Case of rheumatic heart disease and severe mitral stenosis, managed by balloon mitral valvuloplasty in pregnancy

Mitral stenosis (MS) is a progressive situation caused by obstruction of blood flow across the mitral valve from the left atrium to the left ventricle. It is one of the most common valvular heart lesions found during pregnancy. The chances of significant maternal and fetal morbidity and mortality are more in the case of severe MS. Balloon mitral valvuloplasty (BMV) is a life-saving procedure in pregnancy instead of surgical correction. We are presenting the case of a 24-week pregnant woman with severe MS. She developed pulmonary edema and had undergone successful BMV which allowed her to tolerate her pregnancy decently. It leads to a decrease in the left atrial pressure as well as pulmonary arterial pressure. The patient underwent normal delivery uneventfully. Antibiotics were used with proper consultation and the patient was treated conservatively with excellent maternal and fetal outcomes. BMV is turns out to be a life-saving therapy for severe MS complicated by pulmonary edema.

Role of three dimensional transesophageal echocardiography in predicting mitral regurgitation after percutaneous balloon mitral valvuloplasty

Background Percutaneous balloon mitral valvuloplasty (PBMV) can be complicated with significant mitral regurgitation (MR). We performed a pilot, prospective study to evaluate the role of three dimensional transesophageal echocardiography (3D-TEE) in the prediction of MR after PBMV through mitral valve quantification (MVQ). Methods Between October 2014 and October 2016, 37 patients with rheumatic, moderate-to-severe mitral stenosis, referred to the Cath lab of Bab Alshearia University hospitals for PBMV, were divided into two age and sex matched groups. Group I included 25 patients without significant MR following PBMV [vena contract area (VCA) <0.4 cm2], while group II included 12 patients with significant MR after PBMV [VCA ≥0.4 cm2]. Both groups were comparable in terms of TEE data, Wilkins score for favorability of PBMV and baseline hemodynamics. Results Data from MVQ showed that both groups were comparable (p > 0.05) in terms of MV annulus quantification (Anteroposterior diameter, annular sphericity, 3D area and height), MV scallops (A1, A2, A3, P1, P2 and P3) areas, as well as A1 and A2 tenting volumes. However, we recorded significant differences between the two groups as regard total MV, A2, P2 and P3 tenting volumes (p < 0.05) and tenting height (p = 0.03), as well as A2, A3 and P2 prolapse volumes (p < 0.05). Moreover, our data showed a significant difference between both groups in terms of MV coaptation heights (p = 0.01), but not in anterior coaptation length (p = 0.13). Conclusion Mitral valve quantification through 3D-TEE is a simple automated method, easily applicable to patients before PBMV. Moreover, MVQ-derived data, such as MV scallops' tenting and prolapse volumes, coaptation heights, and exposed and total A2 lengths may predict the possibility of significant MR after PBMV.

Feasibility and Effectiveness of Percutaneous Balloon Mitral Valvuloplasty Under Echocardiographic Guidance Only / 中国循环杂志

Objectives: The present first-in-human study aimed to assess the feasibility of percutaneous balloon mitral valvuloplasty (PBMV) for the treatment of isolated mitral stenosis (MS) under echocardiography guidance only. Methods: Data were obtained from 24 consecutive patients with severe MS, who underwent PBMV from October 2016 to October 2017 under the guidance of echocardiography only. Outpatient follow-up including chest radiography, electrocardiography, and transthoracic echocardiography was conducted at 1, 3, 6 and 12 months post procedure. Results: PBMV was successful in all 24 patients under echocardiography guidance without radiation and contrast agent. Mitral transvalvular pressure gradient derived invasive catheterization measurement dropped from(15.0±5.1) mmHg to (6.7±2.9) mmHg (P<0.01). Mitral valve area increased from (0.8±0.1) cm2at pre-PBMV to (1.7±0.1) cm2post-PBMV (P<0.01). Mean balloon diameter was (26.7±1.2) mm. Mild mitral regurgitation developed in 8 patients. Mean follow-up duration was (7.4±3.1) months. At the last follow-up, mitral valve area remained high (1.6±0.1) cm2and mean transmitral pressure gradient remained low (9.0±4.3) mmHg. No pericardial effusion or peripheral vascular complications occurred. Conclusions: In this patient cohort, PBMV could be successfully performed with echocardiography as the single imaging guidance modality, this procedure is safe and effective and avoids the radiation exposure and contrast agent use.

Echocardiographic Evaluation of Left Ventricular Function before and after Percutaneous Balloon Mitral Valvuloplasty / 中国医师杂志

Objective To evaluate left ventricular function before and after percutaneous balloon mitral valvuloplasty (PBMV) by echocardiography. Methods Left ventricular function of 80 patients who underwent PBMV were estimated by echocardiography before and after operation. Results Left ventricular end-diastolic volume (EDV), cardiac output(CO), systolic volume (SV)and ejection fraction (EF) significantly increased 1 week after PBMV, but Left ventricular end-systolic volume (ESV) had no change. EF improved as mitral valve area(MVA)increased, But it had no change while the pressure gradient across the mitral valve(PG)reduced. Left ventricular function had no further improvement 3 months after PBMV. Conclusion Left ventricular function of most of the patients was improved as EDV increased after PBMV, especially early stage after PBMV. MVA was the most important factor which influenced the left ventricular function. There was no significant correlation between EF and the PG reduction after PBMV.

Electrical Cardioversion of Atrial Fibrillation after Successful Percutaneous Balloon Mitral Valvuloplasty

Objectives: There was no previous report about the electrical cardioversion for the patients with atrial fibrillation after successful percutaneous ballon mitral valvuloplasty (PBMV). We performed electrical cardioversion after PBMV to evaluate the effectiveness of this procedure in the view of conversion to and maintenance of the sinus rhythm. METHODS: 28 patients who had persistent atrial fibrillation after successful PBMV were included in this study. All patients were anticoagulated with warfarin. Amiodarone was loaded and maintained before cardioversion. The PBMV procedures were guided by transesophageal echocardiography in all patients. Transthoracic echocardiography was done before and after PBMV and cardioversion, and was followed. RESULTS: The number of patients were 28 (male 9 and female 19) within the mean age of 50.3+/-12.0 years (24-66). Initially 24 patients (86%) succeeded in electrical cardioversion. The energy required for successful conversion was 230+/-75J, on average. There were no complications except for the transient sinus bradycardia in 2 cases. The mean follow-up duration was 357+/-144 days and when followed-up, the sinus rhythm was maintained in 15 patients out of 24 with initial success (63%). No factor was significantly related to the success of cardioversion, but left atrial dimension after 1 month of PBMV was significantly related to the maintenance of the sinus rhythm. CONCLUSIONS: This study suggests that electrical cardioversion of atrial fibrillation after successful PBMV is favorable and recommendable treatment modality of chronic valvular atrial fibrillation with high conversion rate (88%) and good maintenance rate (63%).

Percutaneous Balloon Mitral Valvuloplasty Guided by Transesophageal Echocardiography

BACKGROUND: Balloon mitral valvuloplasty is a favorable procedure as a therapy for mitral stenosis because it minimizes morbidity and shorten hospital stay compared with surgical mitral commissurotomy or mitral valve replacement. Recent reports about concomitant transesophageal echocardiography guide in addition to fluoroscopy suggest that transesophageal echocardiograpy can provide additional benefits during balloon mitral valvuloplasty especially in transseptal puncture, balloon positioning, evaluation of immediate result, and early detection of complications. We performed this study to identify the potential benefits of on-line transesophageal echocardiography guide during balloon mitral valvuloplasty. METHOD: We performed balloon mitral valvuloplasty under on-line transesophageal echocardiography guide in addition to fluoroscopy in 70 patients(male:14, female:56, mean age:44+/-13) with rheumatic mitral stenosis from May 1995 to May 1996. Thirty-two(46%) patients had atrial fibrillation. Included patients were symptomatic with more than NYHA class 2 symptom. Patients with mitral valve score more than 11 and mitral regurgitation more than 2/4 were excluded. Inoue balloons were utilized in all cases. RESULTS: The average mitral valve area increased from 0.9+/-0.2cm2 before valvuloplasty to 1.8+/-0.4cm2 after valvuloplasty(p<0.0001). The averagetransmitral pressure gradient measured by continuous wave Doppler decreased from 14+/-6mmHg before valvuloplasty to 5+/-2mmHg after valvuloplasty(p<0.0001), and the average left atrial pressure measured by catheterization decreased form 22+/-8 mmHg before valvuloplasty to 11+/-5mmHg after valvuloplasty(p<0.0001). The average procedure time was 64+/-22 minutes(ranged from 13 to 150 minutes) and the average fluoroscopy time was 19+/-15 minutes(ranged from 1 to 94 minutes). Two patients underwent surgery due to severe mitral regurgitation associated with papillary muscle rupture which developed after valvuloplasty. In one patient, transesophageal echocardiography detected pericaridal tamponade during the procedure and the transducer was quickly switched to transthoracic transducer to guide the pericardial puncture site. The pericardial tamponade was drained with pigtail catheter and the patient underwent balloon mitral valvuloplasty successfully a week later. Four patients were pregnant at the time of the valvuloplasty procedure and the valvuloplasty was successfully performed with minimal fluoroscopy time(1-3 minutes) without complications in all four patients. Five patients had thrombus in left atrial appendage, but the transesophageal echocardiography was useful in monitoring the ballon position during the procedure and the valvuloplasty was successfully performed without embolic complications in all five patients. CONCLUSION: The transesophageal echocardiography is a very useful guiding adjunct during balloon mitral valvuloplasty in transseptal puncture, balloon positioning, evaluation of immediate result, early detection of complications, and shortening fluoroscopy time especially in pregnant women.

Safety and efficacy of percutaneous balloon mitral valvuloplasty in patients with severe mitral stenosis and thrombus in the left atrial appendage / 中国介入心脏病学杂志

Objective To evaluate the safety and efficacy of percutaneous balloon mitral valvuloplasty (PBMV) in patients with rheumatic severe mitral stenosis and thrombus in the left atrial appendage.Methods We selected 11 patients (9 women and 2 men), the average age being 40.6?5.7 years. All cases received warfarin orally every day for more than 12 weeks before underwent PBMV used Inoue single balloon technique, to see whether systemic thromboembolism complication occurred during the operation and one year follow-up term. Results The successful rate of PBMV was 100%. No systemic thromboembolism occurred during and after PBMV. The parameters of hemodynamics, mitral valve area and cardiac function improved markedly.Conclusion PBMV on patients with severe mitral stenosis and thrombus in the left atrial appendage is safe and effective after certain anticoagulation treatment.

Evaluation of the short-term clinical outcomes (the changes of cardiac function, cardiac cavity size and hemodynamic) after percutaneous balloon mitral valvuloplasty in patients with rheumatic mitral stenosis and small left ventricle / 中国介入心脏病学杂志

Objective To evaluate the changes of cardiac function, cardiac cavity size and hemodynamic after percutaneous balloon mitral valvuloplasty (PBMV) in patients with rheumatic mitral stenosis and small left ventricle Methods PBMV was performed with Inoue technique in 27 patients with rheumatic mitral stenosis and small left ventricle The diameter of balloon was the height (cm) of patient/10+10 mm To measure the changes of hemodynamic during PBMV; to evaluate the cardiac function, size of the left atrium and ventricle, mitral valve area and its mean gradient, maximal pulmonary systolic pressure by echocardiogram 1 week before PBMV and 1 week, 1, 3, 6 month after PBMV Results The left atrial pressure, mean gradient and diastolic murmur decreased; and diastolic pressure of left ventricle increased immediately after PBMV; the cardiac function improved at 1 month after PBMV Conclusion The diameter of balloon can be height (cm) of patient/10+10 mm in the patients with rheumatic mitral stenosis and small left ventricle The cardiac cavity size has significant changes at 1 week and the largest effect was seen at 1 month At 1 month the cardiac function has been improved apparently

The prevention and management of complications during and immediately after percutaneous balloon mitral valvuloplasty / 介入放射学杂志

Objective To approach the cause and treatment of complications during and immediately after percutaneous balloon mitral valvuloplasty. Methods One thousand three hundred and eleven patients with mitral stenosis were treated by percutaneous transseptal balloon mitral valvuloplasty. Among them, 42 patients with complications were retrospectively analyzed. Results The overall complications rate was 3.2% (42/1 311) including atrial fibrillation 0.8%(10/1 311), acute pericardial tamponade 0.31%(4/1 311), severe mitral insufficiency 0.46% (6/1 311), femoral arterial venous fistula 0.69% (9/1 311), acute pulmonary edema and iatrogenic atrial septal defect 0.23%(3/1 311), respectively. Coronary air embolism, arterial thrombosis and transient cerebrovascular accident was 0.15%(2/1 311) for every other one. Balloon rupture was 0.08%(1/1 311).Conclusions The complications of percutaneous balloon mitral valvuloplasty rarely occur. It is a safe and efficient nonsurgical method for treating rheumatic mitral stenosis.

Clinical evaluation of percutaneous mitral valvuloplasty for mitral stenosis complicated with aortic insurfficiency / 中国介入心脏病学杂志

Objective To evaluate the effects of percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral stenosis (MS) and MS associated with aortic regurgitation (AR) of mild to moderate degree. Methods The results of PBMV in the Group A of 26 patient with MS associated with AR of mild to moderate degree and the group B of 34 patient with MS without AR were analyzed and compared.Results In group A, the mean left atrial pressure (MLAP) was 23.5?4.6 mm?Hg and 11.2?2.9 mm?Hg ( P

The Changes of Several Kinds of.Cardiovascular-Regulating Hormones After Percutaneous Balloon Mitral Valvuloplasty / 中国介入心脏病学杂志

The plasma levels of atrial natriuretic factor (ANF), angiotension II (AII, vaso-pressin (VP) and endogenous digitalis-like factor (EDLF) were determined in 23 patients with mi-tral stenosis before and after percutaneous balloon mitral valvuloplasty (PBMV). Before PBMV, the plasma levels of ANF and EDLF were elevated in all patients with lower level of All than nor-mal. After the procedure, with a concomitant decrease of left atrial pressure, the plasma ANF de-creased at 15 minutes (from 317. 4?96. 2 to 164. 9?56. 8ng/L , P

Percutaneous Balloon Mitral Vavuloplasty under General Anesthesia in Patient with Mitral Stenosis and Schizophrenia

Since the introduction of percutaneous mitral valvotomy(PMV) in 1984, PMV was an effecive alternative to surgical commissurotomy in selected patients with severe mitral stenosis. Also PMV was an excellent palliative strategy in such patients who were high risk for operative management or longterm anticoagulation was not feasible. We performed PMV in a patient with very tight mitral stenosis and severe pulmonary hypertension under the general anesthesia because the patient was anticipated to be uncooperative due to mental problem, who was diagnosed as schizophrenia 16 years ago. Robinol was used for premedication and i.v fentanyl was used for maintenance of anesthesia. Inoue balloon was introduced into the LV and gradual ballooning was performed with favorable results. Total anesthesia time and interval from internal jugular vein puncture to the completion of valvuloplasty were 1 hour 45 min and 40 minutes respectively. Hemodynamic variables were improved immediately after intervention and mitral valve area was increased from 0.5cm2 to 1.3cm2.

Change of Plasma Atrial Natriuretic Peptide(ANP) before and after Percutaneous Ballon Mitral Valvuloplasty(PMV)

To evaluate the effect of alteration of left atrial pressure. volume and wall tension on the circulating plasma level of atrial natriuretic peptide(ANP), 15 patients with left atrial hypertension due to mitral stenosis were studied at the time of percutaneous balloon mitral valvuloplasty(PMV). Hemodynamic measurements and plasma atrial natriuretic peptde levels were obtained before, immediately(5-10min) after and 24h after valvuloplasty, and echocardiographic left atrial size, wall tension and mitral valve area were measured bdfore and 24h after valvuloplasty. 1) Immediately after valvuloplasty, left atrial pressure, pulmonary atrial pressure and mean diastolic pressure gradient across the mitral valve decreased, and the mitral valve area by Gorlin's method increased, significantly. Plasma atrial natriuretic peptide level(atright and left atrium, pulmonary artery and aorta) rose significantly after balloon inflation. This rising may reflect a transient increase in left atrial pressure and volume expansion associated with mitral valve occlusion by balloon. 2) Twenty four after valvuloplasty, mitral valve area increased, and left atrial volume and wall tension decreased, significantly. Plasma atrial natriuretic peptide level(at right atrium, pulmonary artery and aorta) fell significantly, too. In conclusion, change of plasma atrial natriuretic peptide le.vel before and after percutaneous balloon mitral valvuloplasty reflect hemodynamic alteration of right and left atrium.

Change of Plasma Atrial Natriuretic Peptide(ANP) before and after Percutaneous Ballon Mitral Valvuloplasty(PMV)

To evaluate the effect of alteration of left atrial pressure. volume and wall tension on the circulating plasma level of atrial natriuretic peptide(ANP), 15 patients with left atrial hypertension due to mitral stenosis were studied at the time of percutaneous balloon mitral valvuloplasty(PMV). Hemodynamic measurements and plasma atrial natriuretic peptde levels were obtained before, immediately(5-10min) after and 24h after valvuloplasty, and echocardiographic left atrial size, wall tension and mitral valve area were measured bdfore and 24h after valvuloplasty. 1) Immediately after valvuloplasty, left atrial pressure, pulmonary atrial pressure and mean diastolic pressure gradient across the mitral valve decreased, and the mitral valve area by Gorlin's method increased, significantly. Plasma atrial natriuretic peptide level(atright and left atrium, pulmonary artery and aorta) rose significantly after balloon inflation. This rising may reflect a transient increase in left atrial pressure and volume expansion associated with mitral valve occlusion by balloon. 2) Twenty four after valvuloplasty, mitral valve area increased, and left atrial volume and wall tension decreased, significantly. Plasma atrial natriuretic peptide level(at right atrium, pulmonary artery and aorta) fell significantly, too. In conclusion, change of plasma atrial natriuretic peptide le.vel before and after percutaneous balloon mitral valvuloplasty reflect hemodynamic alteration of right and left atrium.