Quality of life assessment after successful percutaneous transmitral commissurotomy and ascertain its relationship with gender / Evaluación de la calidad de vida tras comisurotomía mitral percutánea exitosa y determinación de su relación con el sexo

Abstract Background: percutaneous transmitral commissurotomy has become an ideal treatment option for mitral stenosis due to its less adverse events and more favorable outcomes. Patients improve symptomatically after percutaneous transmitral commissurotomy but we have minimal available data about the quality of life after percutaneous transmitral commissurotomy. Objective: to assess the quality of life after percutaneous transmitral commissurotomy through WHOQol scoring covering different aspects of life, to determine its correlation with a net gain in mitral valve area (MVA) and to ascertain its association with gender. Methods: it was a prospective cohort study carried out for a period of 15 months. A total of 100 patients with mitral stenosis who had successful percutaneous transmitral commissurotomy done were enrolled in the study. Among the total included, 4 patients were lost to follow up and data were collected from 96 patients. Quality of life was assessed before the procedure, at 1 month and 3 months follow up after percutaneous transmitral commissurotomy using WHOQol scoring questionnaire. Results: among 96 patients, 64 (67%) were females and 32 (33%) were males. WHOQol scoring improved significantly after percutaneous transmitral commissurotomy from 32.8±8.9 to 54.6±11.2 and 62.8± 9.7, after one month and 3 months respectively. There was a significant association between net gain of MVA and WHOQol scoring with an R value of 0.46 and p value of 0.03. There was no difference in group comparison of all the six domains between male and female patients. Conclusion: successful percutaneous transmitral commissurotomy improves the quality of life in mitral stenosis patients regardless of their gender and has a positive correlation with a net gain in mitral valve area.

Resumen Antecedentes: La comisurotomía mitral percutánea se ha convertido en una opción terapéutica ideal para la estenosis mitral, debido a efectos menos adversos y a resultados más favorables. Los pacientes mejoran sintomáticamente tras la realización de esta técnica, aunque se dispone de escasos datos acerca de la calidad de vida tras su puesta en práctica. Objetivo: Evaluar la calidad de vida tras la comisurotomía mitral percutánea mediante la puntuación WHOQol, que cubre diferentes aspectos de la vida, para determinar su correlación con la ganancia neta del área valvular mitral (AVM), y determinar su asociación con el sexo. Métodos: Estudio prospectivo de cohorte durante un periodo de 15 meses, en el que se incluyeron 100 pacientes con estenosis mitral a quienes se les practicó con éxito comisurotomía mitral percutánea. De entre el total incluido, se perdieron 4 pacientes durante el estudio, por lo que se recolectaron datos de los 96 pacientes restantes. La calidad de vida se evaluó antes del procedimiento, y transcurridos un mes y tres meses de seguimiento, utilizando el cuestionario de puntuación WHOQol. Resultados: De los 96 pacientes, 64 (67%) eran mujeres y 32 (33%) varones. La puntuación WHOQol mejoró considerablemente tras la realización de la comisurotomía mitral percutánea, con valores de 32,8±8,9 a 54,6±11,2 y 62,8± 9,7, transcurridos uno y 3 meses, respectivamente. Se produjo una asociación significativa entre la ganancia neta de AVM y la puntuación WHOQol, con un valor R de 0,46 y un valor p de 0,03. No se produjo diferencia alguna en cuanto a la comparación grupal de los seis dominios entre varones y mujeres. Conclusión: La comisurotomía mitral percutánea exitosa mejora la calidad de vida de los pacientes de estenosis mitral, independientemente del sexo, y tiene una correlación positiva con la ganancia neta del área valvular mitral.

Left Ventricular Pseudoaneurysm Repair 44 Years after Closed Commissurotomy for Mitral Valves / 日本心臓血管外科学会雑誌

A 71-year-old woman with a history of closed commissurotomy for mitral valve stenosis 44 year ago, was diagnosed with left ventricular aneurysm by transthoracic echocardiography. She had no symptom of left ventricular aneurysm. Since there was a high risk of left ventricular rupture, we decided to undertake surgical treatment. During the surgery, we found artificial material near the left ventricular aneurysm. We resected the aneurysm wall and closed the ventricular wall using felt strip reinforcement. The wall of the aneurysm had no myocardium upon pathological examination. We diagnosed that it was a left ventricular pseudoaneurysm, and it seemed to be formed by blood oozing from the apical repair point of the hole for the dilator to perform mitral valvulotomy. The postoperative course was uneventful and she was discharged on postoperative day 20. Left ventricular pseudoaneurysm often results after myocardial infarction, and reports after cardiac surgery are rare, except in cases after mitral valve replacement. We hereby report our experience with this rare case

Changes in hemodynamic of pulmonary arteries and heart chambers after mitral valve surgical commissurotomy evaluated by Doppler ultrasonography

98 patients were operated surgical commissurotomy in the No 108 Military Hospital from March 1995 to May 2000. All patients were performed Doppler ultrasonography pre- and post-operation. All patients were received surgical commissurotomy by Tubs. Hemodynamics was changed with satisfactory results after surgical commissurotomy the pulmonary arteries pressure down from 50.4  15.5 to 36.6  7.9 mmHg; MaxPG (mmHg) down from 22.1  7.6 to 12.3  3.3 and mean PG (mmHg) also down from 13.5  4.8 to 6.9  4.5. For right indication and contraindication in surgical intervention, as well as prognosis of postoperative patient's life, the evaluation of hemodynamic indexes are necessary, in which Doppler ultrasound plays an importance role in assessing the pre- and postoperative results

Experiences with complications relative to mitral commissurotomy : their mechanisms, prevention, and management

Fifty-two cases who underwent mitral commissurotomy were studied for complications. Twenty-two or 42.3 per cent developed twenty-nine complications including four deaths, an immediate mortality of 7.6 per cent. The role of various factors were studied in order to ascertain why complications occur with such a relatively innocuous procedure as mitral commissurotomy, The following seem to be operative: functional classification, duration of symptoms, history and number of congestive heart failures, pre-existing atrial fibrillation, previous embolic history, previous hemoptysis, concomitant lung pathology, extreme heart size, recent infetion or rheumatic activity, transcommissural calcification or clot, and presence of associated cardiac pathologyFactors such as intracardiac instrumentation, too early removal of thoracotomy tubers, too early use of steroids, pre-operative antiarrhythmic medication were also discussed. The responsibility of the internist regarding early referral of the patient to the cardiac surgeon is stressed in an effort to reduce mortality as well as the incidence of complications. (Summary)

The diagnosis of mitral stenosis and the complications of mitral commissurotomy

The symptoms, signs and diagnosis of mitral stenosis are reviewed. 155 cases of mitral commissurotomy are presented. The patients were grouped according to the classification of the New York Heart Association. The usual indication for surgery is the presence of symptoms. The contraindications are enumerated. The complications of mitral commissurotomy are reviewed. (Summary)

Color echocardiography evaluating long-term effectiveness of closed mitral commissurotomy / 第二军医大学学报

A retrospective review of 47 patients underwent closed mitral commissurotomy(CMC) was conducted. It was revealed that the post-operative color echocardiography indices (MVA ,MVG,CO) were significantly improved compared with those of pre-operation (P8 had NYHA class Ⅰ-Ⅱ in 5 years(P

Long-term Clinical Outcome and Echocardiographic Restenosis after Successful Percutaneous Transmitral Commissurotomy

BACKGROUND: The purpose of this study was to assess the clinical outcome and echocardiographic incidence of restenosis after successful percutaneous transmitral commissurotomy (PTMC) and to identify predictors of restenosis. METHODS: Between 1989 and 1992, Inoue PTM (n=73) and double balloon technique (n=85) were used in 158 consecutive patients (male 52, age; 41+/-11 year) with mitral stenosis. Clinical and echocardiographic examinations were performed annually in 137 patients who exhibited good initial result with PTMC (mitral valve area 1.5cm (2) and mitral regurgitation[MR] 2+). Restenosis was defined as a mitral valve area< (MVA) 1.5cm (2) or more than 50% loss of the initial gain in MVA. Commissural mitral regurgitation (CMR) was defined as MR originating from medical or lateral commissure on color flow imaging and regarded as an index of complete commissural splitting. RESULTS: Immediately after PTMC, MVA increased from 0.9+/-0.2cm (2) to 1.8+/-0.3cm (2) and functional class improved up to NYHA class 1 or 2 in all patients. Annual echocardiographic follow-ups were completed in 129 (94%) patients and mean follow-up duration was 54+/-21 months. Adverse events occurred in 16 (13%) patients (1 death, 3 mitral valve replacement, 3 re-PTMCs, 9 deterioration of the NYHA class), and restenosis occurred in 41 (32%) patients. Event-free and restenosis-free survival rates at 7 years were 776 % and 586 %, respectively. According to multivariate Cox analysis, restenosis (p=0.0017, relative risk[r.r]=2.82) was the only predictor of adverse events ; smaller increase ( 1.0cm (2)) of MVA (p=0.0001, r.r=4.8) and the absence of CMR (p=0.0000, r.r=4.8) were independent predictors of restenosis. CONCLUSION: Long-term clinical outcomes and restenosis rates after PTMC are favorable and immediate results after PTMC can predict late restenosis better than baseline clinical and echocardiographic characteristics.

Immediate and Late Outcomes after Percutaneous Mitral Co,mmissurotomy

BACKGROUND: Percutaneous mitral commissurotomy(PMC) has been known as an effective therapeutic modality for moderate to severe mitral stenosis. However, long-term results and factors influencing late outcome after PMC remain to be elucidated. MATERIALS AND METHODS: Three hundred and forty-six patients received PMC at Seoul National University Hospital between August, 1988 and March, 1996. We evaluated long-term results of these patients and assessed demographic, clinical, echocardiographic and hemodynamic variables in order to identify predictors of immediate and late outcomes. RESULTS: PMC was completed without major complication or technical failure in 339(98%) out of 346 cases. A good immediate result was obtained in 67% of cases. Multivariate study identified echocardiographic score(P=0.004) and left atrial volume(P=0.009) as independent predictors of immediate outcome. The estimated 3-year and 5-year event-free survival rates were 95.8+/-2.5% and 90.6+/-4.3%, respectively. According to multivariate analysis, the independent predictors of late outcome were pre-PMC left atrial volume(P=0.03), post-PMC mitral valve area(P=0.01), and severity of mitral regurgitation after PMC(P=0.03). CONCLUSION: Percutaneous mitral commissurotomy as a treatment for patients with mitral stenosis is safe, and achives good long-term results. Pre-procedural echocardiographic score, left atrial volume, post-procedural mitral valve area, and severity of mitral regurgitation affect the immediate and late outcomes after PMC.

Changes of Plasma Endothelin-1 Concentration after Percutaneous Mitral Commissurotomy

BACKGROUND: Endothelin, a very potent vasoconstricting substance released from the endothelium, has been known to be elevated in various cardiovascular disorders, however, the sites of endothelin porduction as well as the influence of acute hemodynamic changes upon plasma endothelin-1 concentration remains elucidated. METHODS: In order to evaluate the probable site of endothelin production and relationship between levels of plasma endothelin and hemodynamic variables, six patients with moderate to severe mitral stenosis underwent percutaneous mitral commissurotomy(PMC) were included. Measurement of mean pulmonary arterial pressure, cardiac output as well as plasma endothelin-1 concentration of renal vein, main pulmonary artery, and ascending aorta were performed before and 20 minutes after PMC. RESULTS: After PMC, cardiac output increased significantly, whereas mean pulmonary artery pressure and transvalvular pressure gradient were reduced significantly(both p<0.05). Before PMC, plasma endothelin-1 concentration tended to be higher in renal vein(6.12+/-3.7pg/ml) and pulmonary artery(5.07+/-1.7) than that in aorta(3.05+/-1.2pg/ml). After hemodynamic improvement with PMC, plasma endothelin-1 concentration decreased at all the site, however the change at pulmonary artery was statistically significant. CONCLUSION: These results suggest that endothelin-1 may be produced mainly somewhere in systemic venous circulation such as kidney rather than pulmonary circulation, and plasma endothelin-1 concentration tends to decrease in response to the acute hemodydnamic im provement.

Transesophageal Echocardiographic Evaluation of Pulmonary Venous Flow Patterns before and after Percutaneous Mitral Commissurotomy

BACKGROUND: Pulmonary venous flow(PVF) is closely related to left atrial pressure(LAP) and percutaneous mitral commissurotomy(PMC) reduces LAP rapidly. However, PVF pattern in mitral stenosis(MS) with sinus rhythm after PMC remains to be elucidated. METHODS: Transesophageal echocardiographic pulsed Doppler examination was performed within 24 hours before and after PMC to evaluate PVF pattern in 10 patients of MS with sinus rhythm. RESULTS: Before PMC, both peak velocity(PV) and velocity time integral(VTI) during systole had significant negative correlations with mean LAP(r=-0.70, r=-0.79, respectively). After PMC, both systolic PV and VTI increased significantly without significant changes in diastolic PV and VTI. However, there was no significant correlation between systolic PV and mean LAP, and between systolic VTI and mean LAP after PMC. CONCLUSION: In mitral stenosis with sinus rhythm, these data suggest that systolic PVF decreases with increase of mean LAP and PMC could reverse this change without affecting diastolic PVF. However, acute hemodynamic changes of left atrium induced by PMC may contribute to the absence of correlation between mean LAP and systolic PVF after PMC.

Long-Term Echocardiographic follow-up of Percutaneous Mitral Balloon Valvuloplasty in Patients with Restenosis after Previous Surgical Commissurotomy

BACKGROUND: Precutaneous mitral balloon valvuloplasty(PMV) is known to produce shortterm hemodynamic and symptomatic improvement in selected patients with restenosis after previous surgical commissurotomy. METHODS: To evaluated the long-term efficacy of PMV and identify the risk factors for restenosis after this procedure in patients with mitral restenosis after previous surgical commissurotomy, we obtained 30.4+/-13.0 months(range, 6-53) follow-up data in 19 patients with restenosis after previous surgical commissurotomy on whom PMV was successfully performed since April, 1988. RESULTS: There were 10 females and 9 males with mean age of 42.7+/-8.7(range, 28-59). 11 patients were in atrial fibrillation. Restenosis occurred in 8 patients(42%) during follow-up. Median value for restenosis by Kaplan-Meier survival analysis was 40 months. Restenosis by univariate analysis correlated with smaller valve area after PMV and short interval from previous surgical commissurotomy to restenosis. Mitral valve area after PMV and echoscore were found to be the determinant predictors of restenosis by Cox proportional hazard analysis. For mitral valve area after PMV, patients with post-PMV valve area less than 1.6cm2have relatively high risk for restenosis than those with post-PMV valve area more than 1.6cm2. CONCLUSION: Half of the patients who underwent PMV due to restenosis after previous surgical commissurotomy maintained optimal result up to 40 months. Poorer long-term outcome can be predicted in patients with unfavorable valve morphology or post-PMV valve area less than 1.6cm2.

Valvoplastia mitral por cateter-baläo em pacientes de alto risco operatório / Percutaneous Mitral Balloon Valvuloplasty in Surgical High Risk Patients

Objetivo - Analisar os reultados da valvoplastia mitral por cateter-baläo (VMCB) em pacientes de alto risco operatório. Métodos - Vinte (12// pacientes dentre 172 comsecutivos submetidos a VMCB foram considerados de alto risco operatório. Dezessete (85//) eram mulheres e a média etária de 43(18-69) anos. Treze (65//) encontravam-se em edema agudo dos pulmöes (3 gestantes, 2 com acidente vascular cerebral (AVC) prévio, 1 com tromboembolismo pulmonar e outro com insuficiência renal crônica) e 7 (35//) em classe funcional (CF) III (2 com insuficiência coronariana crônica, 2 com obesidade maligna, 1 com neoplasia de pulmäo, 1 com caquexia cardíaca e outro com AVC prévio). Realizaram VMCB pela técnica transeptal sendo utilizado duplo baläo em 10(45//), baläo Inoue em 5(25//), monofoíl em 3(15//) e bifoil em 2(10//) pacientes. Resultados - Dezessete (85//) pacientes com sucesso e 2 (10//) com melhora clínica expressiva. Os resultados hemodinâmicos pré x pós-VMCB foram: pressäo de átrio esquerdo (PAE) em mmHg 28,2 ñ 10,0 x 15,2 ñ 9,2 (n = 20) (p < 0,001); gradiente transvalvar mitral médio (G) em mmHg 21,2 ñ 10,7 x 10,7 ñ 6,7 (n = 18) ( , 0,001); área valvar mitral (AVM) em cm² 0,73 ñ 0,6 (n = 11) (p < 0,001); pressäo média de artéria pulmonar em mmHg 52,0 ñ 18,2 x 40,1 ñ 14,7 (n = 18) (p < 0,001); índice cardíaco em L/min/m² 2,1 ñ 0,4 x 2,5 ñ 0,6 (n = 14) (p < 0,001). No ecocardiograma os resultados comparativos pré, pós e após 6 meses da VMCB foram: área valvar mitral (cm²) 1,06 ñ 0,39 x 1,92 ñ 0,51 x 1,65 ñ 0,5 e gradientes transvalvar mitral (mmHg) 13,8 ñ 4,7 x 7,3 ñ 3,6 x 7,3 ñ 4,4. Houve 2 óbitos imediatos (tromboembolismo pulmonar e falência de multiplos órgäos) e 1 extra-hospitalar. As complicaçöes foram: 2(10//) pacientes com complicaçöes neurológicas, 1(5//) com comunicaçäo interatrial e outro com perfuraçäo da átrio direito (5//). Conclusäo - A VMCB oferece alternativa ao tratamento cirurgico em pacientes considerados de alto risco operatório e manutençäo do sucesso em seis meses de seguimento

Purpose - To evaluate percutaneous mitral balloon valvuloplasty (PMBV) in surgical high risk patients. Methods - Twenty (12%) patients out of 172 submitted to a PMBV were considered high surgical risk cases; 17 (85%) were women and mean age was 43 (18- 69). Thirteen (65%) were in acute pulmonary edema (3 were pregnant, 2 had previous cerebrovascular event, 1 had pulmonar thromboembolism and other had chronic renal failure), and 7 (35%) were in functional class (CF) III (2 had coronary artery disease, 2 severe obesity, 1 pulmonar neoplasy, 1 cardiac cachexia and one with previous cerebrovascular event). All patients underwent PMBV through transeptal technique. Double balloon was used in 10 (50%) patients; Inoue balloon in 5 (25%), monofoil in 3 (15%) and bifoil in 2 (10%). Results - Seventeen (85%) obtained success and 2 (10%) had clinical improvement. The hemodinamic results pre versus post-PMBV showed: left atrium pressure (LAP) mmHg 28.2±10,0 x 15.2±9.2 (n=20) (p<0.001), mitral mediam gradient (G) mmHg 21.2±10.7 x 10.7±.7 (n=18)(p<0.001), mitral valve area (MVA) cm2 0.73±0.3 x 1.73±0.6 (n=11) (p<0.001), pulmonary artery pressure mmHg 52.0±18.2 x 40.1±14.7 (n=18) (p<0.001) and cardiac index L/min/m2 2.1±0.4 x 2.5±0.6(n=14) (p<0.001). Comparative echocardiography results pre, post and 6 months after PMBV showed: MVA 1.06±0.39 x 1.92±0.51 x 1.65±0.5 and G 13.8±4.7 x 7.3±3.6 x 7.3±4.4. There were two immediate deaths (pulmonary thromboembolism and multiple organs failure) and other after hospital discharge. The complications were: 2 (10%) patients with neurological complications, 1 (5%) atrial septal deffect and other right atrium perforation (5%). Conclusion - PMBV offers an alternative to surgical treatment in high risk surgical patients and the results are maintained in the 6 month follow-up

Percuteneouus Balloon Mitral Valvuloplasty-A Report of 100 Cases with Results of Follow-up in 53 Cases / 中国介入心脏病学杂志

Percutaneous balloon mitral valvuloplasty (PMV) was performed in 100 cases with rheumatic mitral stenosis. In 94 ceases who successfully underwent the procedure, the mean left atrial pressure lowered from 22. 77?0. 84mmHg to 14. 40?0. 57 mmHg(P

Percutaneous Mitral Balloon Valvotomy in Patients with Restenosis after Surgical Commissurotomy: A Comparative Study

BACKGROUND: Because its efficacy and percutaneous approach, percutaneous mitral ballon valvotomy(PMV) could be an alternative to surgery for mitral restenosis after surgical commissurotomy, somewhat decreasing the mortality and morbidity associated with second thoracotomy. This study assesses the efficacy of PMV in patients with mitral restenosis after surgical commissurotomy compared with in patients without prior surgery. METHODS: PMV were performed in 367 patients to compare the effectiveness between patients with mitral restenosis after surgical commissurotomy(group 1, n=22) and patients with unoperated mitral stenosis(group 2, n=345). Twenty two had undergone closed or open mitral commissurotomy average 11.2 years before. RESULTS: There were no significant differences in clinical profiles between two groups. Mitral valve area was increased from 1.0+/-0.8 to 1.8+/-0.6cm2 in group 1 and 0.9+/-0.3 to 2.0+/-0.7cm2 in group 2(p>0.05). Mitral gradient was decreased from 14+/-5.9 to 6+/-2.6mmHg in group1 and 18+/-7.0 to 7+/-5.3mmHg in group2(p>0.05). Increment of mitral regurgitation and significant left to right shunt after PMV were not significantly different(10% versus 14.7%, 5% versus 10.4% respectively, p>0.05). Optimal results defined as final valve area more than 1.5cm2 with gain a more than 25% of initial valve area were attained in 75% of patients in group1 and in 84.3% of group 2 patients(p>0.05). CONCLUSIONS: PMV in mitral restenosis after surgical commissurotomy may be safe in selected patients and equally effective as in unoperated mitral stenosis.

Percutaneous mitral balloon valvuloplasty in patients with restenosis after surgical commissurotomy: a comparative study

We performed percutaneous mitral balloon valvuloplasty (PMV) in 367 patients to compare the effectiveness of PMV between patients with mitral restenosis after surgical commissurotomy (group 1) and patients with unoperated mitral stenosis (group 2). Twenty-two had undergone closed or open mitral commissurotomy 11.2 years before. There were no significant differences in clinical profiles between the two groups. The mitral valve area was increased from 1.0 +/- 0.8 to 1.8 +/- 0.6 cm2 in group 1 and 0.9 +/- 0.3 to 2.0 +/- 0.7 cm2 in group 2 (p> 0.05). The mitral gradient was decreased from 14 +/- 5.9 to 6 +/- 2.6 mmHg in group 1 and 18 +/- 7.0 to 7 +/- 5.3 mmHg in group 2 (p> 0.05). The increment of mitral regurgitation and significant left to right shunt after PMV were not significantly different (10% versus 14.7%, 5% versus 10.4% respectively). Optimal results were attained in 75% of the patients in group 1 and in 84.3% of the patients in group 2 (p> 0.05). These results suggest PMV in mitral restenosis after surgical commissurotomy may be safe in selected patients and may be equally effective as in unoperated mitral stenosis.

Intervençäo cirúrgica em pacientes submetidos a procedimento para valvoplastia mitral por cateter-baläo / Surgery in patients undergoing to a catheter balloon mitral valvoplasty procedure

Objetivo: Estudar as características d e pacientes submetidos a valvoplastia mitral por cateter-balão (VMPB) que necessitaram de intervenção cirúrgica após a mesma. Casuística e Métodos: 105 pacientes submetidos a VMPB divididos em grupo I (Gl) composto por 18 pacientes operados e Grupo II (GII) por 87 não submetidos à intervenção cirúrgica no coração. Foram analisados: 1 ) idades; 2) sexo; 3) área valvar mitral (AVM) e gradiente transvalvar mitral médio (G) ao ecodopplercardiograma; 4) caráter da VMPB; 5) método utilizado na VMPB; 6) intervalo de tempo entre VMPB e cirurgia relacionado à indicação operatória; 7) achado operatório; 8) operação efetuada; 9) evolução pós-operatória...

Purpose: To study the characteristics of patients undergoing catheter-balloon mitral valvoplasty (CBVM) procedure who needed surgical intervention after CBMV. Patients and Methods: One hundred and five patients submitted a CBMV were divided in to Group I (GI) of eighteen surgical patients and Group II (GII) of eighty-seven non-surgical patients. The following parameters were analyzed. 1) age; 2) sex; 3) mitral valve area (MVA) and mean transvalvar gradiente (G) by echodopplercardography (2D); 4) Character of CBMV; 6) Relation of time between CBMV and Surgery with surgical indication; 7) Surgical fidings; 8) Surgical procedure and 9) Post-operative evolution...