Mid-term (up to 12 years) clinical and echocardiographic outcomes of percutaneous transvenous mitral commissurotomy in patients with rheumatic mitral stenosis

Abstract Background Rheumatic heart disease (RHD) is still a concerning issue in developing countries. Among delayed RHD presentations, rheumatic mitral valve stenosis (MS) remains a prevalent finding. Percutaneous transvenous mitral commissurotomy (PTMC) is the intervention of choice for severe mitral stenosis (MS). We aimed to assess the mid-term outcome of PTMC in patients with immediate success. Methods In this retrospective cohort study, out of 220 patients who had undergone successful PTMC between 2006 and 2018, the clinical course of 186 patients could be successfully followed. Cardiac-related death, undergoing a second PTMC or mitral valve replacement (MVR) were considered adverse cardiac events for the purpose of this study. In order to find significant factors related to adverse cardiac outcomes, peri-procedural data for the studied patients were collected.The patients were also contacted to find out their current clinical status and whether they had continued secondary antibiotic prophylaxis regimen or not. Those who had not suffered from the adverse cardiac events were additionally asked to undergo echocardiographic imaging, in order to assess the prevalence of mitral valve restenosis, defined as mitral valve area (MVA) < 1.5 cm2 and loss of ≥ 50% of initial area gain. Results During the mean follow-up time of 5.69 ± 3.24 years, 31 patients (16.6% of patients) had suffered from adverse cardiac events. Atrial fibrillation rhythm (p = 0.003, HR = 3.659), Wilkins echocardiographic score > 8 (p = 0.028, HR = 2.320) and higher pre-procedural systolic pulmonary arterial pressure (p = 0.021, HR = 1.031) were three independent predictors of adverse events and immediate post-PTMC mitral valve area (IMVA) ≥ 2 cm2 (p < 0.001, HR = 0.06) was the significant predictor of event-free outcome. Additionally, follow-up echocardiographic imaging detected mitral restenosis in 44 patients (23.6% of all patients). The only statistically significant protective factor against restenosis was again IMVA ≥ 2 cm2 (p = 0.001, OR = 0.240). Conclusion The mid-term results of PTMC are multifactorial and may be influenced by heterogeneous peri-procedural determinants. IMVA had a great impact on the long-term success of this procedure. Continuing secondary antibiotic prophylaxis was not a protective factor against adverse cardiac events in this study. (clinicaltrial.gov registration: NCT04112108).

Download Full-text

Effect of Mitral Valve Leaflets Excursion on Mitral Valve area after Percutaneous Trans- Venous Mitral Commissurotomy

Cardiovascular Journal ◽

10.3329/cardio.v10i1.34354 ◽

2017 ◽

Vol 10 (1) ◽

pp. 3-7

Author(s):

Md Abdul Mannan ◽

AAS Majumder ◽

Solaiman Hossain ◽

Mohammad Ullah ◽

SNI Kayes

Keyword(s):

Mitral Valve ◽

Mitral Stenosis ◽

Posterior Leaflet ◽

Anterior Leaflet ◽

Valve Morphology ◽

Mitral Valve Area ◽

A Value ◽

Percutaneous Transvenous Mitral Commissurotomy ◽

Mitral Commissurotomy ◽

Valve Area

Background: Aim of our study was to predict the effect of mitral valve leaflets excursion on mitral valve area following percutaneous transvenous mitral commissurotomy PTMC in patients of mitral stenosis.Methods: Total 70 patients with severe mitral stenosis who underwent PTMC were enrolled in the study.Transthoracic echocardiography was done the day before PTMC and 24-48 hours after PTMC. Mitral valve area, anterior and posterior leaflets excursion were recorded. The relation between leaftlet excursion and mitral valve after PTMC was evaluated.Results: Following PTMC there were significant increasein anterior leaflet excursion from 1.9 ± 0.2 to 2.3 ± 0.2cm (p<0.001), posterior leaflet excursion from 1.6±0.2to1.9 ± 0.2cm (p<0.001). Mitral valve areas increased from 0.8 ± 0.1 to1.7 ± 0.2cm²(p<0.001). Both leaflet excursion increased significantly with the increase in mitral valve area till the area reached a value of about 1.5 cm2, after which any further increase in mitral valve area was not associated with any further increase in leaflet excursion.Conclusion: PTMC is associated with immediate significant changes in mitral valve morphology in terms of splitting of fused mitral commissures, increased leaflets excursion and splitting of the subvalvular structures. Post PTMC leaflet excursion increases significantly with the increase in mitral valve area till the area reaches a value of about 1.5 cm2 after which any further increase in mitral valve area is not associated with any further increase in leaflet excursion.Cardiovasc. j. 2017; 10(1): 3-7

Download Full-text

Abstract 20155: 15-year Outcomes and Predictors of Success for Percutaneous Mitral Commissurotomy for Rheumatic Mitral Stenosis

Circulation ◽

10.1161/circ.130.suppl_2.20155 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

AlFazir Omar ◽

Amin Ariff ◽

Robaayah Zambahari ◽

Rosli Mohd Ali

Keyword(s):

Heart Disease ◽

Mitral Valve ◽

Mitral Stenosis ◽

Long Term Outcomes ◽

Mitral Valve Area ◽

Post Procedure ◽

Mitral Commissurotomy ◽

Procedural Success ◽

Valve Area

Background: Rheumatic heart disease remains the most common acquired heart disease in children, especially in developing countries. This study aims to investigate the predictors of immediate procedural success and the immediate and long-term outcomes in patients undergoing percutaneous mitral commissurotomy (PTMC). Methods: A total of 1552 patients with rheumatic mitral stenosis and underwent PTMC from 1989 to 2012 were identified. We divided the group according to Wilkins score as low risk (≤5), intermediate risk (6-8) and high-risk (≥9). Procedural success was defined as mitral valve area greater than 1.0cm2 with a mean gradient of less than 10mmHg. Results: The median age was 36 years old [IQR 28-45]. The majority of patients was female (78.5%) and did not have any other valve involvements (85.0%). Most of cases were elective (99.5%) although 103 patients were pregnant (6.6%) during PTMC. The mitral valve area increased from 0.8cm2 [IQR 0.7-1.0] pre-procedure to 1.5cm2 [IQR 1.3-1.7] post-procedure, with a reduction in the mean pressure gradient of 15mmHg [IQR 12-20] to 4mmhg [IQR 2-6] post-procedure (all p< 0.05). Using logistic regression analysis, no difference was seen in immediate procedural success between increasing age, previous PTMC, emergency cases, New York Heart Association status, balloon size or increasing risk groups (all p>0.05). During the 15-year follow-up, the majority of patients were still alive. Conclusions: PTMC appears to be safe and effective in our population, irrespective of older age, higher NYHA class, higher Wilkins score and previous PTMC with good immediate and long-term outcomes.

Download Full-text

Three-dimensional evaluation of the mitral valve area and commissural opening before and after percutaneous mitral commissurotomy in patients with mitral stenosis

European Heart Journal ◽

10.1093/eurheartj/ehl206 ◽

2006 ◽

Vol 28 (1) ◽

pp. 72-79 ◽

Cited By ~ 59

Author(s):

D. Messika-Zeitoun ◽

E. Brochet ◽

C. Holmin ◽

D. Rosenbaum ◽

B. Cormier ◽

...

Keyword(s):

Mitral Valve ◽

Mitral Stenosis ◽

Three Dimensional ◽

Mitral Valve Area ◽

Before And After ◽

Mitral Commissurotomy ◽

Valve Area

Download Full-text

Percutaneous Transluminal Mitral Commissurotomy in Nepalese children with Rheumatic Mitral Stenosis

Nepalese Heart Journal ◽

10.3126/njh.v10i1.9743 ◽

2014 ◽

Vol 10 (1) ◽

pp. 23-26 ◽

Cited By ~ 1

Author(s):

Manish Shrestha ◽

Chandra Mani Adhikari ◽

Urmila Shakya ◽

Aayush Khanal ◽

Shradha Shrestha ◽

...

Keyword(s):

Mitral Valve ◽

Mitral Regurgitation ◽

Mitral Stenosis ◽

Left Atrial ◽

Left Atrial Pressure ◽

Mitral Valve Area ◽

Mitral Commissurotomy ◽

Percutaneous Transluminal ◽

Percutaneous Transluminal Mitral Commissurotomy ◽

Valve Area

Background: Rheumatic heart disease is one of the most common heart diseases in developing country; however rheumatic mitral stenosis in children is relatively rare. Percutaneous transluminal mitral commissurotomy is a well established therapeutic intervention for mitral stenosis in adults. The study is conducted to determine the efficacy and safety of PTMC in children with severe mitral stenosis. Methods: A single centre retrospective study is conducted over a 3 and half years period (from 16th November, 2009 to 15th May, 2013) in Shahid Gangalal National Heart Centre, Kathmandu, Nepal. All consecutive patients aged less than 15 years who underwent Percutaneous transluminal mitral commissurotomy for severe mitral stenosis were included. Mitral valve area, left atrial pressure and mitral regurgitation were compared pre and post procedure. Results: During the study period, 2237 patients underwent Percutaneous transluminal mitral commissurotomy. Among them 100 children less than 15 years of age were included. Successful results were obtained in 94 (94%) patients. Mitral valve area increased from 0.7±0.15 cm2 to 1.5±0.32 cm2 (p<0.001). A significant decrease in left atrial pressure was observed from 29±7.9 mmHg to 13.9±6.2 mmHg (p<0.001). There was no significant change in grade of post procedural mitral regurgitation. Conclusions: Percutaneous transluminal mitral commissurotomy in children with severe mitral `stenosis is safe, effective and should be considered as procedure of choice for childrens. Nepalese Heart Journal | Volume 10 | No.1 | November 2013| Pages 23-26 DOI: http://dx.doi.org/10.3126/njh.v10i1.9743

Download Full-text

Percutaneus Mitral Valvuloplasty in Adult Patients with Rheumatic Mitral Stenosis - Results of 200 Cases

University Heart Journal ◽

10.3329/uhj.v6i2.7246 ◽

1970 ◽

Vol 6 (2) ◽

pp. 65-69

Author(s):

Md Khairul Anam ◽

Fazlur Rahman ◽

Khondoker Shahid Hussain ◽

Mir Jamal Uddin ◽

Chaudhury Meshat Ahmed ◽

...

Keyword(s):

Mitral Valve ◽

Mitral Stenosis ◽

Systolic Pressure ◽

Pulmonary Artery Systolic Pressure ◽

Mitral Valve Area ◽

Mean Pressure ◽

Mitral Commissurotomy ◽

Procedural Success ◽

Medical University ◽

Valve Area

This prospective study was carried out in the department of cardiology, Bangabandhu Sheikh Mujib Medical University, Dhaka and National Institute of Cardiovascular Disease (NICVD), Dhaka between July 2006 to July 2010. Total 200 patients underwent percutaneous mitral commissurotomy. Mitral valve dilatation resulted in increase in mitral valve area from .6±0.26 to 1.70±.38cm2 (p<0.001). Mitral valve mean pressure gradient declined from 23.00±5.38 to 6.8±2.98mmHg (p<0.001). The pulmonary artery systolic pressure decreased from 73.8±19.30 to 29.26±11.80mmHg (p<0.001). Procedural success, as defined as final mitral valve area >1.5cm2 or >50% increase in area, was achieved in 95% patients. Serious complications occured in 10 patients Death occurred in two patient (1%). Minor complication such as vasovagal reaction (5%), balloon rupture without sequel (0.5%), pericardiocentesis (.5%), mitral regurgitation (3%), hypotension (1%), seizure (2%), drug reaction (1%) were also noted. The adverse hemodynamic effect of mitral stenosis may be relieved by percutaneous transvenous mitral commissurotomy but it is not without risk. The morbidity & mortality is very low in properly selected patient. This study demonstrate excellent short term clinical & hamodynamic outcome of this procedure and very low procedure related complications.Key words: Mitral Stenosis; Balloon Valvuloplasty DOI: 10.3329/uhj.v6i2.7246University Heart Journal Vol. 6, No. 2, July 2010 pp.65-69

Download Full-text

Role of Closed Mitral Commissurotomy for Mitral Stenosis: Mid- and Long-term Surgical Outcome of 36 Patients

The Heart Surgery Forum ◽

10.1532/hsf98.20041137 ◽

2005 ◽

Vol 8 (1) ◽

pp. 55 ◽

Cited By ~ 2

Author(s):

Azman Ates ◽

Yahya �nl� ◽

Ibrahim Yekeler ◽

Bilgehan Erkut ◽

Yavuz Balci ◽

...

Keyword(s):

Mitral Valve ◽

Mitral Regurgitation ◽

Mitral Stenosis ◽

Operating Time ◽

Term Survival ◽

Long Term Outcome ◽

Mitral Commissurotomy ◽

Closed Mitral Commissurotomy

Purpose: To evaluate long-term survival and valve-related complications as well as prognostic factors for mid- and long-term outcome after closed mitral commissurotomy, covering a follow-up period of 14 years. Material and Methods: Between 1989 and 2003, 36 patients (28 women and 8 men, mean age 28.8 6.1 years) underwent closed mitral commissurotomy at our institution. The majority of patients were in New York Heart Association (NYHA) functional class IIB, III, or IV. Indication for closed mitral commissurotomy was mitral stenosis. Closed mitral commissurotomy was undertaken with a Tubbs dilator in all cases. Median operating time was 2.5 hours 30 minutes. Results: After closed mitral commissurotomy, the mitral valve areas of these patients were increased substantially, from 0.9 to 2.11 cm2. No further operation after initial closed mitral commissurotomy was required in 86% of the patients (n = 31), and NYHA functional classification was improved in 94% (n = 34). Postoperative complications and operative mortality were not seen. Follow-up revealed restenosis in 8.5% (n = 3) of the patients, minimal mitral regurgitation in 22.2% (n = 8), and grade 3 mitral regurgitation in 5.5% (n = 2) patients. No early mortality occurred in closed mitral commissurotomy patients. Reoperation was essential for 5 patients following closed mitral commissurotomy; 2 procedures were open mitral commissurotomies and 3 were mitral valve replacements. No mortality occurred in these patients. Conclusions: The mitral valve area was significantly increased and the mean mitral valve gradient was reduced in patients after closed mitral commissurotomy. Closed mitral commissurotomy is a safe alternative to open mitral commissurotomy and balloon mitral commissurotomy in selected patients.

Download Full-text

A novel mitral stenosis assessment using projected transmitral gradient improves the diagnostic and prognostic yields of doppler-based gradient

European Heart Journal ◽

10.1093/ehjci/ehaa946.1996 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

N Kato ◽

R Padang ◽

C Pislaru ◽

C.G Scott ◽

V.T Nkomo ◽

...

Keyword(s):

Mitral Valve ◽

Mitral Stenosis ◽

Diagnostic Yield ◽

Cardiac Events ◽

Final Formula ◽

Hemodynamic State ◽

Tertiary Center ◽

Novel Concept ◽

The Impact

Abstract Background Transmitral gradient (TMG) is highly dependent on hemodynamic state, leading to discordance between TMG and mitral valve area (MVA). The effect of heart rate (HR) and stroke volume (SV) on TMG among patients with mitral stenosis (MS) is poorly understood. Purposes We aimed to (1) develop a formula for projected TMG (proTMG) for assessment of MS severity under varying hemodynamics; (2) assess the prognostic value of proTMG in patients with MS. Methods All patients evaluated for suspected MS without ≥moderate other valve disorder at our tertiary center between 2001 and 2017 were analyzed. Projected TMG is the expected gradient under normal flow (SV 80–94 ml and HR 60–79 bpm), and was modeled based on the observed impact of HR and SV on TMG by multiple regression analysis. The data were randomly split (2:1) into training and testing sets. The improvement in agreement between MVA and proTMG was evaluated. Composite cardiac events including all-cause death and mitral valve interventions were compared according to TMG grade using TMG and proTMG. Severe and moderate MS were defined as MVA ≤1.5 cm2 and 1.5–2.0 cm2 respectively, by the continuity equation. MVA ≤1.0 cm2 was considered as very severe MS. Results Of 4973 patients with suspected MS (age 73±12 years, 33% male), severe MS was present in 437 (9%, including 98 with very severe MS) and moderate MS in 934 (19%). In 838 patients with normal HR and SV, very severe, severe and moderate MS corresponded to TMG ≥12 mmHg, ≥6 mmHg and 4–6 mmHg, respectively. In the training set (n=3315), the median [interquartile range] of HR and SV were 70 [61–80] bpm and 97 [83–113] mL in men (n=1120), and 72 [63–82] bpm and 84 [71–97] mL in women (n=2195), respectively. The impact of HR and SV on TMG for men and women were 0.07 and 0.08 mmHg per 1 bpm increase in HR (95% confidence interval [CI] 0.06–0.07 and 0.07–0.08), and 0.03 and 0.05 mmHg per 1 mL increase in SV (95% CI 0.03–0.03 and 0.04–0.05), respectively. Therefore, the final formula to calculate proTMG was: proTMG=TMG-0.07(HR-70)-0.03(SV-97) in men and proTMG=TMG-0.08(HR-72)-0.05(SV-84) in women. In the testing set (n=1658), the proTMG (kappa=0.63, 95% CI 0.60–0.66) had better agreement with MS severity by MVA than TMG (kappa=0.28, 95% CI 0.24–0.32). To explore the prevalence of patients reclassified using proTMG, in 98 with TMG ≥12 mmHg, proTMG remained ≥6 mmHg. Of 657 with TMG 6–12 mmHg, proTMG remained ≥6 mmHg in 356 (54%), and decreased to <6 mmHg in 301 (46%). In patients with TMG 6–12 mmHg, proTMG ≥6 mmHg was associated with higher probability of cardiac events compared with <6 mmHg during follow-up of 2.8±3.1 years (Figure). Conclusion We propose a novel concept of projected TMG defined as the expected transmitral gradient at normal HR and SV levels. This improved the diagnostic yield of Doppler TMG measurements for MS severity assessment and identified a low-risk subset of patients with elevated TMG due to high HR or SV. Funding Acknowledgement Type of funding source: None

Download Full-text

Two-dimensional transesophageal echocardiographic determination of mitral valve area in adults with mitral stenosis

American Heart Journal ◽

10.1016/0002-8703(94)90055-8 ◽

1994 ◽

Vol 127 (5) ◽

pp. 1348-1353 ◽

Cited By ~ 6

Author(s):

Marcus F Stoddard ◽

Charles R Prince ◽

Nasar M Ammash ◽

John L Goad

Keyword(s):

Mitral Valve ◽

Mitral Stenosis ◽

Two Dimensional ◽

Mitral Valve Area ◽

Valve Area

Download Full-text

Closed Mitral Valvotomy for Mitral Stenosis in Mirror Image Dextrocardia

Asian Cardiovascular and Thoracic Annals ◽

10.1177/021849239500300211 ◽

1995 ◽

Vol 3 (2) ◽

pp. 75-77 ◽

Cited By ~ 1

Author(s):

Gutti Ramasubrahmanyam ◽

Dronamraju Dilip ◽

Pirovam Venkat Ramnarayan ◽

Raju Subramaniam Iyer ◽

Kothapalle Venugopal Naidu

Keyword(s):

Mitral Valve ◽

Surgical Approach ◽

Mitral Stenosis ◽

Mirror Image ◽

Abnormal Position ◽

Mitral Valve Area ◽

Anterolateral Thoracotomy ◽

Mitral Valvotomy ◽

Valve Area

A 22-year-old female with mirror image dextrocardia and rheumatic valvular mitral stenosis underwent closed mitral valvotomy using a Tubb's dilator with good results. Despite abnormal position of situs, the surgical approach was simple through right anterolateral thoracotomy, and the operator's hands were mirror image to that of levocardia valvotomy in certain steps. Preoperative mitral valve area was 0.8 cm2, and peak and mean diastolic gradients were 21 and 15 mmHg respectively. Postoperatively, valve area improved to 2.16 cm2, and peak and mean diastolic gradients were 8 and 3.1 mmHg, respectively.

Download Full-text