Page 14 - Journal of Structural Heart Disease Volume 3, Issue 2

Original Scienti c Article
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Discussion
Despite a dramatic decline in the incidence of rheumatic fever, the disease continues to a ect many people [7]. Balloon mitral valvotomy, which was rst performed in 1982 by Kanji Inoue in Japan, produces excellent results equivalent to those obtained with open or closed surgical valvotomy. In countries with a high prevalence of rheumatic heart disease, such as Egypt, mitral stenosis is a common presentation, and PBMV is a particularly valuable treatment modality. Here, utilizing a prospective, single-center study de- sign, we describe the outcomes of PBMV for elderly patients with mitral stenosis, including those with high Wilkin’s scores, relative contraindications, and refusal of valve replacement.
In earlier studies, percutaneous balloon commis- surotomy was used in patients with pliable noncalci- ed mitral valves [2], while more recent studies report the e cacy of balloon commissurotomy even in cal- ci c disease (70% of our patients had Wilkin’s scores of 9 or 10) [9]. The results of the present study con rm those of a previous multicenter trial by Inoue et al. [5], which showed that PBMV using the Inoue balloon catheter technique signi cantly increases mitral valve area in patients with severe mitral stenosis. In asso- ciation with an increased valve area, we observed signi cantly reduced mitral valve gradient, left atrial pressure and size, and mean pulmonary artery systol- ic pressure. These hemodynamic bene ts were mir- rored by clinical improvements in patients’ symptoms and signi cant downgrades in NYHA functional clas- si cation. Therefore, consistent with previous studies [6, 7, 10, 11, 12], our results show that PBMV produces immediate hemodynamic and clinical improvements in most patients.
In our experience, PBMV has a high technical success rate and an encouraging safety record. In the present study, trans-septal catheterization was suc- cessful and uncomplicated, and there was no in-hos- pital mortality. These results are comparable to those from Palacios et al., who reported only one death (3%) and one thromboembolic episode (3%) after valvuloplasty [13]. McKay et al. also reported only one death (2%) and two embolic cerebrovascular accidents (3%) in a large series involving 63 patients, speculating that their success was due to the nature of the Inoue balloon, especially its ow-directed pas-
sage from the left atrium to the left ventricle [9]. In the present study, an Inoue balloon also achieved a smooth delivery in most patients.
An increase in mitral regurgitation is one possible complication after percutaneous balloon commissur- otomy. However, in most cases, the degree of mitral regurgitation slightly increases after PBMV without requiring surgical intervention. The mechanism of the increase or new appearance of mitral regurgitation is reported to be excessive tearing of the commissures(s) or the posterior/anterior lea et at the noncommissural part, incomplete closure of a calci ed lea et, localized rupture of the subvalvular apparatus, or shortened chordate tendineae after splitting of the commis- sure(s). Although the incidence of mitral regurgitation has slightly decreased in the past few years, the appearance or worsening of mitral regurgitation af- ter balloon mitral valvotomy is still a major concern [14, 15, 16, 17, 18]. Although approximately half of patients undergoing balloon mitral valvotomy exhibit a small increase in mitral regurgitation [19, 20], severe mitral regurgitation is relatively rare, with a frequency ranging from 1.4 to 9.4% [13, 21]. There are even some reports of a decrease in mitral regurgitation after bal- loon mitral valvotomy [22, 23, 24]. In the present study, we observed no change in mitral regurgitation in the majority of patients and severe mitral regurgitation (≥3 grade) in only one patient (2.5%).
We found that elderly patients with a higher calci - cation score and more subvalvular involvement were more likely to exhibit an increase in mitral regurgita- tion, whereas total Wilkin’s score did not predict the occurrence of mitral regurgitation. This is consistent with the nding of Aslanabadi et al. that calci cation is the most important component of Wilkin’s classi - cation in that it can predict mitral regurgitation [25]. By contrast, others reported that an increase in mitral regurgitation is not predicted by any valvular or sub- valvular apparatus features, patient clinical character- istics, or technical aspects of the procedure [26, 27].
Limitations
Our study has several limitations. The study was performed at a single center with a relatively small sam- ple size, which limits the generalizability of the results to all patients with mitral stenosis. Therefore, multicenter
Journal of Structural Heart Disease, April 2017
Volume 3, Issue 2:35-42