Percutaneous Balloon Valvuloplasty of A Porcine Xenograft Bioprosthesis in the Mitral Position: Late (1 Year) Hemodynamic Observations

Balloon valvuloplasty is a procedure recently applied to porcine xenograft bioprostheses. We report the percutaneous dilatation of a critically stenosed Carpentier-Edwards bioprosthesis in the mitral position via an atrial transseptal approach. Hemodynamic measurements revealed an increase in mitral valve area from 0.88 cm² to 1.34 cm² and a decrease in the transvalve gradient from 22 mmHg to 12 mmHg. The patient's symptoms dramatically improved, but recurred 8 months later. Repeat cardiac catheterization at 1 year documented restenosis of the porcine xenograft bioprosthesis with a mitral valve area of 0.87 cm². Thus, stenosis of porcine bioprostheses may be managed by balloon valvuloplasty. As with native valves subjected to balloon valvuloplasty, restenosis is a concern.     

Percutaneous transseptal mitral valvotomy-progress report

Background : Percutaneous transseptal mitral valvotomy (PTMV) has been established as an alternative to surgery in the treatment of mitral stenosis.
Aim : To review our experience in the first 200 attempted PTMV procedures in patients with mitral stenosis, and the short and medium term follow-up.
Methods : PTMV was attempted on 200 occasions in 189 patients with significant mitral stenosis between May 1988 and May 1994. There were 156 females and 33 males, mean age 53.5 years (range 14 to 83 years). Six patients were pregnant at the time of the procedure.
Results : Valve split was achieved at the initial attempt in 183/189 procedures (97%). Clinical improvement of at least one New York Heart Association (NYHA) functional class was achieved in 172/189 patients (91%). The mean mitral valve gradient (mean±SD) decreased from 11.5±5.1 mmHg to 4.9±4.1 mmHg, mean cardiac output rose from 3.9±1.1 L/minute to 4.4±1.4 L/minute and mean calculated mitral valve area increased from 1.0±0.3 cm² to 2.1±0.9 cm². Ten patients developed clinically significant mitral incompetence requiring surgical mitral valve replacement. There were two transient cerebral embolic events. Small atrial septal defects were detected echocardio-graphically in 42 patients, but none has been a clinical problem. There were no early deaths; there were 11 late deaths, four of which were non-cardiac. Twenty patients have had repeat PTMV for re-stenosis, four to 67 months after the first.
Conclusions : PTMV provides significant haemodynamic and clinical improvement with low risk and should be considered the treatment of choice in patients with mitral stenosis.     

Retrograde Mitral Valvuloplasty—A Further Approach to Balloon Commissurotomy

Mitral valve balloon dilatation usually requires transseptal puncture. We performed a mitral valve dilatation without transseptal puncture, introducing guidewires and balloons exclusively from the arterial side in a 37-year-old woman with post-rheumatic mitral stenosis. Three months later, pulmonary artery pressure had decreased from 60/35 to 40/20 mmHg and the enddiastolic pressure gradient from 20 to 8 mmHg. The mitral valve area increased from 1.3 to 2. 3 cm^2. The severely disabled patient was asymptomatic following the procedure. This case demonstrates the possibility of performing retrograde balloon dilatation of the mitral valve without transseptal puncture.     

Percutaneous Mechanical Mitral Commissurotomy with the Metallic Valvulotome: Detailed Technical Aspects and Overview of the Results of the Multicenter Registry on 882 Patients

Percutaneous mechanical mitral commissurotomy (PMMC) is a new technique that has been developed over the last 3 years for the treatment of mitral stenosis. The device used opens the commissures by a direct action of two parallel bars located in a metallic head screwed at the distal end of a 13Fr catheter. Opening of the bars is obtained with the use of activating pliers attached at the proximal end of the catheter. The metallic dilator and the pliers can be safely reused after sterilization. The device and the direrent steps of the procedure are detailed in this article. The results of an international registry including 882 patients are reported here. PMMC could be achieved in 863 (98%) cases. Maximal opening of the bars was 40 mm in 90% of the cases. The technique resulted in an increase of the mitral valve area from 0.94 ± 0.2 cm² to 2.12 ± 0.4 cm². Bilateral splitting of the commissures was achieved in 85% of the cases. Complications occurred in 33 (3.7%) patients: pericardial tamponade in 1.4% (12 cases, one death), mitral regurgitation > grade 2 in 2.1% (18 cases, surgery required in 4), and transient stroke in 0.3% (3 patients). The role of the learning curve in the occurrence of complications has been clearly demonstrated. The cost of the procedure has been markedly decreased in developing countries due to multiple reuses of the device after sterilization.     

Percutaneous transseptal mitral commissurotomy in pregnant women with critical mitral stenosis.

BACKGROUND: Percutaneous transseptal mitral commissurotomy has been successfully performed in selected pregnant patients with severe symptomatic mitral stenosis. Its safety and efficacy needs to be evaluated in a large number of cases. METHODS AND RESULTS: Percutaneous transseptal mitral commissurotomy was performed in 85 severely symptomatic (New York Heart Association functional class III or IV) pregnant women aged 22.7+/-4.1 years (range 18-39 years) with critical mitral stenosis at 24.8+/-4.7 weeks (range 20-34 weeks) of gestation. Percutaneous valvotomy was performed using a flow-guided Inoue balloon in all the patients. The procedure was considered successful in 80 (94%) patients. The hemodynamic mean end-diastolic gradient decreased from 26.7+/-6.8 mm Hg (range 16-35 mmHg) to 4.5+/-3.8 mmHg (range 0-14 mmHg) (p<0.001). The mean diastolic gradient decreased from 29.1+/-9.1 mmHg (range 18-38 mmHg) to 7.2+/-4.1 mmHg (range 4.1-18 mmHg) (p<0.001). The mean mitral valve area assessed by echocardiography increased from 0.75+/-0.5 cm2 (range 0.4-1.0 cm2) to 2.0+/-0.5 (range 1.0-2.7 cm2) (p<0.001). The mean fluoroscopy time was 3.6+/-3.2 minutes. The results of the mitral valvotomy were considered suboptimal in 4 patients. Mitral regurgitation increased by 1 grade in 16 patients and more than 2 grades in 2 patients. One patient developed pericardial tamponade during the procedure and was managed by catheter drainage. Percutaneous mitral valve dilatation was then successfully performed in this patient. No fetal abortion occurred after the procedure. CONCLUSIONS: The results of this study indicate that percutaneous transseptal mitral commissurotomy is a safe and effective procedure for severe symptomatic mitral stenosis in pregnancy.     

Left Atrial Contribution to Left Ventricular Filling in Patients with Mitral Stenosis: Combined Analysis of Transmitral and Pulmonary Venous Flow Velocities

We recorded transmitral and pulmonary venous flow velocities using transthoracic continuous-wave and transesophageal pulsed Doppler echocardiography, respectively, in 36 patients with mitral stenosis who were in sinus rhythm to investigate the left atrial contribution to left ventricular filling in mitral stenosis. The mitral valve area was determined by transthoracic two-dimensional short-axis echocardiography. Patients were classified as having mild stenosis (± 1.5 cm², n = 17) or moderate stenosis (< 1.5 cm², n = 19). The mean pulmonary capillary wedge pressure and left atrial maximal diameter were significantly larger, and left atrial volume change during atrial contraction was significantly smaller in the moderate group than in the mild group. The percent left atrial contribution to left ventricular filling, estimated from the transmitral flow velocity, the peak atrial systolic velocity, and the percent ratio of left atrial systolic regurgitation to left atrial filling, estimated from the pulmonary venous flow velocity, were significantly lower in the moderate group than in the mild group. The percent left atrial contribution to left ventricular filling, the peak atrial systolic velocity, and the percent ratio of left atrial systolic regurgitation to left atrial filling were positively correlated with the mitral valve area and negatively correlated with the mean pulmonary capillary wedge pressure. These results suggest that the left atrial contribution to left ventricular filling in patients with mitral stenosis in sinus rhythm decreases as the severity of valve stenosis increases, and that analysis of the atrial systolic waves of the transmitral and pulmonary venous flow velocities provides important information for evaluation of left atrial systolic performance in patients with mitral stenosis.     

Commissurotomie mitrale percutanée associée à une communication interauriculaire type sinus venosus et un retour veineux anormal partiel : à propos d’un cas

Lutembacher's syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. It is rarely associated to partial anomalous pulmonary venous connection. This condition is treated surgically by mitral commissurotomy or mitral valve operation with concomitant closure of the atrial septal defect with correction of the abnormal pulmonary venous connection. Percutaneous mitral commissurotomy before surgery can be a therapeutic alternative when mitral valve stenosis is severe and valve anatomy is favourable. The authors bring back the case of a 24 years old man having mitral stenosis in sinus rhythm associated to sinus venosus septal defect and partial anomalous pulmonary venous connection. The diagnosis was made for the age of 17 years old on the occasion of dyspnea. He benefited in February 2003 of rescue percutaneous mitral commissurotomy because of pulmonary oedema. Mitral valve area increased from 0.7 cm² to 1.6 cm². The patient was clinically approved, so that he refused surgery and was lost sight. Seven years later (August 2010) he was taken back for a second rescue percutaneous mitral commissurotomy because of a very severe mitral stenosis (mitral valve area was 0.8 cm²), in pulmonary oedema with echocardiographic evaluated pulmonary hypertension at 68 mmHg. The trans-septal complicated of a false road from the right atrium, towards the pericardic cavity. The patient was operated as the matter of urgency, and benefited from a mitral valve replacement by mechanical prosthesis, of closure of sinus venosus septal defect by PTFE patch and correction of abnormal pulmonary venous connection. Operating suites were simple, and the postoperative echocardiography concludes to a good prosthesis profile, the absence of residual shunt and a decrease of pulmonary artery blood pressure from 68 to 40 mmHg. In conclusion, percutaneous mitral commissurotomy may be a waiting procedure for surgery of this disease or emergency treatment of it's valve anomaly, with regular monitoring while awaiting surgery faster and in better conditions.     

Prophylactic aortic valve replacement in older patients for mild aortic stenosis during coronary bypass surgery

Coronary bypass surgery (CBS) is performed in many older patients who frequently also have mild calcific aortic stenosis. It is important that a correct assessment of the severity of aortic stenosis is done by calculating the aortic valve area. Mild aortic stenosis is aortic valve area >1.5 cm², >0.9 cm²/m²; severe aortic stenosis is aortic valve area = 1.0 cm², = 0.6 cm²/m². Patients who have severe aortic stenosis should have aortic valve replacement (AVR) at the time of CBS. Patients with mild aortic stenosis should not have AVR simultaneously with CBS because: 1) patients having AVR+CBS have a higher operative and 10-year mortality; 2) prosthetic heart valves are associated with a complication rate of 2%-6% per year; and 3) only about 12% of patients with mild aortic stenosis will have developed severe aortic stenosis in 10 years. Performing AVR for mild aortic stenosis at the time of CBS will probably result in 91 unnecessary AVRs and 29 excess deaths in 10 years.     

Hemodynamic Support Using the Impella 2.5 Catheter System during High-Risk Percutaneous Coronary Intervention in a Patient with Severe Aortic Stenosis

The Impella 2.5 catheter is a percutaneously implanted left ventricular assist device cleared by the Food and Drug Administration to provide circulatory support for up to 6 hours. The presence of aortic stenosis is deemed to be a contraindication to its use, and ongoing clinical trials exclude patients with an aortic valve area of 1.5 cm² or less. We describe a case of severe aortic stenosis with an estimated valve area of 0.9 cm² and severe ischemic cardiomyopathy in whom the Impella catheter was successfully used for high-risk multivessel percutaneous coronary intervention. (J Interven Cardiol 2010;23:66–69)     

Mitral Balloon Valvuloplasty as an Outpatient Procedure Using Inoue Balloon Technique

Objective: To evaluate the safety and feasibility of mitral balloon valvuloplasty (MBV) as an outpatient procedure. Background: MBV is usually done as an inpatient procedure, requiring 3–4 days of hospital admission. Only one report is available about MBV as a day case procedure in the English literature. Methods: Between October 1994 and December 1996, 128 patients underwent MBV using an Inoue balloon. Of those, 31 patients (Group I) had the procedure as outpatients and 97 patients (Group II) as inpatients. Their mean age in Group I was 29 ± 9 years and in Group II 32 ± 10 years (P < 0.3). Atrial fibrillation was present in 4 patients in Group I and in 13 patients in Group II (P < 0.99). Results: Hemodynamic study revealed that mitral valve area increased from 0.9 ± 0.2 to 1.9 ± 0.5 cm²* in Group I and from 0.8 ± 0.2 to 1.7 ± 0.5 cm²* in Group II, Left atrial pressure decreased from 24 ± 5 to 15 ±6 mm Hg* in Group I and 24 ± 6 to 16 ± 5 mmHg in Group II.* Mitral valve gradient decreased from 15 + 5 to 5 + 2 mmHg in Group I and 15 + 5 to 6 + 3 mmHg in Group II* (*P < 0.001). Patients in Group I stayed in the Preadmission Unit for a mean period of 9.5 ± 2.5 hours. Patients in Group II stayed for a mean of 2.5 days in the hospital. Severe mitral regurgitation developed in one patient in each Group and needed semiurgent mitral valve replacement without sequela. No death, convulsions, or thromboembolism were encountered, and three patients in both Groups developed minor hematoma and needed no additional treatment. Conclusion: MBV as an outpatient procedure is feasible and safe and could significantly decrease the cost of medical care.     

Results of percutaneous double-balloon mitral commissurotomy in one medical center in Tunisia

Percutaneous balloon mitral commissurotomy was attempted in Tunisia, where rheumatic fever is still endemic, in 463 consecutive patients with severe rheumatic mitral valve stenosis. Their mean age ±SD was 33 ± 12 years (range 8 to 68), 324 patients (70%) were women, and 327 (71%) were in sinus rhythm. Valvotomy was technically successful in 454 patients (98%). The mean mitral valve gradient decreased from 20 ± 7 to 6 ± 4 mm Hg, mean left atrial pressure decreased from 27 ± 8 to 15 ± 6 mm Hg, cardiac index increased from 3.0 ± 0.7 to 3.6 ± 0.8 L/min/m², and Gorlin mitral valve area, from 0.97 ± 0.19 to 2.2 ± 0.4 cm² (all p < 0.001). Two-dimensional echocardiographic mitral valve area increased from 1.03 ±0.18 to 2.15 ± 0.36 cm² (p < 0.00001). A final valve area of ≥1.5 cm² was achieved in 98% of patients. Multivariate analysis identified a pre-mitral valve area <0.8 cm² and an echocardiographic score (echo score) ≥12 as the strongest predictors of residual stenosis (final mitral valve area <1.5 cm²). Major procedural complications included mortality (0.4%), tamponade (0.7%), thromboembolism (2.0%), severe mitral regurgitation (4.6%), significant (pulmonary to systemic flow ratio ≥1.5) interatrial shunt (4.8%). Four hundred thirty patients were followed up between 6 and 82 months (mean 37 ± 22): 95% were in functional class I to II without reintervention, and 7 patients died (1.6%); restenosis (echocardiographic mitral valve area <1.5 cm²) occurred in 10.4% of patients. The 3-year Kaplan-Meier freedom from restenosis was 92%, and from reintervention 93%. Because fluoroscopic calcium and postprocedure mitral valve area <-1.8 cm² were the independent predictors of restenosis, patients with calcified valves should be selected for this procedure on a case-to-case basis.     

Valve Resistance in Mitral Stenosis

To evaluate the value and the determinants of valve resistance in mitral stenosis, 95 patients with pure mitral stenosis were examined by Doppler echocardiography during their clinical follow-up, measuring cavity dimensions, left ventricular function, mitral area (by planimetry and pressure half time), mean transmitral pressure gradient, aortic flow, and pulmonary artery systolic pressure. The mitral resistance was calculated as mean transmitral pressure gradient/aortic flow ratio. To graduate the severity of the morphological abnormalities in valvular structure, we used a point score system with evaluation of leaflet and subvalvular thickness, calcification, and valvular mobility. The functional class was determined according to NYHA classifcation. In this study, both mitral area (r = -0.79, P < 0.001 and r_p= -0.60, P < 0.001) and mitral score (r = 0.68, P < 0.001 and r_p= 0.25, P = -0.013) were independent determinants of mitral resistance. In multivariate analysis, mitral resistance and female gender were selected by multiple linear regression analysis as determinants of pulmonary artery systolic pressure, and mitral area and pulmonary artery systolic pressure were selected by logistic linear regression analysis as determinants of NYHA functional class. In patients with moderate or severe mitral stenosis, the estimated probability for III and IV NYHA functional class considering mitral area 1 cm² or below went from 51.1–86.4% when mitral resistance below or above 130 dynes.sec.cm,⁻⁵ respectively, was considered together. Thus, mitral valve resistance should be used as a complement to the mitral area method in assessment of mitral stenosis, adding the effects of the reduction in mitral area and the damage in mitral valve apparatus.     

Echocardiographic Criteria in Selection of Patients for Percutaneous Mitral Commissurotomy

The purpose of this report is to review the role of echocardiography in the selection of patients for percutaneous mitral commissurotomy (PMC). Echocardiography has become the standard for the assessment of the severity of mitral stenosis and of its consequences. PMC is usually performed only in patients with a valve area of < 1.5 cm², whereas pulmonary hypertension or spontaneous echo contrast in the left atrium may lead to intervention in patients with few symptoms. The next step of the echocardiographic evaluation is to eliminate contraindications: left atrial thrombosis (by the systematic performance of a transesophageal examination before PMC), mitral regurgitation ≥ 2/4, severe aortic valve disease, mixed tricuspid valve disease, and massive or bicommissural calcification. Finally, echocardiography allows the classification of patients into different anatomic groups for prognostic consideration. There is controversy regarding the best echo score system in the prediction of the results of PMC. Scores using a global evaluation of the valve anatomy are the most widely used, whereas more recently, scores taking into account the uneven distribution of the disease have had promising preliminary results. Overall, echo scores are useful criteria for selecting candidates for PMC, but they should be considered together with the other clinical and procedural variables. Thus, echocardiography has an important role in the selection of patients for PMC, as well as for the guidance of the procedure, the evaluation of the results, and surveillance.     

Immediate and Long-Term Outcome of Redo Percutaneous Mitral Valvuloplasty: Comparison with Initial Procedure in Patients with Rheumatic Mitral Restenosis

Aims: We explored the immediate and long-term outcome of redo percutaneous mitral valvuloplasty (PMV) in a series of patients with mitral restenosis in comparison with initial PMV in the same series.
Methods: We enrolled 40 consecutive patients presenting with mitral restenosis after successful initial PMV. Redo PMV was performed by the antegrade transseptal approach using either the Inoue technique or the multitrack technique. Reassessment by transthoracic echocardiography was repeated 48 hours later, and annually thereafter. Procedural success was defined as 50% or more increase of mitral valve area (MVA) with a final MVA ≥1.5 cm², without major complications. Restenosis was defined as loss of >50% of the initial gain of MVA by the preceding PMV with a final MVA <1.5 cm².
Results: Procedural success was achieved in 37 (92.5%) patients. Both the initial and redo procedures were similar concerning the final MVA and mean transmitral pressure gradient (P > 0.05 for all). The gain of MVA was higher in the initial as compared to the redo procedure (P < 0.001). The initial mitral valve score correlated negatively with the final MVA in both the initial and redo procedures, and was the only independent predictor of the time to redo procedure, by multivariate regression analysis. At long-term follow-up (61 ± 2.8 months), the mean MVA was 1.6 ± 0.3 cm². Three patients—out of 12 available for follow-up—developed restenosis.
Conclusion: Redo PMV for mitral restenosis is feasible, safe, and achieves immediate and long-term outcome comparable to initial PMV. (J Interven Cardiol 2010;23:1–6)     

Percutaneous balloon mitral valvuloplasty in comparison with open mitral valve commissurotomy for mitral stenosis during pregnancy.

OBJECTIVES: We sought to compare the maternal and fetal outcomes of patients with severe mitral stenosis submitted to percutaneous balloon dilation versus open mitral valve commissurotomy (MVC) during pregnancy. BACKGROUND: Heart failure in patients with mitral stenosis complicating pregnancy is a common problem in developing countries. Since 1984, percutaneous dilation of the mitral valve using a balloon catheter has become a therapeutic alternative to open heart surgery. Although the efficacy of percutaneous mitral valve balloon dilation is well established, its results have never before been compared with the results of commissurotomy during pregnancy. METHODS: We compared the clinical and obstetric complications in 45 women who were treated with percutaneous mitral valve balloon dilation (group I, n = 21; from 1990 to 1995) or open MVC (group II, n = 24; from 1985 to 1990) for severe heart failure due to mitral stenosis during pregnancy. RESULTS: In our study, percutaneous balloon dilation of the mitral valve had a success rate of 95% (Gorlin formula) and 90.5% (echocardiographic "pressure half-time" method), as demonstrated by the final mitral valve area achieved. This improvement was followed by a marked decrease in the mitral valve gradient, left atrial pressure and mean pulmonary artery pressure. Patients in both groups had similar improvements in symptoms. Patients who underwent percutaneous balloon dilation had significantly fewer fetal complications, with a reduction in fetal and neonatal mortality (1 death in group I vs. 8 in group II, p = 0.025). CONCLUSIONS: Percutaneous balloon mitral valvuloplasty is safe and effective and appears to be preferable for the fetus, compared with open MVC during pregnancy.     

DOPPLER ECHOCARDIOGRAPHIC DETERMINATION OF AORTIC VALVE AREA USING THE CONTINUITY EQUATION

The noninvasive measurement of aortic valve area by use of the continuity equation has been proposed as an accurate method for determining the severity of aortic stenosis. In 32 patients (mean age 64±14 years) with proven aortic stenosis and without significant regurgitation, aortic valve areas derived by the Gorlin equation from cardiac catheterisation data were compared with valve areas calculated from the continuity equation using Doppler echocardiography.
There was a close correlation between Doppler and catheter derived aortic valve areas (r = 0.87, SEE = 0.17 cm²). The interobseryer error for aortic valve area measurement in 20 patients was 9.0 ± 6.8%. The specificity of this method for critical aortic stenosis (aortic valve area less than 0.75 cm²) was 73% and the sensitivity 88%.
We conclude that in an adult, predominantly elderly population with calcific aortic stenosis, this Doppler echocardiographic method is reproducible and can be used accurately to derive aortic valve area.     

Technique and Results of Percutaneous Mitral Valvuloplasty with the Multi-Track System

The Multi-Track System is a simplified double-balloon technique for percutaneous mitral valvuloplasty. Here we describe the technique and report the results obtained using it. The Multi-Track catheter has a short distal tip for connection to the guidewire. This leaves the rest of guidewire free to receive other catheters. Various catheters can be introduced over the same guidewire. The balloons are introduced one after the other allowing a smaller size of vascular access and transseptal passage. Furthermore, simultaneous pressure measurements in the left atrium and left ventricle are possible through a simple venous access, allowing avoidance of arterial puncture. We used this technique worldwide between June 1994 and February 2000 for the treatment of 153 patients with mitral stenosis worldwide. In 12 cases, the procedure was done using the exclusive venous approach. The mean mitral valve area increased from 0.75 ± 0.22 to 2 ± 0.33 cm²and the mean left atrial pressure dropped from 27 ± 8 to 11 ± 4 mmHg. Four patients had a significant increase in mitral regurgitation, requiring surgical treatment in two patients. There was no mortality. The Multi-Track system is a valid user-friendly and cost-effective alternative for the treatment of mitral stenosis. It is a rapid and effective procedure associated with low risks.     

Percutaneous balloon dilatation of the mitral valve in critically ill young patients with intractable heart failure.

OBJECTIVE--To assess the outcome of percutaneous balloon dilatation of the mitral valve in critically ill young patients with intractable heart failure. DESIGN--Retrospective analysis of all such patients presenting over a period of 4 years. PATIENTS--Of 432 consecutive patients undergoing percutaneous balloon dilatation of the mitral valve, 12 (mean age 29 years) with intractable heart failure were identified. Nine had severe pulmonary oedema and three had pulmonary oedema with severe right heart failure and hypotension. Three patients were pregnant and three required mechanical; ventilatory support. PROCEDURE--Percutaneous balloon dilatation of the mitral valve was performed using the Inoue balloon technique. The procedure was shortened by excluding full right study, cardiac output measurement, and left ventriculography. The mitral valve morphology and mitral valve area were determined before and after percutaneous balloon dilatation using cross sectional Doppler echocardiography. RESULTS--The procedure was technically successful in all patients. The mean (SD) echocardiographic value of the mitral valve area increased from 0.7 (0.1) to 1.4 (0.2) cm2 with a concomitant reduction in pulmonary artery systolic pressure (Doppler) from 81 (17) to 50 (7) mm Hg. There was a significant clinical improvement in all patients. The mean (range) fluoroscopy time for the procedure was 6.9 (1.7-14.1) min. During follow up (mean 10 months) nine patients were in New York Heart Association (NYHA) functional class I, one was in class II, one under NYHA elective mitral valve replacement, and one, who refused elective surgery, died suddenly at home. CONCLUSION--Percutaneous balloon dilatation of the mitral valve can be performed as a life saving procedure in critically ill patients with mitral stenosis, as even a modest increase in valve area in these patients produces gratifying clinical improvement.     

Treatment of severe mitral stenosis with percutaneous balloon valvotomy in pregnant patients

Background: Pregnancy can cause life-threatening complications in women with mitral stenosis. Frequently, there is an urgent need to increase the mitral valve area mechanically. In selected cases, percutaneous mitral balloon valvotomy (PMBV) has emerged as a safe and effective alternative to surgical commissurotomy. Hypothesis: The study evaluates the effects of PMBV by the Inoue technique in nine pregnant patients with severe symptomatic mitral stenosis. Methods: The patients were in New York Heart Association (NYHA) functional class II to IV and had echocardiographic scores of ≤ 8. The mean gestational age was 24.8 ± 6.1 weeks. The patient's pelvic and abdominal regions were covered with a lead apron to protect the fetus from radiation. A stepwise dilatation technique was used. Fluoroscopy time was kept to 10 to 15 min. Results: One patient developed severe mitral regurgitation requiring emergency valve replacement. The remaining eight patients showed marked immediate symptomatic and hemodynamic improvement. After dilatation, the transmittal pressure gradient decreased from 20.8 ± 6.5 to 7.3 ± 1.4 mmHg (p = 0.001) and the calculated mitral valve area increased from 0.9 ± 0.1 to 1.8 ± 0.4 (p < 0.001). All patients had uneventful term deliveries of normal babies. On follow-up they were in NYHA functional class I. Conclusions: Percutaneous mitral balloon valvotomy is a safe and effective procedure for selected pregnant patients with severe mitral stenosis. The procedure is well tolerated by the fetus. Severe mitral regurgitation requiring immediate surgery may occur occasionally. The possible harmful effects to the fetus from its exposure to radiation during PMBV are unknown.     

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.