FREQUENCY OF ACUTE MITRAL REGURGITATION IN POST PERCUTANEOUS TRANSVENOUS MITRAL COMMISSUROTOMY PATIENTS WITH SEVERE MITRAL STENOSIS

Objectives: To determine the frequency of Acute Mitral Regurgitation in Post Percutaneous Transvenous Mitral Commissurotomy (PTMC) patients with severe mitral stenosis (MS). Methodology: A cross-sectional study was conducted at the Tabba Heart Institute, Karachi, Pakistan between September 2019 and April 2021. All patients irrespective of gender, aged between 19-80 years, and those who did not undergo PTMC were eligible to partake in the study. Patients with mitral regurgitation along with mitral stenosis, or those with clot in left atrium, or those suffering with the last stage of renal disease were excluded from the study. A predefined Proforma was used as a research instrument through which medical records of patients of PTMC are collected. The variables of the Proforma include patient’s age, name, sex, echo findings, treatment procedure, post-procedure data and complications. Results: A mean age of 40.6 ± 12.63 years was reported. 86 (81.9%) of the patients developed ‘no complications’, 15 (14.3%) of the PTMC patients suffered from ‘severe mitral regurgitation’, 2 (1.9%) had local hematoma, and one patient had a cardiac tamponade after the procedure. Only one patient died post-procedure. Post-stratification analysis showed that the majority of the female patients and 83% of the patients with no previous commissurotomy history did not have any complications. While a total of 14.7% who had no history of previous commissurotomy suffered from severe MR. Conclusion: Our study revealed that only a small number of patients who underwent PTMC suffered from severe mitral regurgitation. Overall, the procedure is safe with a good outcome.

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

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).

Percutaneous Transvenous Mitral Commissurotomy in Middle Aged Indian Population- A Cross-sectional Study

Introduction: Mitral Stenosis (MS) is a chronic complication seen among patients with Rheumatic Heart Disease (RHD). Percutaneous Transvenous Mitral Commissurotomy (PTMC) is a non surgical intervention indicated exclusively for MS with favourable valve morphology. Aim: To determine the outcomes of PTMC in middle aged Indian population in relation to clinical and haemodynamic parameters. Materials and Methods: This retrospective cross-sectional study conducted at a tertiary care hospital in Chennai, Tamil Nadu, between 1994 and 2019. Study was based on analysis of data from 82 patients diagnosed with MS, that underwent successful PTMC. Patients in the age group of 40 to 60 years with symptomatic MS {Mitral Valve Area (MVA) <1.5 cm2 on echocardiogram} were included in this study. Successful PTMC was defined in terms of MVA >1.5 cm2. Participants were divided into two groups based on Wilkins score of 8 as a cut-off. The continuous variables of the study subjects were described and interpreted by averages and compared between the groups by independent t-test. The pre, post and follow-up characteristics were analysed by averages and interpreted by paired t-test and confirmed by repeated measures of ANOVA. Results: Group A with Wilkin’s score ≤8 showed better results in terms of functional status improvement [New York Heart Association (NYHA) classification], MVA, mean gradient across mitral valve and Pulmonary Arterial Pressure (PAP) with p-values <0.05 after a mean follow-up period of one year. Conclusion: Long-term outcomes of PTMC is better in patients with lower Wilkin’s score than those with higher scores in terms of functional status improvement, maintenance of MVA and mitral valve mean gradient pressure. These factors favour the optimal utilisation of PTMC as an alternative to surgery especially among middle aged population.

Echocardiographic assessment before and after Percutaneous Transvenous Mitral Commissurotomy in patients with Rheumatic Mitral Stenosis

Objectives: To determine the changes produced in mitral valve morphology after Percutaneous Trans-Venous Mitral Commissurotomy. Methods: Patients with mitral stenosis who underwent PTMC at the cardiology department of Lady Reading Hospital, Peshawar, Pakistan, from 2006-2016 were included in this study. All the data were manually obtained from the electronic medical record (M.F.E.). Wilkin’s echocardiographic scoring system was used to assess the severity of mitral valve thickness, leaflet mobility, valvular calcification, and Subvalvular disease. The student t-test was used for mean comparison. P-value < 0.05 was considered significant. Results: Of the total 229 patients, males were 96(41.9%), and females were 133(58.1%). The mean [SD] age of the patients was 25 ± 11years. The total Wilkin score was 7 ±1.5. 151(65.9%) were in New York Heart Association (NYHA) functional class III, and 78(34.1%) were in NYHA class IV. There was no immediate change after PTMC in systolic myocardial velocities (SV) measured at the lateral tricuspid annulus. The 2D mitral valve area increased from 0.98±0.94 cm2 to 1.78 ± 0.44 cm2 (P=0.001). Left Atrium diameter was 5.16±0.75 mm prior to PTMC, significantly decreased to 4.7± 0.7 mm (p=0.005) after PTMC. Ejection fraction (Left Ventricular Ejection Fraction) changed from 60.45± 8.25 mm Hg to 62.76±10 mm Hg (p=0.001). Mean Right Ventricular Ejection Fraction (RVEF) of patients before PTMC was 48.7 ± 4.7%, did not change significantly immediately after PTMC. Conclusion: PTMC is associated with significant changes in mitral valve morphology in terms of splitting of the fused mitral commissures, increased MVA, improved leaflet excursion, and splitting of the subvalvular structures. doi: https://doi.org/10.12669/pjms.37.1.2446 How to cite this:Khan A, Shafiq I, Jan M, Hassan Z. Echocardiographic assessment before and after Percutaneous Transvenous Mitral Commissurotomy in patients with Rheumatic Mitral Stenosis. Pak J Med Sci. 2021;37(1):104-108. doi: https://doi.org/10.12669/pjms.37.1.2446 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.