenosis or regurgitation in 40 CMC patients. 15 (38%) of these patients were associated with pulmonary hypertension, and 22 (55%) patients had secondary tricuspid regurgitation. On the other hand, only 1 OMC patient and 1 MVR patient had reoperation due to restenosis or thrombosed artificial valve. These results suggest that PMV should be indicated for restricted cases of mitral stenosis.