Left atrial structural and functional remodeling following balloon mitral valvuloplasty.

Mitral stenosis (MS) is associated with left atrial (LA) functional and morphological changes as a result of chronic increase in LA pressure. Relieving the mitral obstruction via balloon mitral valvuloplasty (BMV) might be associated with LA structural and functional remodeling. To study alterations of LA volume and functions 1 year following successful BMV in patients with isolated rheumatic severe mitral stenosis. Thirty patients (median age 33 years, 22 women) with severe rheumatic MS were included in the study. Using biplane method, trans-thoracic 2D echocardiography was used to estimate LA volume indexed to body surface area (BSA). Maximal, minimal and pre-A left atrial volumes were measured and indexed to BSA. LA volumetric functions were then assessed and the measurements were repeated 6 months and 1 year after successful valvuloplasty. At baseline, median mitral valve area (MVA) was 0.9 (0.6-1.3) cm2 measured by planimetry with a mean pressure gradient of 12.5 (8-24) mmHg. Following BMV, a significant regression of left atrial volume index was noticed at 6 months compared to baseline (51 vs. 60 ml/m2, p = 0.001) with a further decrease at 1 year (48 vs. 51 ml/m2, p = 0.03). At 6 months, volumetric assessment of left atrial functions showed a significant improvement in LA total emptying fraction (42% vs 30%, p = 0.001) as well as in LA passive emptying fraction (26% vs 14%, p = 0.033) and LA active emptying fraction (20% vs. 18%, p = 0.016). All these indices showed further improvement at 1 year [47% (P = 0.02), 29% (p = 0.03) and 31% (p = 0.001) respectively]. In patients with isolated rheumatic MS, mitral valvuloplasty was associated with a significant decline of LA volume accompanied by a significant improvement of its volumetric functions.

Impact of balloon mitral valvuloplasty on left ventricular rotational deformation: Magnetic Resonance Imaging follow up study.

In patients with rheumatic mitral stenosis (MS), some previous studies have investigated the influence of balloon mitral valvuloplasty (BMV) on left ventricular (LV) systolic function. However, the impact of BMV on LV twisting motion in this clinical setting has not been studied before yet. To describe changes in LV torsion in patients with rheumatic MS following BMV. Thirty patients (median age 33 years, 22 women) with isolated severe MS were studied. CMR myocardial tissue tagging was used for assessment of LV rotational deformation. LV torsion was calculated as the twist value (the net difference between apical counterclockwise and basal clockwise rotation) normalized to the length of the ventricle and multiplied by the mean radius at the base and apex. All patients had CMR studies before, 6 months and 1 year after successful BMV. At baseline, patients had a mitral valve area of 0.9 (0.6-1.3) cm2, mean pressure gradient of 12.5 (8-24) mmHg across the valve as measured by transthoracic echocardiography. Median LV ejection fraction (LVEF) estimated by CMR was 57 (range: 45-69) %. A significant improvement in LV base-apex torsion was shown at 6 months (3.3° vs. 2.5°, p < 0.001) with a further improvement at 1 year (4.1° vs. 3.3°, p = 0.05). Similar pattern of change was seen in LV base-mid torsion with a significant increase at 6 months (3.6° vs. 2.3°, p < 0.001) and a further increase at 1 year (4.7° vs. 3.6°, p = 0.007). These changes were associated with a significant increase in LVEF (62% vs. 57%, p < 0.001) at 1 year following BMV. Successful BMV is associated with a significant improvement in LV torsion that is accompanied by a significant improvement in LVEF.

Mitral balloon valvuloplasty.

Percutaneous mitral balloon valvuloplasty (MBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, MBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of MBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0-0.5%), cerebral accident (1-2%), mitral regurgitation (MR) requiring surgery (1.6-3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with MBV and surgical commissurotomy. Restenosis after MBV ranges from 4% to 70% depending on the patient selection, valve morphology, and duration of follow-up. Restenosis was encountered in 31% of the author's series at mean follow-up 9 ± 5.2 years (range 1.5-19 years) and the 10, 15, and 19 years restenosis-free survival rates were (78 ± 2%) (52 ± 3%) and (26 ± 4%), respectively, and were significantly higher for patients with favorable mitral morphology (MES â©½ 8) at 88 ± 2%, 67 ± 4% and 40 ± 6%), respectively (P < 0.0001). The 10, 15, and 19 years event-free survival rates were (88 ± 2%, 60 ± 4% and 28 ± 7%, respectively, and were significantly higher for patients with favorable mitral morphology (92 ± 2%, 70 ± 4% and 42 ± 7%, respectively (P < 0.0001). The effect of MBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of MBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.

Long-term results up to 19 years of mitral balloon valvuloplasty.

Clinical and echocardiographic data of 547 consecutive patients (mean age, 31.5 years) undergoing mitral balloon valvuloplasty with follow-up of 1.5-19 years, were analyzed. Immediately after valvuloplasty, mitral valve area increased significantly from 0.92 +/- 0.17 to 1.95 +/- 0.29 cm(2). Restenosis occurred in 169 (31%) patients; it was less common (20%) in those with a mitral echocardiographic score 8 and preexisting atrial fibrillation as predictors of combined events. Valvuloplasty provides excellent results in selected patients with mitral stenosis. The long-term outcome can be predicted from the baseline characteristics of the mitral valve.

Long-term (up to 18 years) clinical and echocardiographic results of mitral balloon valvuloplasty in 531 consecutive patients and predictors of outcome.

OBJECTIVES: The study aim was to assess the long-term results (up to 18 years) of mitral balloon valvuloplasty (MBV) and to identify predictors of restenosis and event-free survival. METHODS: The immediate and long-term results for 531 consecutive patients (mean age 31 +/- 11 years) who underwent successful MBV and were followed up for a mean of 8.5 +/- 4.8 years (range: 1.5-18 years) are reported. RESULTS: The mitral valve area (MVA) increased from 0.92 +/- 0.17 to 1.95 +/- 0.29 cm(2) (p < 0.0001). Restenosis was 31 and 19% in patients with mitral echocardiographic score (MES) < or =8. Actuarial freedom from restenosis at 10, 15 and 18 years was 77 +/- 2, 46 +/- 3 and 18 +/- 4% and 86 +/- 2, 62 +/- 4 and 31 +/- 7% for MES < or =8, respectively (p < 0.001). Event-free survival (death, redo MBV, mitral valve replacement, NYHA class III or IV) at 10, 15 and 18 years was 88 +/- 1, 53 +/- 4, and 21 +/- 5% and 93 +/- 2, 65 +/- 5 and 38 +/- 8% for MES < or =8, respectively (p < 0.001). Multivariable Cox regression analysis identified MES >8 (p < 0.0001) and previous surgery (p = 0.043) as predictors of restenosis, and MES >8 (p < 0.0001) and baseline atrial fibrillation (p = 0.03) as predictors of combined events. CONCLUSION: MBV provides excellent long-term results. The baseline clinical and MES characteristics are predictors of outcome.

Twenty-two years of follow-up results of balloon angioplasty for discreet native coarctation of the aorta in adolescents and adults.

BACKGROUND AND AIMS: Although the immediate and intermediate-term results of balloon angioplasty (BA) for patients with aortic coarctation (AC) have been encouraging, there is paucity of data on long-term follow-up results. This study evaluated the long-term (up to 22 years) follow-up results of BA in adolescent and adult patients with discrete (shelf-like) coarctation of the aorta. METHODS: Follow-up data of 58 patients (mean age 24+/-9 years) undergoing BA for discrete AC at median interval of 13.4 years including cardiac catheterization, magnetic resonance imaging, and Doppler echocardiography form the basis of this study. RESULTS: No early deaths occurred. Balloon angioplasty produced immediate reduction in peak AC gradient from 60+/-22 mm Hg to 8.5+/-8 mm Hg (P<.0001). Follow-up catheterization 12 months later revealed a residual gradient of 5+/-6.4 mm Hg (P=.01). Five patients (8%) with suboptimal initial outcome (peak gradient>20 mm Hg) developed restenosis, and 4 of these had successful repeat angioplasty. Aneurysm developed at the site of dilatation in 4 patients (7%). Magnetic resonance imaging follow-up results revealed no new aneurysm. In one patient, the aneurysm increased in size, but no recoarctation or appreciable changes in the Doppler gradient across the AC site was noted. The blood pressure had normalized without medical treatment in 29 (50%) of the 58 patients. CONCLUSION: Long-term results of BA for discrete AC are excellent and should be considered as first option for treatment of this disease.

Immediate and long-term results of mitral balloon valvuloplasty in patients with severe pulmonary hypertension.

BACKGROUND AND AIM OF THE STUDY: Mitral stenosis (MS) with severe pulmonary hypertension (PHT) constitutes a high-risk subset for surgical commissurotomy or valve replacement. Mitral balloon valvuloplasty (MBV) has emerged as the treatment of choice for patients with severe pliable MS. The efficacy of this procedure in patients with severe PHT has not been fully elucidated, notably with regards to the long-term outcome. METHODS: MBV was successfully performed in 531 consecutive patients. Of these patients, 82 (15%) had severe PHT at baseline (group A), defined as pulmonary artery systolic pressure (PASP) at rest > 60 mmHg, compared to the remaining 449 patients, who served as controls (group B). RESULTS: Patients with PHT had a higher echo score and were more symptomatic, the majority (52.4%) having moderate to severe tricuspid regurgitation (TR). When comparing PHT with controls, the left atrial pressure was higher (28 +/- 4.9 versus 25.6 +/- 4.6 mmHg; p < 0.0001), the mean mitral gradient was similar (14.6 +/- 3.8 versus 14.4 +/- 2.1 mmHg; p = 0.30), the baseline mitral valve area (MVA) was smaller (0.72 +/- 0.17 versus 0.86 +/- 0.19 cm2; p < 0.0001), pulmonary vascular resistance was higher (612 +/- 343 versus 211 +/- 183 dyne/s/cm(-5); p < 0.0001), and post-procedure MVA was smaller (1.7 +/- 0.44 versus 1.85 +/- 0.54 cm2; p = 0.007). The PASP decreased significantly over 12 months after MBV, from 79 +/- 14 to 36.7 +/- 7.53 mmHg (p < 0.0001). Freedom from restenosis in PHT patients at 10 and 15 years, respectively, was 66 +/- 6% and 45 +/- 8% versus 78 +/- 2% and 47 +/- 3% in controls (p = 0.0066). Event-free survival at 10 and 15 years, respectively, was 77 +/- 6% and 41 +/- 11% in PHT patients versus 89 +/- 1% and 54 +/- 4% for controls (p = 0.0169). In total, 33 patients (40%) had moderate TR and 10 (12%) had severe TR at baseline. At follow up, only 12 patients had moderate TR and none had severe TR. CONCLUSION: MBV is a safe and effective technique for treating patients with MS and severe PHT. Although the immediate results were comparable with those in controls, the long-term results proved to be slightly inferior, with a regression of PHT and concomitant severe TR.

Impact of atrial fibrillation on immediate and long-term results of mitral balloon valvuloplasty in 531 consecutive patients.

BACKGROUND AND AIM OF THE STUDY: Conflicting evidence exists regarding the impact of atrial fibrillation (AF) on the immediate and long-term outcome of mitral balloon valvuloplasty (MBV). The study aim was to investigate such outcome in 531 consecutive patients. METHODS: The immediate and long-term (up to 18 years) clinical and echocardiographic results of MBV of 71 patients with AF at baseline were prospectively collected and compared with those of 460 patients in normal sinus rhythm (NSR). RESULTS: Typically, patients in AF were older (42 +/- 12 years versus 30 +/- 10 years; p <0.0001) and had higher echocardiographic scores (8.45 +/- 1.14 versus 7.95 +/- 1.0; p = 0.005) than those in NSR. In patients with AF, MBV resulted in inferior immediate and long-term results, as reflected by a smaller immediate mitral valve area (MVA) (1.89 +/- 0.23 versus 2.0 +/- 0.3 cm2; p = 0.005), smaller MVA at follow up (1.49 +/- 0.39 versus 1.6 +/- 0.4 cm2; p = 0.037), and a higher restenosis rate (44% versus 30%; p = 0.012). Actuarial freedom from restenosis at 10 years was 67 +/- 6% for AF patients versus 77 +/- 2% for NSR patients (p = 0.11); values at 15 years were 34 +/- 8% and 46 +/- 4%, respectively (p = 0.18). An echo score >8 (p < 0.0001) and previous surgery (p = 0.043) were identified as predictors of restenosis. Actuarial survival at 15 years was lower in AF patients (72 +/- 11% versus 96 +/- 1%; p = 0.029). Likewise, event-free survival was lower in AF patients after 10 years (72 +/- 1% versus 89 +/- 1%; p <0.0001) and 15 years (40 +/- 9% versus 55 +/- 4%; p = 0.128). An echocardiography score > 8 (p < 0.0001) and baseline AF (p = 0.03) were identified as predictors of combined events (p < 0.0001) at follow up. CONCLUSION: AF has a negative impact on the immediate and long-term outcome after MBV. In addition, the presence of AF is a marker of clinical and morphological features associated with inferior results after MBV.

Long-term (up to 18 years) clinical and echocardiographic results of mitral balloon valvuloplasty in children in comparison with adult population.

AIMS: The purpose of this study was to assess the safety, efficacy, and long-term results (up to 18 years) of mitral balloon valvuloplasty (MBV) in children in comparison to adults. METHODS: 57 children age < or = 18 years (group A) and 474 adult patients (group B) who underwent successful MBV and were followed up for a mean 8.5 +/- 4.8 (range 1.5-18) years were analyzed. RESULTS: Patients in group A had a lower mitral echocardiographic score (echo score), 7.6 +/- 1.3 vs. 8.1 +/- 1 (P = 0.0005); smaller Doppler mitral valve area (MVA), 0.82 +/- 0.16 cm(2) vs. 0.92 +/- 0.17 cm(2) (P < 0.0001); and higher mitral valve gradient, 15.2 +/- 2.3 mmHg vs. 14.3 +/- 2.1 mmHg (P = 0.0003), than group B. Immediately after MBV, group A had larger MVA whether measured by catheter, 1.99 +/- 0.57 cm(2) vs. 1.8 +/- 0.52 cm(2) (P < 0.001), or by Doppler, 2.0 +/- 0.27 cm(2) vs. 1.97 +/- 0.28 cm(2) (P < 0.01), and similar complication rates, compared to group B. After a mean follow-up of 8.5 +/- 4.8 (range 1.5-18 years), restenosis in group A was 26% vs. 31% for group B (P = 0.41). Echo score > 8 (P = 0.046) was a predictor of restenosis in children and echo score > 8 (P < 0.0001) and previous surgery (P = 0.043) were predictors of restenosis in adults. Actuarial freedom from restenosis at 10, 15, and 18 years for groups A and B were 78%+/- 7%, 64%+/- 9%, and 18%+/- 14% and 77%+/- 2%, 43%+/- 4%, and 17%+/- 4%, respectively (P = 0.26). Event-free survival rates at 10, 15, and 18 years were 87%+/- 6%, 62%+/- 1%, and 20%+/- 2% versus 87%+/- 1%, 51%+/- 4%, and 20%+/- 5% for groups A and B, respectively (P = 0.51). Postprocedure MVA < 2.0 cm(2) (P = 0.043) and previous surgery (P = 0.03) were identified as predictors of events in children. Echo score > 8 (P < 0.0001) and prevalvuloplasty AF (P = 0.03) were identified as predictors of events in adults. CONCLUSION: MBV is safe and effective in children with rheumatic MS. It provides better immediate results than in adults and excellent long-term results that are comparable to those seen in adults.

Long-term effects of balloon angioplasty on left ventricular hypertrophy in adolescent and adult patients with native coarctation of the aorta. Up to 18 years follow-up results.

BACKGROUND: Little is known regarding the long-term follow-up results of balloon angioplasty (BA) for patients with native aortic coarctation (AC) on left ventricular hypertrophy (LVH) regression. OBJECTIVES: The purpose of this study was to define the long-term effect of BA of AC on LVH in adolescent and adult patients. METHODS: Follow-up data of 53 patients (36 male) mean age 24 +/- 9 years undergoing BA for discrete AC at median interval of 11.8 years (range 4-18 years) including cardiac catheterization, magnetic resonance imaging, and Echocardiography form the basis of this study. Patients were divided into two groups at 1 year after BA based on absence (group A) or presence (group B) of persistent hypertension and need for medication. RESULTS: Forty-nine patients had baseline LVH, BA produced an immediate reduction in peak AC gradient from 66 +/- 23 mm Hg (95% confidence interval [CI]: 59.5-72.7) to 10.8 +/- 7 mm Hg (95% CI: 8.8-12.5) (P < 0.0001). Follow-up catheterization 12 months later revealed a residual gradient of 6.2 +/- 6 mm Hg (95% CI: 4.4-7.9) (P < 0.001). The blood pressure had normalized without medication in 38 of the 49 patients (165 +/- 17 to 115 +/- 10 mm Hg). Left ventricular mass index (LVMI) decreased significantly (>20% decrease LVMI from baseline) in 48 patients (98%) at median interval 1.4 years (range 0.5-3 years) post BA, group A (38 patients) LVMI decreased from 132 +/- 30.7 g/m(2) (95% CI: 122-141.9) to 86 +/- 19.9 g/m(2) (95% CI: 79.5-92.5) (P < 0.0001). Similarly, in 10 patients (group B) the LVMI decreased from 157 +/- 38.7 g/m(2) (95% CI: 127-185) to 102 +/- 29 g/m(2) (95% CI: 105-151) (P < 0.0001) at follow-up. Mild (<20% decrease in LVMI) regressions were noted in one patient from group B. There was no progression to LVH in the four patients who had normal baseline LVMI. CONCLUSION: (1) Long-term results of BA for discrete AC are excellent and should be considered as first option for treatment of this disease; (2) Regression of LVH (> or =20% reduction in LVMI) occurred in 98% of patients after BA.

Seventeen years' clinical and echocardiographic follow up of mitral balloon valvuloplasty in 520 patients, and predictors of long-term outcome.

BACKGROUND AND AIM OF THE STUDY: Long-term echocardiographic follow up studies of mitral balloon valvuloplasty (MBV) are scarce. The study aim was to assess the long-term results (up to 17 years) of MBV and to identify predictors of restenosis and event-free survival. METHODS: The immediate and long-term clinical and echocardiographic results for 520 consecutive patients (mean age 31 +/- 11 years) who underwent successful MBV for severe mitral stenosis (MS) and were followed up for a mean of 7.3 +/- 4.35 years (range: 1 to 17 years) after MBV, were reported. RESULTS: Immediately after MBV, the mitral valve area (MVA) was increased from 0.92 +/- 0.17 to 1.96 +/- 0.29 cm2 (p < 0.0001). Restenosis occurred in 133 patients (25.6%), and was less frequent (16.7%) in patients with a low mitral echo score (MES < or = 8). Actuarial freedom from restenosis at 10, 15, and 17 years was 73 +/- 2%, 43 +/- 4%, and 23 +/- 6%, respectively, and was significantly higher in patients with MES < or = 8 (84 +/- 2%, 52 +/- 6%, and 36 +/- 9%, respectively; p < 0.001). Event-free survival (death, redo MBV, mitral valve replacement, NYHA class III or IV) at 10, 15, and 17 years was 82 +/- 2%, 45 +/- 5%, and 31 +/- 6% respectively, and was significantly higher for patients with MES < or = 8 (90 +/- 2%, 60 +/- 5%, and 51 +/- 8%, respectively; p < 0.001). Cox regression analysis identified MES > 8 (p < 0.0001) and post-procedure MVA (p = 0.044) as predictors of restenosis, and MES < or = 8 (p < 0.0001), age (p < 0.0001), and post-procedure MVA (p = 0.016) as predictors of event-free survival. CONCLUSION: MBV provides excellent long-term results for selected patients with MS. The long-term outcome of this procedure can be predicted from the baseline clinical and echocardiographic characteristics of the mitral valve.

Long-term results (up to 17 years) of pulmonary balloon valvuloplasty in adults and its effects on concomitant severe infundibular stenosis and tricuspid regurgitation.

BACKGROUND: Significant infundibular stenosis and significant tricuspid regurgitation (TR) occasionally result from severe pulmonary valve stenosis in adults, and these 2 conditions have an adverse impact on morbidity and mortality in patients who undergo corrective surgery. The goal of this study was (1) to evaluate the long-term (up to 17 years) outcome of pulmonary balloon valvuloplasty (PBV) in adults and (2) to determine the effect of successful PBV on severe infundibular stenosis and severe TR. METHODS: Pulmonary balloon valvuloplasty was performed in 90 consecutive patients (49 women, 41 men) of mean age 23 +/- 9 years (range 15-54 years) with congenital pulmonary valve stenosis. Clinical and echocardiographic assessment was performed 2 to 17 years (mean 10 +/- 3.9 years) after PBV. Repeat cardiac catheterization was performed 6 to 24 months after PBV in 43 patients who had concomitant moderate to severe infundibular stenosis (infundibular gradient > or = 30 mm Hg). RESULTS: There were no immediate or late deaths. The mean catheter peak pulmonary gradient (gradient between pulmonary artery and right ventricular body) before and immediately after PBV was 105 +/- 39 and 34 +/- 26 (P < .0001), respectively. The corresponding values for right ventricular pressure were 125 +/- 38 and 59 +/- 21 mm Hg (P < .0001), respectively. The infundibular gradient (in 43 patients) immediately after PBV was 42.9 +/- 24.8 (30-113) mm Hg, and it regressed at second catheterization to 13.5 +/- 8.3 mm Hg (P < .0001), whereas cardiac index improved from 2.68 +/- 0.73 to 3.1 +/- 0.4 L min(-1) m(-2) (P < .05). Doppler pulmonary gradient before PBV and at 1-year and long-term follow-up were 91 +/- 33 (range 36-200), 28 +/- 12 (range 10-60) (P < .0001), and 26 +/- 11 (range 7-60) mm Hg (P = .2), respectively. New mild pulmonary regurgitation was noted in 24 patients (28%) after PBV. Significant TR in 7 patients either regressed or disappeared after PBV. CONCLUSIONS: Long-term results of PBV in adults are excellent. Severe infundibular stenosis and severe TR regressed after successful PBV. Therefore, PBV should be considered as the treatment of choice for adult patients with valvular pulmonary stenosis even in the presence of severe infundibular stenosis or severe TR.

Long-term results (up to 18 years) of balloon angioplasty on systemic hypertension in adolescent and adult patients with coarctation of the aorta.

BACKGROUND: Little is known regarding the long-term follow-up results of balloon angioplasty (BA) for patients with aortic coarctation (AC) on systemic hypertension. HYPOTHESIS: To define the long-term effect of BA of AC on systemic hypertension in adolescent and adult patients. METHODS: Follow-up data of 53 patients (36 male), mean age 24 +/- 9 years, undergoing BA for discrete AC at median interval of 11.8 years (range, 4-18 years), including cardiac catheterization, magnetic resonance imaging (MRI), and echocardiography. Patients were divided into two groups at 1 year after BA on the basis of absence (group A: 40 patients) or presence (group B: 11 patients) of persistent hypertension and need for medication. RESULTS: Fifty-one patients had baseline hypertension, BA produced an immediate reduction in peak AC gradient from 66 +/- 23 mmHg to 10.8 +/- 7 mmHg (p < 0.0001). The immediate systolic blood pressure (SBP) decreased from 165 +/- 17 mmHg (95% CI: 159 to 171) to 125 +/- 10 mmHg (95% CI: 122 to 131) (p < 0.001) in 40 patients (group A) and from 184 +/- 19 mmHg (95% CI: 169 to 198) to 142 +/- 22 mmHg (95% CI: 124 to 156) (p<0.001) in 11 patients (group B). At 1-year follow-up, SBP decreased further to 115 +/- 10 in group A (95% CI 111-119) and 134 +/- 19 in group B (95% CI 122-142) (p<0.001). The blood pressure had normalized without medication in group A (165 +/- 17 to 115 +/- 10 mmHg). CONCLUSION: Long-term results of BA for discrete AC are excellent and should be considered as the first option for treatment of this disease. No paradoxical hypertension occurred post angioplasty, and normalization of blood pressure without medication occurred in 78% of the patients after BA.

Percutaneous mitral balloon valvotomy.

Percutaneous mitral balloon valvotomy (PMBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, PMBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of PMBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0-0.5%), cerebral accident (0.5-1%), mitral regurgitation (MR) requiring surgery (1.6-3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with PMBV and surgical commissurotomy. Restenosis after PMBV ranges from 4 to 70% depending on the patient selection, valve morphology, and duration of follow up. Restenosis was encountered in 21% of the author's series at mean follow-up 6 +/- 4.5 years and the 10 and 15 years restenosis-free survival rates were (70 +/- 3)% and (44 +/- 5)%, respectively, and were significantly higher for patients with favorable mitral morphology (85 +/- 3% and 65 +/- 6%), respectively (P < 0.0001). The 10 and 15 years event-free survival rates were (79 +/- 2)% and (43 +/- 9)% and were significantly higher for patients with favorable mitral morphology (88 +/- 2)% and (66 +/- 6)%, respectively (P < 0.0001). The effect of PMBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of PMBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.

The impact of mitral valve morphology on the long-term outcome of mitral balloon valvuloplasty.

BACKGROUND: The effect of mitral valve morphology (MVM) on the long-term results of mitral balloon valvuloplasty (MBV) is not well established. The aim of the study was to evaluate the impact of MVM on long-term outcome of MBV. METHODS: Five hundred and eighteen consecutive patients (mean age, 31+/-11 years) who underwent successful MBV were followed up for 0.5-16.5 (mean, 6+/-4.5) years. Patients were divided into two groups according to their mitral echo score (MES) before MBV: group A (n=340; MES8). RESULTS: We report the immediate and long-term clinical and echocardiographic results of the above-mentioned 518 consecutive patients. The mitral valve area was significantly larger in group A than in group B, both immediately after MBV (2.0+/-0.3 vs. 1.82+/-0.3 cm2, respectively; P<0.0001) and also at the last follow-up (1.8+/-0.33 vs. 1.5+/-0.33 cm2, respectively; P<0.0001). Restenosis occurred in 38/340 (11%) in group A vs. 73/178 (41%) in group B (P<0.0001). Actuarial freedom from restenosis at 5, 10, 15 years were 92+/-2%, 85+/-3%, 65+/-6% for group A vs. 72+/-4%, 44+/-5%, 9+/-6% for group B (P<0.001). Event-free survival rates at 5, 10, 15 years for group A were 93+/-1%, 88+/-2%, 66+/-6% vs. 82+/-3%, 59+/-6%, 8+/-7% for group B (P<0.0001). Stepwise Cox multivariate regression analysis identified MES, preprocedure functional class, and postprocedure mitral valve area

Immediate and long-term results of mitral balloon valvotomy for restenosis following previous surgical or balloon mitral commissurotomy.

This study compared immediate with long-term results of mitral balloon valvotomy (MBV) in patients who underwent MBV as an initial procedure versus those who underwent repeat MBV. Fifty-six patients who were a mean age of 28 +/- 8.8 years (group A) and had mitral restenosis after surgical or balloon commissurotomy underwent MBV and were compared with 524 patients who were a mean age of 31 +/- 11 years (group B) and underwent MBV as an initial procedure. Prospective data obtained included demographic, hemodynamic, echocardiographic, and clinical follow-up for 0.5 to 15 years after MBV. No deaths or technical failure were encountered after MBV. Mitral regurgitation >2/4 occurred in 1 patient (2%) in group A and in 9 patients (2%) in group B (p = 0.24). Fifty-two of 56 patients (93%) in group A had good immediate results (mitral valve area >or=1.5 cm(2), mitral regurgitation <2/4), as did 504 of 524 patients (96%) in group B (p = 0.4). Actuarial values for freedom from restenosis at 10 years were 58 +/- 7% for group A versus 69 +/- 3% for group B (p = 0.18). Ten-year event-free survival rate was 54 +/- 7% for group A versus 80 +/- 3% for group B (p <0.005). The predictors of event-free survival were age (p = 0.003), echocardiographic score (p <0.0001), and baseline atrial fibrillation (p = 0.01). In conclusion, MBV is safe and provides good immediate results in patients who have restenosis. Long-term results are inferior compared with de novo mitral stenosis but is still satisfactory. More than 50% of patients remained improved at 10 years, thus enabling the operation or reoperation to be deferred.

Cardiac unilateral pulmonary edema: is it really a rare presentation?

Unilateral pulmonary edema is a distinctly unusual clinical entity that presents interesting and confusing diagnostic challenges. It is usually described as occurring with re-expansion of a collapsed lung after rapid thoracocentesis of pleural air or pleural fluid. Unilateral pulmonary edema as an initial presenting manifestation for heart failure is uncommon and can be confused with other more common causes of alveolar or interstitial infiltrate, which can lead to a significant delay in treatment.

Long-term clinical and echocardiographic results after successful mitral balloon valvotomy and predictors of long-term outcome.

AIMS: To assess the long-term outcome of mitral balloon valvotomy (MBV) and identify predictors of restenosis- and event-free survival. METHODS AND RESULTS: We report the immediate and long-term clinical and echocardiographic results in 493 patients, mean age 31+/-11, who underwent successful MBV and were followed-up for 0.5-15 years (median 5+/-3) with clinical and echocardiographic examination. After MBV, mitral valve area increased from 0.84+/-0.2 to 1.83+/-0.53 cm(2) (P<0.0001) as measured by catheter and from 0.92+/-0.17 to 1.96+/-0.29 cm(2) as measured by two-dimensional echo. Restenosis occurred in 86/493 (17.4%) patients and it was less frequent in patients with low echo score. Actuarial freedom from restenosis at 5, 7, 10, and 13 years were 89+/-1, 81+/-2, 68+/-3, and 51+/-6%, respectively, and was significantly higher in patients with low echo score. Event-free survival (death, redo MBV, mitral valve replacement, New York Heart Association functional Class III or IV) at 5, 7, 10, and 13 years were 92+/-1, 87+/-2, 80+/-3, and 74+/-3%, respectively, and was significantly higher for patients with low echo score. Cox regression analysis identified mitral echocardiographic score (MES) >8 as predictors of restenosis (P=0.0004) and MES and age as predictors of event-free survival (P=0.0003 and 0.004, respectively). CONCLUSION: MBV has excellent long-term results for selected patients with mitral stenosis. The long-term outcome after this procedure can be predicted from baseline clinical and valvular characteristics.

Prevalence and fate of severe pulmonary hypertension in 559 consecutive patients with severe rheumatic mitral stenosis undergoing mitral balloon valvotomy.

BACKGROUND AND AIM OF THE STUDY: The prevalence of severe pulmonary hypertension (PH) in patients with severe mitral stenosis (MS) remains unknown, and the long-term effect of mitral balloon valvotomy (MBV) in large numbers of these patients is not well characterized. METHODS: Details from the prospective MBV database at the authors' institution relating to 559 consecutive patients who had successful MBV were analyzed. Patients were allocated to three groups on the basis of their pulmonary artery systolic pressure (PASP) at cardiac catheterization immediately before MBV: group A (n = 345) had PASP <50 mmHg; group B (n = 183) had PASP 50-79 mmHg; and group C (n = 31) had PASP > or =80 mmHg. Patients were evaluated clinically and echocardiographically at six months after MBV, and annually thereafter for up to 13 years. RESULTS: No mortality was encountered after MBV. Immediately after MBV, the mean PASP was 38.5+/-6.8 mmHg in group A (mild PH), 59.0+/-7.7 mmHg in group B (moderately severe PH), and 97.8+/-17.0 mmHg in group C (severe PH). At follow up (ca. 4 years), Doppler-monitored PASP fell to normal, and was similar in groups A, B and C (29+/-8, 31+/-9, and 29+/-5 mmHg, respectively; p = NS). CONCLUSION: MBV was shown to be safe and effective in treating patients with MS and severe PH. The latter condition regressed to normal levels over 6-12 months after successful MBV.

Regression of significant tricuspid regurgitation after mitral balloon valvotomy for severe mitral stenosis.

BACKGROUND: Significant tricuspid regurgitation (TR) is occasionally associated with severe mitral stenosis and has an adverse impact on morbidity and mortality in patients undergoing mitral valve surgery. However, the effect of successful mitral balloon valvotomy (MBV) on significant TR is not fully elucidated. The aim of this study was to investigate TR after MBV in patients with severe mitral stenosis. METHODS: We analyzed the data of 53 patients with significant TR (grade > or =2, on a 1 to 3 scale) from the mitral balloon valvotomy database at our hospital. Patients were evaluated by Doppler echocardiography before valvotomy and at follow-up 1 to 13 years after MBV. Patients were divided into group A (27 patients), in whom TR regressed by > or =1 scale, and group B (26 patients), in whom TR did not regress. RESULTS: The Doppler-determined pulmonary artery systolic pressure was initially higher and decreased at follow-up more in group A (from 70.7 +/- 23.8 to 36.5 +/- 8.3 mm Hg; P < .0001) than in group B (from 48.7 +/- 17.8 to 41.6 +/- 13.1 mm Hg; P = NS). Compared with patients in group B, patients in group A were younger (25 +/-10 vs 35 +/- 11 years; P < .005), had higher prevalence of functional TR (85% vs 8%; P < .0001), and had lower incidence of atrial fibrillation (7% vs 38%; P < .005). Significant decrease in right ventricular end-diastolic dimension after MBV was noted in group A but not in group B. The mitral valve area at late follow-up was larger in group A than in group B (1.8 +/- 0.3 vs 1.6 +/- 0.3 cm2; P < .05). CONCLUSIONS: Regression of significant TR after successful MBV in patients with severe mitral stenosis was observed in patients who had severe pulmonary hypertension. This improvement in TR occurred even in the presence of organic tricuspid valve disease.