Percutaneous balloon mitral valvuloplasty in severe restenosis of the mitral valve: Analysis of factors affecting the short term outcomes – A single center experience

Abstract

Introduction: Rheumatic heart disease (RHD) is still a major problem in developing countries, with mitral stenosis being the most frequent manifestation. Percutaneous mitral valvuloplasty has emerged as the procedure of choice in most patients with symptomatic mitral stenosis. Late recurrence of symptoms after the procedure is mostly related to mitral restenosis. A few reports are available about percutaneous valvuloplasty in restenosis of the mitral valve, but factors predicting the outcomes are not clear. In this study we tried to explore clinical characters and short term out-comes of percutaneous balloon mitral valvuloplasty in symptomatic severe mitral restenosis. Materials and methods: Thirty five consecutive inpatients who underwent percutaneous balloon mitral valvuloplasty (PBMV) for symptomatic and severe mitral restenosis after previous surgery or valvuloplasty were included in this single center prospective study. Comprehensive transthoracic and transesophageal echocardiographic examination was done and mitral valve morphology was assessed. To define more accurately the relation between the mechanism of restenosis and the immediate results of repeat PBMV, we focused on commissural morphology and sub classified patients into 2 groups: patients with bilateral fused commissures and patients with either unilateral or bilateral split commissures. PBMV was done according to standard technique. Procedural success was defined as an increase of 50% of mitral valve area or a final area of 1.5cm 2 , with no more than one grade increment in MR severity assessed by echocardiography 24 hours after the procedure. Patients with persistent left atrial or left atrial appendage thrombus, more than moderate mitral regurgitation(MR), severe or bicommissural calcification, severe concomitant aortic valve disease, severe organic tricuspid stenosis, severe concomitant coronary artery disease requiring bypass surgery and severe subvalve disease were excluded from the study. Results: A total of 35 patients were enrolled into the study (mean age 37.51±10.29 years). Of these 35 patients, 22 (62.8%) were males and 13 (37.14%) were females. patients were divided into two groups as group 1 (bilaterally fused commissure ) and group 2 (one split commissure) Bilateral fused commisures were in 7 patients and either of commissure was split in remaining 28 patients. Mean age of the study population was 37.51±10.29 years. Mean mitral valve area was 1.02±0.15 (cm 2 ) and 1.07±0.19 (cm 2 ) in either commissure split and bilateral fused commisures groups respectively (p =0.23). Mean mitral valve gradient, peak mitral valve gradient, systolic pulmonary artery pressure and LA size were not statistically significant between two groups. LA thrombus was absent in both the groups. average Post PTMC mitral valve area in bilateral fused commisures group was 1.77±0.09 cm 2 and in either of commissure split group was 1.52±0.42 cm 2 (p =0.001). Mean mitral valve gradients were 5.04±1.69 mmHg and 3.71±4.08 mmHg (p=0.025) and peak mitral valve gradient was 9.54±2.52 and 7.14±3.39 (p=0.02) which are statistically significant in either commissure split and bilateral fused commisures group respectively. There was no statistically significant difference in, systolic pulmonary artery pressures between the two groups. In the present study optimal results were obtained in 30 (85.78%) patients and sub-optimal results were obtained in 5(14.22%) patients of whom insufficient mitral valve area observed in 3 (8.5%) patients and mitral regurgitation was observed in 2 (5.7%) patients . Commissural calcification has positive correlation with development of MR ( P=0.007 ) MR has slightly inverse correlation with mobility (correlation coefficient -0.1) (p=0.546) and thickness has direct correlation with development of MR (p=0.0000001 coefficient 0.98) which is highly correlated . But development of MR is not correlated with pre mitral valve area overall(cc 0.189 p=.138) either commissure split (cc 0.108 p=0.2684) bicommisural fused (cc 0.158 p=0.182) Percutaneous balloon mitral valvuloplasty in severe restenosis of the mitral valve: Analysis of .... DOI: 10.9790/0853-1607022734 www.iosrjournals.org 28 | Page Conclusion: Commissural morphology is the most important predictor of outcomes for PBMV in restenotic valves. Adequate assessment by echocardiography improves the success of PBMV and decreases the complication rates.