Advantage of Inoue balloon catheter in mitral balloon valvotomy: Experience with 220 consecutive patients

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon catheter was attempted in 220 consecutive patients with severe symptomatic mitral stenosis. Their age range was 10–63 mean 30 ± 10 years; 161 patients were females and 59 were males; 29 patients were in atrial fibrillation. Eleven patients were pregnant; 14 patients underwent previous surgical commissurotomy. The procedure was technically successfully performed in 215 (97.7%) patients. The mean fluoroscopy time was 15.5 ± 6.4 min and mean procedure time was 109 ± 79 min. Optimal results (group I) was achieved in 207 patients who have mitral score of 7 ± 1. PMV resulted in decrease in left atrial pressure from 23 ± 5 to 14 ± 4 mm Hg (P < 0.001), the mean mitral valve gradient (MVG) decreased from 15 ± 4 to 6 ± 3 mm Hg (P < 0.001). The mitral valve area (MVA) by catheter increased from 0.7 ± 0.2 to 1.7 ± 0.5 cm² (P < 0.001) and MVA as determined by echocardiography (2DE) increased from 0.8 ± 0.1 to 1.9 ± 0.3 cm² (P < 0.001). The results were suboptimal in eight patients who have a mitral score of 10 ± 1 (group II) MVA by catheter increased from 0.7 ± 0.2 to 1 ± 0.1 cm² and Doppler MVA increased from 0.8 ± 0.1 to 1.3 ± 0.1 cm². There were no deaths or thromboembolism. Two patients developed cardiac tamponade; mild mitral regurgitation (MR) developed in 24 patients (11%) and increased by one grade in another 22 patients (10%). Severe MR was encountered in three patients (1.4%). A small ASD (QP/QS ≤ 1.3) was detected by oximetry in 5% of patients and by color-flow mapping in 26% of patients. One hundred fifty-eight patients from group I were followed up, for a mean of 32 ± 12 months; MVA remained at 1.7 ± 0.4 cm². Seven patients developed mitral restenosis in group I, and 5 out of 8 patients developed restenosis in group II. We conclude that the hemodynamic results are good and comparable with those reported with double balloon technique. However, the Inoue balloon has several advantages over the double balloon technique: (1) low incidence of mitral regurgitation and ASDs; (2) shorter procedure and fluoroscopy time; and (3) low complication rates and the valve anatomy affects the immediate and late outcome of mitral balloon valvotomy. © 1996 Wiley-Liss, Inc.     

Balloon mitral valvotomy by using the twin-at catheter: Immediate results and complications in 110 patients

Balloon mitral valvotomy, using a new Twin AT catheter (two balloons attached side by side over one shaft), was performed in 110 consecutive cases. The age of the patients ranged from 19–78 yr (mean 46 ± 15). From a total of 94 females and 16 males, 23 of the patients (22%) had mitral valve calcification, 47 patients (46%) had atrial fibrillation, and 39 patients (37%) had mitral regurgitation (< +2). Twenty patients (18%) presented with restenosis following surgical commissurotomy. Total catheterization time was 101 ± 26 min and the duration of the valvotomy procedure was 37 ± 21 min in these cases. For the entire population, there was a significant reduction in mitral valve gradient (15 2 6 to 4.8 ± 2.6 mmHg, p < .001), an increase in mitral valve area (MVA) (1.1 ± 0.3 to 2.35 ± 0.7 cm² ,p < .001), and a decrease in mean pulmonary arterial pressure (31 ± 12 to 26 ± 11, p <.002) after the balloon mitral valvotomy. Sixteen patients (1 4%) developed significant left to right shunt, and in 22 patients (20%) mitral regurgitation increased moderately but without resulting in emergency valve replacement. There was one incidence of embolic episode and one pericardial tamponade. Adequate hemodynamic results (MVA > 1.5 cm² and % increase in MVA ≥ 50%) without major complications were obtained in 99 cases. In 9 patients with severely diseased valve (2 previous commissurotomy, one restenosis after balloon valvotomy), or small left ventricular cavity, insufficient results were obtained by the Twin-AT catheter. The Twin-AT balloon catheter was exchanged for larger 2 balloons combinations in 5 patients and lnoue catheter in 4, and significant improvement in MVA was obtained in 5 cases. Thus, BMV can be safely and effectively performed in most cases with this new Twin-AT catheter, thereby saving time and cost. © 1993 Wiley-Liss, Inc.     

Predicting mitral regurgitation following percutaneous mitral valvotomy with the Inoue balloon: comparison of two echocardiographic scoring systems.

BACKGROUND: Percutaneous balloon mitral valvotomy (PBMV) has become the procedure of choice for many patients with symptomatic mitral stenosis. However, the development of significant mitral regurgitation (MR) remains an infrequent but very important complication. The echocardiographic scoring system described by Padial et al. has been successful in predicting the development of severe MR following PBMV using the double balloon technique. HYPOTHESIS: We aimed to assess the applicability of this new scoring system in predicting a significant increase in MR with the Inoue balloon and to compare it with the established Wilkins score. METHODS: The echocardiograms of 23 patients who had undergone PBMV for symptomatic mitral stenosis were analyzed retrospectively using both scoring systems, and the severity of MR was determined from pre- and postprocedural studies. RESULTS: Post PBMV, significant MR occurred in four patients (17%) while severe MR occurred in two patients (9%). Padial scores [mean (standard error of the mean)] in the group of patients with and without significant MR were [9.1 (0.8)] and [6.0 (0.3)], respectively (p = 0.002), while the Wilkins score was [7.5 (1.0)] and [6.4 (0.5)], respectively (p = 0.3). Using 8 as a cutoff point, the sensitivity and specificity of the newer scoring system was 83 and 100%, respectively, while the sensitivity and specificity of the Wilkins score was 50 and 50%, respectively. The positive predictive value > 8 was 100% (4/4) for the Padial and 25% (1/4) for the Wilkins system. Accordingly, the negative predictive value < 8 was 89% (17/19) for the Padial and 73% (14/19) for the Wilkins system. CONCLUSION: The newer scoring system is better at reliably identifying patients at risk of developing significant MR from PBMV with the Inoue balloon.     

Effect of atrial septal occlusion on mitral area after Inoue balloon valvotomy

The purpose of this study was to examine the influence of the atrial communication created during transseptal passage of the Inoue balloon catheter on calculated mitral valve area after balloon valvotomy for severe mitral stenosis. Even in the absence of oxymetric evidence for a shunt, atrial septal puncture may result in left-to-right shunting of blood with reported spurious increases in postvalvotomy mitral valve area calculations ranging from 16–29% in prior studies. Occlusion of the septal puncture site after double balloon valvotomy has previously been shown to result in decreased postvalvotomy mitral valve area determinations. We evaluated 20 patients undergoing mitral dilation. Each patient had three postvalvotomy measurements made: (1) with the Inoue balloon catheter positioned across the septum, (2) during septal occlusion with a 7F balloon-tip catheter, and (3) without any catheters across the septum. With the Inoue catheter across the septum after successful valvotomy, the cardiac output was 4.6 ± 1.5 L/min and the calculated mitral valve area was 1.7 ± 0.5 cm². No difference was found in either cardiac output or valve area when the septum was unobstructed by catheters. During septal occlusion, however, the postvalvotomy cardiac output decreased to 4.3 ± 1.3 L/min (P<0.001) and the calculated mitral area decreased by 12% to 1.5 ± 0.5 cm² (P<0.001). The calculated mitral valve areas determined with the Inoue catheter in place after valvotomy were in agreement with echo derived data. Although statistically significant differences in post-Inoue valvotomy cardiac output and calculated mitral valve area were found during septal occlusion, these differences were small. Furthermore, echocardiographic valve area measurments agreed with invasively determined mitral valve areas regardless of whether or not the septum was ccluded. We conclude that septal occlusion is not necessary for valve area measurement after Inoue balloon mitral valvotomy. © Wiley-Liss, Inc.     

Balloon aortic valvuloplasty in young adults by antegrade,transseptal approach using Inoue balloon

Transvenous, transseptal, antegrade balloon aortic valvuloplasty (BAV) was successfully performed in 16 consecutive young adults with noncalcific aortic stenosis using Inoue balloon catheter. There were 13 males and three females, with a mean age of 20.4 ± 5.8 years (range 14–30 years). All the patients had normal left ventricular systolic function. All procedures were performed electively by the antegrade technique, except the initial index case in whom, the stenosed aortic valve could not be crossed retrogradely. Dilatation was performed using stepwise technique keeping the balloon:annulus ratio ≤100% in all the cases. Transaortic peak systolic gradient decreased from 113.4 ± 42.6 (range 70–210) mm Hg to 11.2 ± 9.2 (range 4–32) mm Hg; P = 0.0005. Following BAV, three patients developed grade 2⁺ aortic regurgitation, who were managed medically. None of the patients developed tamponade, vascular complications, excessive bleeding, or thromboembolism. Significant left to right atrial shunt (Qp/Qs ≥ 1.5:1) was observed in one case. The average procedure time was 20 ± 8 min (range 18–35 min). On follow-up (n = 11 patients) at 4 ± 1.5 months (range 2–7 months) all the patients were asymptomatic. Doppler transaortic peak systolic gradient was found to be 15 ± 10.3 mm Hg (range 4–36 mm Hg). Antegrade BAV technique using Inoue balloon for noncalcific aortic stenosis in young adults is safe, effective and may be technically advantageous. Cathet. Cardiovasc. Diagn. 44:297–301, 1998. © 1998 Wiley-Liss, Inc.     

外科二尖瓣交界分离术后再狭窄二尖瓣球囊成形术

将６６例二尖瓣狭窄患者首次行ＰＢＭＶ和１８例外科分离术后再狭窄患者行ＰＢＭＶ进行比较，结果表明两者扩瓣治疗前、后的血流动力学指数有明显差异（Ｐ＜０．００１），但将两者术后相应的血流动力学指数进行比较差异无显著性（Ｐ＞０．０５）。说明外科二狭分离术后再狭窄患者成功地进行ＰＢＭＶ可显著改善临床症状，仍是一种有效的方法。     

Significance of commissural calcification on outcome of mitral balloon valvotomy

OBJECTIVE—To evaluate the significance of commissural calcification, identified by transthoracic echocardiography, on the haemodynamic and symptomatic outcome of mitral balloon valvotomy.
METHODS—Commissural calcification was graded from 0-4 using parasternal short axis transthoracic views. The morphology of the mitral valve was also assessed using the Massachusetts General Hospital echo score.
SETTING—A tertiary cardiac centre in Scotland.
PATIENTS—300 patients were studied, 85 retrospectively and 215 prospectively. Mean (SD) age was 59.8 (12.7) years, range 13 to 87; 30% had been judged unsuitable for surgery. Median echo score was 6.8 (3.0), range 2-16.
MAIN OUTCOME MEASURES—Immediate increase in mitral valve area and in New York Heart Association functional class 1-3 months after balloon valvotomy.
RESULTS—On univariate and multivariate analysis, commissural calcification grade was a significant predictor of achieving a mitral valve area of > 1.50 cm² without severe mitral reflux. Its influence was greatest in patients with an echo score ⩽ 8: those with commissural calcification grade 0/1 had significantly greater improvement in valve area and symptom status than those with grade 2/3; the proportions of patients achieving a final valve area of > 1.50 cm² were 67% and 46%, respectively (p < 0.05). In patients with an echo score of > 8, the influence of commissural calcification was smaller and not significant.
CONCLUSIONS—Commissural calcification as assessed by transthoracic echocardiography is a useful predictor of outcome in patients with otherwise "good" valves (echo score ⩽ 8). Calcification of one commissure or more predicts a less than 50% probability of achieving a valve area above 1.50 cm² and is an indication for valve replacement in those who are suitable for surgery.


     

Maternal and fetal outcomes in pregnant women undergoing balloon mitral valvotomy for rheumatic mitral stenosis

BackgroundRheumatic mitral stenosis constitutes a major cause of acquired heart disease complicating pregnancy in India. In the present study, we have studied the fetal and maternal outcomes of women undergoing balloon mitral valvotomy during pregnancy.Methods and results49 pregnant ladies were included in this study in whom balloon mitral valvotomy was performed. The mean age of these patients was 25.7 ± 3.1 years. The mean gestational age was 23.5 ± 5.2 weeks (12–36 weeks). The procedure was successful in 48 patients (95.9%). Mean two-dimensional MVA increased from baseline value of 0.93 ± 0.17 cm² to 1.75 ± 0.27 cm² (p value <0.0001). Pre-procedure peak pulmonary artery pressure was 43.05 ± 15.88 mmHg, which decreased to 22.31 ± 6.36 mmHg (p value <0.0001). Hemodynamic data showed pre-BMV left atrial mean pressure of 29.6 ± 6.6 mmHg, which decreased to 13.7 ± 4.8 mmHg after the procedure (p value <0.0001). Mean fluoroscopy time was 6.4 ± 1.2 min. There was no maternal mortality in our study. One procedure had to be abandoned, because of failed septal puncture. One of the patients developed cardiac tamponade and another patient developed severe mitral regurgitation, which were managed medically. The patient who developed severe mitral regurgitation later underwent mitral valve replacement. Post-procedure follow-up showed an improvement in NYHA status by at least one class in 81.3% of patients. Thirty-nine (81.3%) patients had a term normal vaginal delivery and 8 (16.7%) underwent cesarean section for obstetric indications. One of the patients had abortion on the second day of the procedure.ConclusionPercutaneous mitral valvotomy during pregnancy is safe and provides excellent symptomatic relief and hemodynamic improvement. This should be considered as the treatment of choice when managing pregnant women with severe mitral stenosis.     

Angiographic recognition of a proximal balloon tear during inoue balloon mitral valvotomy

Two patients in whom a proximal balloon tear accompanied by a unique angiographic appearance occurred during percutaneous balloon mitral valvotomy using the Inoue balloon catheter are described.     

Percutaneous mitral balloon valvotomy in a patient with coexistent mitral stenosis and hypertrophic cardiomyopathy

A patient with coexistent mitral stenosis and hypertrophic cardiomyopathy is described, in whom symptoms related to impaired left ventricular diastolic filling improved after successful percutaneous mitral balloon valvotomy.     

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.     

Echocardiographic long-term evaluation of percutaneous balloon mitral valvotomy

Percutaneous balloon mitral valvotomy (BMV) is an alternative therapeutic method for patients with mitral stenosis. We studied 62 patients (56 females, mean age 36.4 years) who underwent balloon mitral valvotomy. Five patients were pregnant and in New York Heart Association Functional Class IV. Doppler echocardiographic studies were performed prior to the procedure, and at 7 days, 6 months, 12 months, and 24 months after the procedure. We studied the following parameters: echo-score by the sum of valvular mobility, thickening, and calcification, and subvalvular disease, graded from 1 to 4; and mitral valve area (MVA) and mitral pressure gradient (MPG) by Doppler echocardiography. The patients were separated into two groups: group I with an echo-score less than or equal to 8 (40 patients), and group II with an echo-score greater than or equal to 9 (22 patients). Mitral valve area and MPG were compared with hemodynamics through the correlation coefficient and linear regression. Comparison between groups I and II was performed using the unpaired Student's t-test. Follow-up of MVA and MPG was analyzed by analysis of variance. The Student's t-test did not show any significant difference between MVA and MPG before balloon mitral valvotomy. There was significant decrease of MVA in group II (P less than 0.01) in the last three studies. There was significant increase in MPG in group II (P less than 0.01) in every postvalvotomy study. The analysis of variance of group I showed statistical increase of the MVA, and significant decrease of the MPG after BMV. The analysis of variance of group II showed significant increase in MVA and significant decrease in MPG between the pre- and the first postvalvotomy study. There was significant decrease (P less than 0.01) in MVA, and increase in MPG in the three postvalvotomy studies. Complications included mitral regurgitation, residual interatrial communication, pericardial effusion due to an atrial wall perforation, and peripheral embolization. Atrial fibrillation did not significantly alter the results of BMV. Results were considered positive when MVA was greater than 1.5 cm 2 and area increase was greater than 25%. Patients with an echo-score less than or equal to 8 (group I) benefit from BMV, with a positive predictive value greater than 78%. In pregnant patients the symptomatology was alleviated by BMV, without any signs of fetal compromise.     

Subvalvular apparatus and adverse outcome of balloon valvotomy in rheumatic mitral stenosis

Background

Balloon mitral valvotomy (BMV) is a well-established therapeutic modality for rheumatic mitral stenosis (RMS). However, there are chances of procedural failure and the more ominous post-procedural severe mitral regurgitation. There are only a few prospective studies, which have evaluated the pathogenic mechanisms for these major complications of BMV, especially in relation to the subvalvular apparatus (SVA) pathology.

Methods

All symptomatic patients of RMS suitable for BMV by echocardiographic criteria in a span of 1 year were selected. In addition to the standard echocardiographic assessment of RMS (Wilkins score and score by Padial et al.), a separate grading and scoring system was assigned to evaluate the severity of the SVA pathology. The SVA score was ‘I’, when none of the two SVAs had severe disease, ‘II’ when one of the two SVAs has severe disease, and ‘III’ when both SVAs had severe disease. With these scoring systems, the outcomes of BMV (successful procedure, failure, and post-procedural mitral regurgitation) were analyzed. Emergency valve replacement was performed depending on clinical situation, and in cases of replacement, the pathology of the excised mitral valves were compared with echocardiographic findings.

Results

Of the 356 BMVs performed in a year, 43 patients had adverse outcomes in the form of failed procedure (14 patients) and mitral regurgitation (29 patients). Forty-one among these had a SVA score of III. The sensitivity and specificity of the MR score was lesser than the SVA score (sensitivity 0.34 vs. 1.00, specificity 0.92 vs. 0.99, respectively). The mitral valvular morphology in 39 patients who underwent post-procedural valve replacements correlated well with echocardiography findings.

Conclusion

It is important to assess the degree of SVA pathology in the conventional echocardiographic assessment for RMS, as BMV would have adverse events when both SVAs were severely diseased.     

Percutaneous mitral balloon valvotomy.

Percutaneous mitral balloon valvotomy (PMBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, PMBV 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 PMBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0-0.5%), cerebral accident (0.5-1%), 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 PMBV and surgical commissurotomy. Restenosis after PMBV ranges from 4 to 70% depending on the patient selection, valve morphology, and duration of follow up. Restenosis was encountered in 21% of the author's series at mean follow-up 6 +/- 4.5 years and the 10 and 15 years restenosis-free survival rates were (70 +/- 3)% and (44 +/- 5)%, respectively, and were significantly higher for patients with favorable mitral morphology (85 +/- 3% and 65 +/- 6%), respectively (P < 0.0001). The 10 and 15 years event-free survival rates were (79 +/- 2)% and (43 +/- 9)% and were significantly higher for patients with favorable mitral morphology (88 +/- 2)% and (66 +/- 6)%, respectively (P < 0.0001). The effect of PMBV 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 PMBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.     

Long term outcome of percutaneous mitral balloon valvotomy in patients aged 70 and over

OBJECTIVE—To assess the immediate haemodynamic improvement and long term symptomatic benefit of percutaneous mitral balloon valvotomy in patients aged over 70 years.DESIGN—Pre- and postprocedure haemodynamic data and follow up for 1 to 10 years by clinic visit or telephone contact.SETTING—Tertiary referral centre in Scotland.SUBJECTS—80 patients age 70 and over who had mitral balloon dilatation: 55 were considered unsuitable for surgical treatment because of frailty or associated disease. In an additional four patients mitral dilatation was not achieved.MAIN OUTCOME MEASURES—Increase in valve area after balloon dilatation and survival, freedom from valve replacement, and symptom class at follow up.RESULTS—Mean (SD) valve area increased by 89% from 0.84 (0.28) to 1.59 (0.67) cm². There was a low rate of serious complications, with only two patients having long term major sequelae. Of 55 patients unsuitable for surgical treatment, 28 (51%) were alive without valve replacement and with improvement by at least one symptom class at one year, and 14 (25%) at five years. In the 25 patients considered suitable for surgical treatment, 16 (64%) achieved this outcome at one year and nine (36%) at five years.CONCLUSIONS—Percutaneous mitral balloon valvotomy is a safe and useful palliative procedure in elderly patients who are unsuitable for surgery. Balloon dilatation should also be used for elderly patients whose valve appears suitable for improvement by commissurotomy, but echo score is an imperfect predictor of haemodynamic improvement.     

Balloon mitral valvuloplasty at Monash Medical Centre: follow up of 201 procedures over an 11-year period

Over a period of 11 years from 1988 to 1999, 201 patients underwent balloon mitral valvuloplasty (BMV) at Monash Medical Centre, Australia. Before BMV,133 patients (66%) were symptomatic with minimal activity or at rest. BMV increased mitral valve area and cardiac output, and reduced transmitral, left atrial and pulmonary pressures, with infrequent procedural complications (<8%). At the initial 3-month follow up after BMV, symptoms were absent or minimal in 178 patients (89%), with 85% remaining event free at 12 months. At long-term follow up (median: 30 months; range: 0-129 months), cumulative event-free survival was 73% after 5 years. After BMV, 37 patients (18%) underwent mitral valve surgery, while a repeat BMV was performed in three patients (1.5%). The results of this series provide additional data for the growing body of evidence which suggests that BMV is a relatively safe and effective procedure for producing long-term benefit in patients with symptomatic mitral stenosis.     

Assessment of mitral valve commissural morphology by transoesophageal echocardiography predicts outcome after balloon mitral valvotomy

BackgroundBalloon mitral valvotomy (BMV) is a safe and an effective treatment in patients with symptomatic rheumatic mitral stenosis. This study was conducted to validate the importance of assessing the morphology of mitral valve commissures by transoesophageal echocardiography and thereby predicting the outcome after balloon mitral valvotomy [BMV].Materials and methodsStudy consisted of 100 patients with symptomatic mitral stenosis undergoing BMV. The Commissural Morphology and Wilkins score were assessed by transoesophageal echocardiography. Both the commissures (anterolateral and posteromedial) were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2) and calcification (score 0) and combined giving an overall commissural score of 0–4. Outcome of BMV was correlated with commissural score and Wilkins score.ResultsThe commissural score and outcome after BMV correlated significantly. 66 of 70 patients (94%) with a commissural score of 3–4 obtained a good outcome compared with only six (20%) patients of 30 with a commissural score of 0–2 (positive and negative predictive accuracy 94% and 80%, respectively, p < 0.001). Increase in 2DMVA post BMV was more in patients with higher commissural score (score of 3–4). Wilkins score <8 usually predicts a good outcome but even in patients with Wilkins score >8 a commissural score >2 predicts a 50% chance of a good result.ConclusionsA higher commissural score predicts a good outcome after BMV hence it can be concluded that along with Wilkins score, commissural morphology and score should be assessed with TOE in patients undergoing BMV.     

Percutaneous transvenous mitral commissurotomy using Inoue balloon in children less than 12 years

Rheumatic mitral stenosis in some parts of the world afflicts even young children. Percutaneous transvenous mitral commissurotomy (PTMC) using Inoue balloon in these children is not well reported. Forty-five children (aged 7–12 years, mean 11.0 ± 1.2 years) with severe rheumatic mitral stenosis (mitral valve area [MVA] 0.64 ± 0.14 cm²) underwent PTMC. The pulmonary artery wedge pressure (PAW) decreased from 24.3 ± 8.6 to 14.7 ± 7.2 mmHg (P < 0.0001) and mean diastolic gradient decreased from 24.3 ± 7.7 to 7.9 ± 5.9 mmHg with the final MVA of 1.63 ± 0.45 cm² (P < 0.0001). Complications included significant mitral regurgitation (MR) in three children and atrial shunting in two patients. No procedural death, systemic embolism, and cardiac tamponade were encountered. Twenty-four children had maximum balloon size (MBS) same as recommended balloon size (RBS) derived according to the height (group I) and 21 children had MBS 1–3 mm less than RBS (group II). Despite the lesser maximum balloon size, the final results were comparable in both groups (MVA group 1.66 ± 0.44 vs. group II 1.61 ± 0.48 P = NS). The incidence of significant MR (2 and 1 in group I and group II, respectively) was similar. On follow-up of 20.4 ± 16.3 months (range 3–56 months), one child developed restenosis. We conclude that PTMC is safe and effective in children less than 12 years of age. However, the smaller balloon size than the RBS derived from height may be equally effective and possibly safer. Cathet. Cardiovasc. Diagn. 43:408–411, 1998. © 1998 Wiley-Liss, Inc.