Balloon mitral valvotomy in a patient with Ebstein's anomaly of tricuspid valve and rheumatic mitral stenosis.

We report a young woman with Ebstein's anomaly of tricuspid valve and rheumatic mitral stenosis who successfully underwent mitral valvotomy using double balloon technique. The clinical and haemodynamic benefits are sustained at 1 year followup.     

Effect of balloon mitral valvotomy on left ventricular function in rheumatic mitral stenosis

AimMitral stenosis (MS) is found to produce left ventricular (LV) dysfunction in some studies. We sought to study the left ventricular function in patients with rheumatic MS undergoing balloon mitral valvotomy (BMV). Ours is the first study to analyze effect of BMV on mitral annular plane systolic excursion (MAPSE), and to quantify prevalence of longitudinal left ventricular dysfunction in rheumatic MS.MethodsIn this prospective cohort study, we included 43 patients with severe rheumatic mitral stenosis undergoing BMV. They were compared to twenty controls whose distribution of age and gender were similar to that of patients. The parameters compared were LV ejection fraction (EF) by modified Simpson's method, mitral annular systolic velocity (MASV), MAPSE, mitral annular early diastolic velocity (E′), and myocardial performance index (MPI). These parameters were reassessed immediately following BMV and after 3 months of procedure.ResultsMASV, MAPSE, E′, and EF were significantly lower and MPI was higher in mitral stenosis group compared to controls. Impaired longitudinal LV function was present in 77% of study group. MAPSE and EF did not show significant change after BMV while MPI, MASV, and E′ improved significantly. MASV and E′ showed improvement immediately after BMV, while MPI decreased only at 3 months follow-up.ConclusionsThere were significantly lower mitral annular motion parameters including MAPSE in patients with rheumatic mitral stenosis. Those with atrial fibrillation had higher MPI. Immediately after BMV, there was improvement in LV long axis function with a gradual improvement in global LV function. There was no significant change of MAPSE after BMV.     

Concurrent double balloon valvotomy for combined rheumatic mitral and tricuspid stenosis

We expanded the application of percutaneous balloon valvotomy (PBV) to 4 adults (age 14 to 30 years, average 22.2 years) with combined rheumatic mitral and tricuspid stenosis. Double balloon dilatation reduced the transmitral gradient from 17.36 +/- 3.54 to 5.52 +/- 0.89 (P less than 0.025) and transtricuspid gradient from 12.65 +/- 2.67 to 3.67 +/- 0.95 (P less than 0.025). Mitral and tricuspid valve area increased from 0.73 +/- 0.20 to 2.57 +/- 0.67 (P less than 0.005) and from 0.77 +/- 0.24 to 2.67 +/- 0.24 cm2 (P less than 0.005), respectively. The procedures were well tolerated, with no significant increase in valvular regurgitation or left to right shunt across the atrial septum. The excellent symptomatic and haemodynamic benefits are sustained at 3-24 months follow-up. It is concluded that combined dilatation of stenotic valves by double balloon technique can emerge as an alternative to surgery in selected patients with polyvalvar rheumatic heart disease.     

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.     

风湿性心脏病二尖瓣狭窄患者球囊扩张术后6个月疗效观察

目的　评价经皮二尖瓣球囊扩张术 (PBMV)在老年及瓣膜钙化程度重的患者中的 6个月效果。　方法　选择我院行PBMV患者 6 82例 ,以血液动力学评价术前及术后即刻左房压、肺动脉平均压、二尖瓣跨瓣压差及二尖瓣瓣口面积 ;超声心动图评价术前和术后 6个月二尖瓣口面积及跨瓣压差。　结果　PBMV有效缓解二尖瓣口的机械性狭窄 ,引起左房压、二尖瓣跨瓣压 ,肺动脉压力下降及二尖瓣口面积 (MVA)增加 ,两组患者均获益 ,老年组分别平均下降 (9 1± 1 1)mmHg、(10 9± 2 2 )mmHg、(9 1± 1 5 )mmHg、MVA增加 (0 5 2± 0 16 )cm2 ;非老年组分别为 (8 9± 2 4 )mmHg、(7 3± 0 8)mmHg、(7 3± 2 3)mmHg、MVA增加 (0 6 6± 0 11)cm2 。超声随访结果显示 ,PBMV疗效稳定。　结论　PBMV较为明显的改善二尖瓣狭窄症状 ,具有微创、低风险的特点。适用于瓣膜钙化重、条件差和高危围术期而不适合二尖瓣置换术的老年患者。     

A rare association of Ebstein's anomaly of tricuspid valve with rheumatic mitral stenosis

Mitral valve abnormalities have been described in Ebstein's anomaly, but acquired rheumatic mitral valve disease is an extremely rare association. We describe a classical case of Ebstein's anomaly of tricuspid valve with severe rheumatic mitral stenosis. This patient had mild mitral regurgitation, pulmonary hypertension and atrial fibrillation.     

Percutaneous mitral balloon valvotomy in a case of situs inversus dextrocardia with severe rheumatic mitral stenosis

The efficacy, safety and applicability of Inoue balloon technique for BMV are clearly established worldwide in selected subset of patients with rheumatic mitral stenosis (MS). However, in altered cardiac anatomy it offers technical challenges. Distorted cardiac anatomy and cardiac malpositions considerably increase the complications involved in interatrial septal puncture and left ventricular entry during BMV. There are only a few reports worldwide on successful BMV in altered cardiac anatomy using the standard Inoue technique. Here we describe a case of a 27-year-old female with situs inversus and dextrocardia, where BMV was successfully performed with a few modifications of the standard Inoue technique previously described in similar patients.     

Single balloon valvotomy for rheumatic mitral restenosis

Four male patients aged 22 to 35 years (mean 29 +/- 5.6) with mitral restenosis following closed mitral valvotomy 6 to 12 years (mean 8.5 +/- 2.5) ago were subjected to percutaneous single balloon valvotomy. There was significant increase in the area of the mitral valve accompanied by a substantial reduction in the transmitral gradient (P less than 0.01). Mitral regurgitation of grade +1 developed in one patient. Balloon valvotomy may be safely and effectively performed in selected patients with mitral restenosis after surgical commissurotomy.     

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.     

Percutaneous balloon valvotomy for patients with severe mitral stenosis

Thirty-five patients with severe mitral stenosis underwent percutaneous mitral valvotomy (PMV). There were 29 female and six male patients (mean age 49 +/- 3 years, range 13 to 87). After transseptal left heart catheterization, PMV was performed with either a single- (20 patients) or double- (14 patients) balloon dilating catheter. Hemodynamic and left ventriculographic findings were evaluated before and after PMV. There was one death. Mitral regurgitation developed or increased in severity in 15 patients (43%). One patient developed complete heart block requiring a permanent pacemaker. PMV resulted in a significant decrease in mitral gradient from 18 +/- 1 to 7 +/- 1 mm Hg (p less than .0001) and a significant increase in both cardiac output from 3.9 +/- 0.2 to 4.6 +/- 0.2 liters/min (p less than .001) and in mitral valve area from 0.8 +/- 0.1 to 1.7 +/- 0.2 cm2 (p less than .0001) Effective balloon dilating diameter per square meter of body surface area correlated significantly with the decrease in mitral gradient but did not correlate with the degree of mitral regurgitation. There was no correlation of age, prior mitral commissurotomy or mitral calcification with hemodynamic results. PMV is an effective nonsurgical procedure for patients with mitral stenosis, including those with pliable valves, those with previous commissurotomy, and even those with mitral calcification.     

Balloon mitral valvotomy in youngest documented rheumatic mitral stenosis patient

Juvenile rheumatic mitral stenosis (MS) is common in the Indian subcontinent. Early recognition and management is essential. Rarely rheumatic MS may occur in <5 years of age, wherein rapid hemodynamic progression and cardiac morbidity and mortality occurs. Severe/symptomatic MS in preschool age requires urgent and meticulous decision making. Condition of valve and wishes of parents may complicate management decisions. Percutaneous transmitral commissurotomy (PTMC) may, therefore, become the only life‐saving intervention in these cases unless contraindicated, although the procedure entails considerable technical issues in this age group. Herein, we report a successful balloon mitral valvotomy in a 4‐year‐old child with severe rheumatic MS (documented since 2 years 6 months of age) presenting with repeated pulmonary edema. To the best of our knowledge, this child is the youngest documented case of established rheumatic heart disease and also one of the youngest PTMC procedure performed. This report supports the clinical usefulness of PTMC in childhood MS; however, pertinent technical issues are raised, which needs a proper consensus. © 2015 Wiley Periodicals, Inc.     

Percutaneous mitral valvotomy in rheumatic mitral stenosis: a new approach

Three patients with rheumatic mitral stenosis were treated with percutaneous mitral valvotomy. A Brockenbrough catheter was advanced transseptally into the left atrium and then into the left ventricle over a long guide wire. An angle wire loop retriever was advanced through a 10 Fr straight catheter via the femoral artery into the left ventricle. The retriever was used to catch the flexible end of the long guide wire. This end of the long guide wire was then drawn out of the right femoral artery by the retriever through the straight catheter. The straight catheter was left in the descending aorta; the Brockenbrough catheter was removed and a 7 Fr balloon catheter was introduced percutaneously over the long guide wire through the femoral vein. This balloon catheter was used for interatrial septal dilatation and right femoral venous dilatation. In two patients this catheter was replaced over the long guide wire with a 9 Fr Schneider-Medintag Grüntzig catheter (3 X 12 mm diameter when inflated) and in the other by a Mansfield (18 mm diameter when inflated). The procedure was well tolerated in these three patients and there were no complications. Haemodynamic function improved, there was appreciable decrease in dyspnoea, and exercise tolerance was increased. This procedure has several advantages: the balloon is more easily positioned through the mitral valve; the stability of the balloon during inflation is improved by traction at both ends of the long guide wire; and there is the option of rapidly exchanging one balloon for a larger one over the long guide wire. This technique seems to be less arrhythmogenic and results in less blood loss because manual compression of the femoral vessels after the procedure is easier.     

Critical mitral stenosis causing ischemic hepatic failure. Successful treatment by percutaneous balloon mitral valvotomy.

We report a 52-year-old patient with severe mitral stenosis who developed new onset atrial fibrillation, low output congestive heart failure and fulminant ischemic hepatic failure with subsequent severe coagulopathy. Percutaneous mitral valvotomy resulted in dramatic clinical improvement with complete resolution of liver function. This case illustrates the potential life-saving role for percutaneous balloon mitral valvotomy in treating critically ill patients who are unable to undergo thoracotomy due to coexisting medical illness.