Echocardiography can predict the development of severe mitral regurgitation after percutaneous mitral valvuloplasty by the Inoue technique.

Severe mitral regurgitation (MR) following mitral balloon valvuloplasty is a major complication of this procedure. We recently described a new echocardiographic score that can predict the development of severe MR following mitral valvuloplasty with the double balloon technique. The present study was designed to test the usefulness of this score for predicting severe MR in patients undergoing the procedure using the Inoue balloon technique. From 117 consecutive patients who underwent mitral valvuloplasty using the Inoue technique, 14 (11.9%) developed severe MR after the procedure. A good quality echocardiogram before mitral valvuloplasty was available in 11 patients. These 11 patients were matched by age, sex, mitral valve area, and degree of MR before valvuloplasty with 69 randomly selected patients who did not develop severe MR after Inoue valvuloplasty. The total MR-echocardiographic (MR-echo) score was significantly greater in the severe MR group (10.5 +/- 1.4 vs 8.2 +/- 1.1; p <0.001). In addition, the component grades for the anterior leaflet (2.9 +/- 0.5 vs 2.2 +/- 0.4; p <0.001), posterior leaflet (2.6 +/- 0.7 vs 1.9 +/- 0.8), commissures (2.4 +/- 0.8 vs 2.0 +/- 0.5; p <0.05) and subvalvular apparatus (2.6 +/- 0.5 vs 1.9 +/- 0.4; p <0.001) were also higher in the MR group. Using a total score of > or = 10 as a cut-off point for predicting severe MR with the Inoue technique, a sensitivity of 82%, specificity of 91%, accuracy of 90%, and negative predictive value of 97% were obtained. Stepwise logistic regression analysis identified the MR-echo score as the only independent predictor for developing severe MR with the Inoue technique (p <0.0001). Thus, the MR-echo score can also predict the development of severe MR following mitral balloon valvuloplasty using the Inoue technique.

Calcium antagonists and mortality risk in men and women with hypertension in the Framingham Heart Study.

BACKGROUND: Several recent studies have suggested that calcium antagonist drugs, which are widely used for the treatment of hypertension, are associated with increased risk of cardiovascular disease. These studies have cast doubts on the long-term safety of calcium antagonists. OBJECTIVE: To examine the association of calcium antagonist use with mortality in subjects with hypertension followed up in the Framingham Heart Study. SUBJECTS AND METHODS: We stratified 3539 subjects (mean+/-SD age, 64+/-13 years) from the Framingham Heart Study who had hypertension at routine clinic examinations, according to the use of calcium antagonists and presence of coronary heart disease at the baseline examination. At each follow-up examination (every 2-4 years), subjects were reclassified with regard to the use of calcium antagonists. The end point of the study was all-cause mortality. Hazard ratios and 95% confidence intervals associated with the use of calcium antagonists were obtained using Cox proportional hazards regression models. RESULTS: There were 970 deaths during follow-up. Hazard ratios for mortality associated with the use of calcium antagonists were 0.93 (95% confidence interval, 0.72-1.21; P=.59) for subjects with hypertension without coronary heart disease, and 0.92 (95% confidence interval, 0.69-1.24; P=.58) for those with coronary heart disease at baseline. All models were adjusted for age, sex, current smoking, systolic and diastolic blood pressure, use of beta-blockers, and use of other antihypertensive medications. CONCLUSIONS: In this cohort of 3539 subjects with hypertension there were no differences in mortality among subjects with hypertension using a calcium antagonist compared with those who were not. Results were similar among subjects with hypertension with and without coronary heart disease. The results of ongoing long-term, randomized clinical trials will provide more definitive data on the safety of calcium antagonists.

Comparison of the usefulness of Doppler pressure half-time in mitral stenosis in patients < 65 and > or = 65 years of age.

Doppler pressure half-time is a reliable method for estimating mitral valve area when net left atrial and ventricular compliance remain stable. The accuracy of Doppler pressure half-time in estimating mitral valve area in older patients is unknown. We studied 80 patients (65 women and 15 men, aged 56 +/- 14 years) with cardiac catheterization and echocardiography. Mitral valve area was calculated using the Gorlin formula and by the Doppler pressure half-time method. Patients were stratified into those aged < 65 years (n = 57), and those aged > or = 65 years (n = 23). The discordance between pressure half-time and Gorlin-derived mitral valve area was assessed and related to multiple clinical, echocardiographic, and hemodynamic variables. The difference between pressure half-time and Gorlin-derived mitral valve area was greater in the older than in the younger patient (0.34 +/- 0.30 vs 0.15 +/- 0.27 cm2, p = 0.009) but the older group had smaller mitral valve areas by the Gorlin method (0.72 +/- 0.18 vs 0.89 +/- 0.32 cm2, p = 0.02) and lower cardiac output. The difference between pressure half-time and Gorlin remained greater in the group of older patients (0.32 +/- 0.30 vs 0.19 +/- 0.22 cm2, p = 0.04), even when the analysis was restricted to patients with similar mitral valve area (< 1 cm2 by the Gorlin method). Using multivariate analysis, age > or = 65 years remained the only significant predictor of the discrepancy between pressure half-time and Gorlin mitral valve area. Thus, when compared with Gorlin-derived mitral valve area, pressure half-time overestimated valve area in older patients, and this technique for estimating mitral valve area should be used with caution in patients > or = 65 years of age.

Left atrial myxoma and acute myocardial infarction. A dangerous duo in the thrombolytic agent era.

Systemic embolization is a common complication of left atrial myxoma; however, coronary embolism leading to acute myocardial infarction is rare. The use of echocardiography has increased the detection of intracardiac tumors when signs and symptoms are not evident. Echocardiography is the diagnostic procedure of choice in the initial evaluation of patients with suspected left atrial myxoma.

Effects of dobutamine on Gorlin and continuity equation valve areas and valve resistance in valvular aortic stenosis.

Previous studies demonstrated changes in aortic valve area calculated by the Gorlin equation under conditions of varying transvalvular flow in patients with valvular aortic stenosis (AS). To distinguish between flow-dependence of the Gorlin formula and changes in actual orifice area, the Gorlin valve area and 2 other measures of severity of AS, continuity equation valve area and valve resistance, were calculated under 2 flow conditions in 12 patients with AS. Transvalvular flow rate was varied by administration of dobutamine. During dobutamine infusion, right atrial and left ventricular end-diastolic pressures decreased, left ventricular peak systolic pressure and stroke volume increased, and systolic arterial pressure did not change. Heart rate increased by 19%, cardiac output by 38% and mean aortic valve gradient by 25%. The Gorlin valve area increased in all 12 patients by 0.03 to 0.30 cm2. The average Gorlin valve area increased from 0.67 +/- 0.05 to 0.79 +/- 0.06 cm2 (p < 0.001). In contrast, the continuity equation valve area (calculated in a subset of 6 patients) and valve resistance did not change with dobutamine. The data support the conclusion that flow-dependence of the Gorlin aortic valve area, rather than an increase in actual orifice area, is responsible for the finding that greater valve areas are calculated at greater transvalvular flow rates. Valve resistance is a less flow-dependent means of assessing severity of AS.

Unusual sequelae after percutaneous mitral valvuloplasty: a Doppler echocardiographic study.

Percutaneous mitral valvuloplasty is a promising new technique for the treatment of mitral stenosis, with a relatively low complication rate reported to date. To assess the sequelae of this procedure, Doppler echocardiographic studies were prospectively performed before and after percutaneous mitral valvuloplasty in a series of 172 patients (mean age 53 +/- 17 years). After balloon dilation, mitral valve area increased from 0.9 +/- 0.3 to 2 +/- 0.8 cm2 (p less than 0.0001), mean gradient decreased from 16 +/- 6 to 6 +/- 3 mm Hg (p less than 0.0001) and mean left atrial pressure decreased from 24 +/- 7 to 14 +/- 6 mm Hg (p less than 0.0001). Although most patients were symptomatically improved, six (4%) were identified who had unusual sequelae evident on Doppler echocardiographic examination immediately after percutaneous mitral valvuloplasty. These included rupture of a posterior mitral valve leaflet, producing a flail distal leaflet portion with severe mitral regurgitation detected on Doppler color flow mapping (n = 1); asymptomatic rupture of the chordae tendineae attached to the anterior mitral valve leaflet with systolic anterior motion of the ruptured chordae into the left ventricular outflow tract (n = 1); a double-orifice mitral valve (n = 1); and evidence of a tear in the anterior mitral valve leaflet (n = 3), producing on both pulsed Doppler ultrasound and color flow mapping a second discrete jet of mitral regurgitation in addition to regurgitation through the main mitral valve orifice. All six patients made a satisfactory recovery and none has required mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Left atrial dimensions in growth and development: normal limits for two-dimensional echocardiography.

Reference values for normal left atrial dimensions have been based primarily on blind M-mode measurements, with no reports based on two-dimensional echocardiography to provide a comprehensive analysis of the two-dimensional measurements from infancy to old age. This report analyzes the left atrial dimensions from two-dimensional echocardiographic studies in 268 normal healthy subjects to determine normal limits and relations among linear, area and volume measurements of the left atrium. The group mean values change with body size, fitting well to the exponential growth model (r = 0.78 to 0.92). The variance about the mean (which determines normal limits) is represented effectively by a quadratic function of body surface area (r = 0.84 to 0.99). The variables determined by this modeling simplify evaluation of normal limits for any body size at any desired level of confidence, and the data are useful reference standards for interpretation of two-dimensional echocardiograms.

Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study.

To test the hypothesis that atrial enlargement can develop as a consequence of atrial fibrillation, left and right atrial dimensions were measured echocardiographically at two different time points in patients with atrial fibrillation. Patients were selected who initially had normal atrial sizes and who had no evidence of significant structural or functional cardiac abnormalities other than atrial fibrillation either by history or two-dimensional and Doppler echocardiography. Fifteen patients were studied (12 men and three women; mean age, 67.3 years). Average time between studies was 20.6 months. Three orthogonal left atrial dimensions and two right atrial dimensions were measured, and all were found to increase significantly between studies. Also, highly significant increases in calculated left atrial volume (from 45.2 to 64.1 cm3, p less than 0.001) and right atrial volume (from 49.2 to 66.2 cm3, p less than 0.001) were observed. The relative extents of left and right atrial volume increase did not differ, and left ventricular size did not change significantly between studies. These results indicate that atrial enlargement can occur as a consequence of atrial fibrillation. The maintenance of sinus rhythm, therefore, may prevent atrial enlargement and its adverse clinical effects.

Prediction of successful outcome in 130 patients undergoing percutaneous balloon mitral valvotomy.

We studied 130 patients undergoing percutaneous balloon mitral valvotomy. The relation between valvular morphology according to a previously described echocardiographic scoring system and hemodynamic outcome expressed as qualitative ("good" and suboptimal) and as absolute change in valve area was analyzed. The relative importance of the individual components of this echocardiographic score (valvular thickening, mobility, calcification, and subvalvular disease) to the change in valve area after valvotomy was also examined. Mean transmitral pressure gradient decreased from 16 +/- 6 to 6 +/- 3 mm Hg (p less than 0.0001), and mitral valve area increased from 0.9 +/- 0.3 to 1.8 +/- 0.7 cm2 (p less than 0.0001). Results in individual patients were variable. Eighty-four percent (61 of 73) of patients with an echocardiographic score of 8 or less had a "good" outcome (final valve area greater than or equal to 1.5 cm2 and an increase in valve area of greater than or equal to 25%), whereas 58% (33 of 57) of patients with an echocardiographic score of 8 or more had a suboptimal result (p less than 0.001). The sensitivity of an echocardiographic score of 8 or less for predicting a "good" outcome was 72%, and the specificity was 73%. The echocardiographic score correlated negatively (r = -0.40, p less than 0.0001) with the absolute increase in mitral valve area after valvotomy, but there was substantial scatter in the data. Of the four components of the total echocardiographic score, valvular thickening correlated best with the absolute change in value area (r = -0.47, p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic regurgitation shortens Doppler pressure half-time in mitral stenosis: clinical evidence, in vitro simulation and theoretic analysis.

Mitral valve areas determined by Doppler pressure half-time were compared with areas obtained by planimetry in two groups of patients with mitral stenosis: 24 patients without aortic regurgitation and 32 patients with more than grade 1 aortic regurgitation. The severity of aortic regurgitation was assessed by color flow mapping; 17 patients had grade 2, 10 had grade 3 and 5 had grade 4 aortic regurgitation. Regression equations for pressure half-time area versus planimetry mitral valve area were calculated separately for the aortic regurgitation (r = 0.88) and the nonaortic regurgitation group (r = 0.86); analysis of covariance revealed a significant (p less than 0.001) difference between the two groups leading to overestimation of planimetry area by the pressure half-time method in the aortic regurgitation group. The mitral valve areas in the group without regurgitation were best calculated with the expression 239/T1/2 (r = 0.77) as compared with a best fit of 195/T1/2 (r = 0.85) for the aortic regurgitation group. To elucidate the mechanisms affecting pressure half-time in aortic regurgitation, an in vitro model of mitral inflow in the presence of varying regurgitant volumes and different ventricular chamber compliances was used. Aortic regurgitation shortened directly measured pressure half-time proportional to the regurgitant fraction but an increase in left ventricular compliance could offset this effect. Finally, in a mathematic model of mitral inflow the competing effects of aortic regurgitation and chamber compliance could be confirmed. In conclusion, aortic regurgitation results clinically in a significant net shortening of pressure half-time leading to mitral valve area overestimation. However, the effect is moderate and individually unpredictable because of changes in chamber compliance.

Prevalence of valvular regurgitation by Doppler echocardiography in patients with structurally normal hearts by two-dimensional echocardiography.

The prevalence of valvular regurgitation in a large population with structurally normal hearts remains unknown. From the computer database of the echocardiography laboratory of the hospital, 7209 records containing results of both two-dimensional and Doppler echocardiographic examinations were identified, from which 867 (12%) with no structural abnormality on two-dimensional echocardiograms were obtained for analysis. Of these 867 records, 291 (34%) had evidence of regurgitation by Doppler technique in at least one cardiac valve. Mitral regurgitation was found in 167 (19%), tricuspid regurgitation in 151 (17%), pulmonic regurgitation in 45 (5%), and aortic regurgitation in 29 records (3%). Regurgitation of just one valve was the most common and occurred in 207 records (24%). This was followed by regurgitation of two valves (69 records, 8%), three valves (13 records, 2%), and four valves (two records, 0.2%). The prevalence of mitral, tricuspid, and aortic regurgitation was found to increase significantly with increasing age, as was the prevalence of regurgitation involving multiple valves. In 98% and 95% of mitral and tricuspid regurgitations, respectively, the jets were confined to the proximal one fourth of the atria, suggesting only trivial or mild regurgitation. Thus valvular regurgitation occurs not uncommonly in patients with structurally normal hearts referred for echocardiographic evaluation. These findings caution against the inappropriate diagnosis of clinical disease in the many patients who fall into this category. The increasing prevalence of valvular regurgitation with increasing age suggests that a wear-and-tear phenomenon rather than a congenital cause is involved in most instances.

Inaccuracy of mitral pressure half-time immediately after percutaneous mitral valvotomy. Dependence on transmitral gradient and left atrial and ventricular compliance.

Mitral pressure half-time (T1/2) is widely used as an independent measure of mitral valve area in patients undergoing percutaneous mitral valvotomy. However, fluid dynamics theory predicts T1/2 to be strongly dependent on chamber compliance and the peak transmitral gradient, which are variables that change dramatically with valvotomy. These theoretical predictions were tested in an in vitro model of the left heart where valve area, chamber compliance, and initial gradient were independently adjusted. Measured T1/2 was observed to vary inversely with orifice area and directly with net chamber compliance and the square root of the initial pressure gradient. Theoretical predictions of T1/2 agreed with observed values with r = 0.998. To test this theory in vivo, the hemodynamic tracings of 18 patients undergoing mitral valvotomy were reviewed. Predictions were made for T1/2 assuming dependence only on valve area; these showed some correlations before valvotomy (r = 0.48-0.64, p less than 0.05) but none after valvotomy (r = 0.05-0.28, p = NS). Predictions for T1/2 based on the theoretical derivation (and thus including compliance and pressure in their calculation) were much better: before valvotomy, r = 0.93-0.96, p less than 0.0001; after valvotomy, r = 0.52-0.66, p less than 0.05. These data indicate that T1/2 is not an independent inverse measure of mitral valve area but is also directly proportional to net chamber compliance and the square root of the initial transmitral gradient. These other factors render T1/2 an unreliable measure of mitral valve area in the setting of acute mitral valvotomy.

Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation.

Twenty two patients (four men, 18 women, mean age 56 years, range 21 to 88 years) with a history of rheumatic mitral stenosis were studied by cross sectional echocardiography before and after balloon dilatation of the mitral valve. The appearance of the mitral valve on the pre-dilatation echocardiogram was scored for leaflet mobility, leaflet thickening, subvalvar thickening, and calcification. Mitral valve area, left atrial volume, transmitral pressure difference, pulmonary artery pressure, cardiac output, cardiac rhythm, New York Heart Association functional class, age, and sex were also studied. Because there was some increase in valve area in almost all patients the results were classified as optimal or suboptimal (final valve area less than 1.0 cm2, final left atrial pressure greater than 10 mm Hg, or final valve area less than 25% greater than the initial area). The best multiple logistic regression fit was found with the total echocardiographic score alone. A high score (advanced leaflet deformity) was associated with a suboptimal outcome while a low score (a mobile valve with limited thickening) was associated with an optimal outcome. No other haemodynamic or clinical variables emerged as predictors of outcome in this analysis. Examination of pre-dilatation and post-dilatation echocardiograms showed that balloon dilatation reliably resulted in cleavage of the commissural plane and thus an increase in valve area.

Echocardiographic evaluation of mitral valve structure and function in patients followed for at least 6 months after percutaneous balloon mitral valvuloplasty.

Although beneficial results have been reported immediately after percutaneous mitral balloon valvuloplasty, little information is available concerning the longer-term outcome of this procedure. The anatomic and functional results of percutaneous mitral valvuloplasty were assessed in 20 patients, in whom two-dimensional and Doppler echocardiographic examination could be obtained both immediately and 6 to 11 months (mean 7.5 +/- 2.0) after balloon dilation. Mean valve area measured by planimetry decreased slightly but significantly from 1.90 +/- 0.59 cm2 immediately after valvuloplasty to 1.62 +/- 0.55 cm2 (p less than 0.001) at follow-up. Individual changes in valve area were variable, and in four patients valve area decreased by greater than 25%. Echocardiographic scores of valvular morphology were obtained by assigning scores of 0 to 4 (with increasing abnormality) to each of four morphologic characteristics of the valve, namely, leaflet mobility, thickening, calcification and subvalvular thickening. This score was higher in the four patients with a decrease in valve area greater than 25% at follow-up than in the other patients (11 +/- 2 versus 7 +/- 2, p less than 0.002). Multiple regression analysis of several hemodynamic and echocardiographic factors identify first the echocardiographic score and second the valve area postvalvuloplasty as the only significant predictors of the percent decrease in valve area (r = 0.70, p less than 0.006). Mitral regurgitation graded by pulsed Doppler ultrasound decreased from 1.9 +/- 1.2 immediately after valvuloplasty to 1.0 +/- 0.9 (p less than 0.003) at follow-up, whereas there was no change in mean transmitral pressure gradient by Doppler echocardiography (5 +/- 2 versus 6 +/- 3 mm Hg, p = NS) and left atrial volume (74 +/- 34 versus 72 +/- 27 cm3, p = NS). Thus, 6 to 11 months after balloon mitral valvuloplasty, mean mitral valve area decreases slightly. Individual changes in valve area, however, are variable. Valvular morphology assessed by two-dimensional echocardiography may be useful for identifying those patients who have an increased likelihood of developing valvular restenosis.

Combined influence of ventricular loading and relaxation on the transmitral flow velocity profile in dogs measured by Doppler echocardiography.

The relation of the Doppler transmitral flow velocity profile to left ventricular loading conditions and diastolic properties remains poorly described. We studied seven adult mongrel dogs with an open-chest right heart bypass model in which left atrial pressure, representing preload, was varied by controlling blood flow into the pulmonary artery and left ventricular systolic pressure, representing afterload, was controlled independently by pumping blood into or from the femoral arteries. Heart rate was kept constant by crushing the sinus node and pacing the right atrium. Mitral inflow velocity profiles were measured by pulsed-wave Doppler echocardiography at multiple left atrial and left ventricular systolic pressures. In individual dogs, the peak E-wave velocity increased linearly with increasing left atrial V-wave pressure at constant left ventricular systolic pressure and decreased with increasing left ventricular systolic pressure at constant left atrial pressure. Stepwise multiple linear regression analysis of data pooled from all experimental stages in all dogs identified left atrial V-wave pressure, the time constant of relaxation (TL), and left ventricular systolic pressure, in order of decreasing significance, as predictors of the peak E-wave velocity (n = 82, multiple r = 0.87, p less than 0.0001). Multivariate analysis with the same three factors in individual dogs yielded higher r values (mean r = 0.89; range, 0.85-0.97), suggesting the presence of important interdog differences that were not accounted for by these three factors alone. When the values of codeterminant hemodynamic factors were kept within narrower limits, correlations between peak E-wave velocity and left atrial V-wave pressure (n = 35, multiple r = 0.83, p less than 0.0001), TL (n = 76, multiple r = -0.54, p less than 0.0001) and left ventricular systolic pressure (n = 20, multiple r = -0.59, p less than 0.005) improved substantially. In the pooled data, the relation of the peak E-wave velocity to left atrial V-wave pressure was shifted downward by an increase in TL (reduced relaxation rate), and the relation of the peak E-wave velocity to TL was shifted upward by an increase in left atrial V-wave pressure. Multivariate analysis also selected left atrial V-wave pressure and TL as the two most significant correlates of the velocity-time integral and deceleration rate of the E wave.(ABSTRACT TRUNCATED AT 400 WORDS)

Percutaneous balloon mitral valvotomy for patients with mitral stenosis. Analysis of factors influencing early results.

Percutaneous balloon mitral valvotomy has recently been developed as an alternative to surgical commissurotomy for patients with rheumatic mitral stenosis. We analyzed our initial experience with 60 consecutive procedures performed in 49 patients over 1 1/2 years and identified factors influencing the immediate hemodynamic results. For the total patient population, the mitral valve area increased after percutaneous mitral valvotomy from 0.8 +/- 0.04 to 1.6 +/- 0.11 cm2 (p less than 0.001). Mean diastolic mitral gradient fell from 18 +/- 1 to 7 +/- 0.4 mm Hg (p less than 0.001), and cardiac output increased from 3.8 +/- 0.2 to 4.5 +/- 0.2 L/min (p less than 0.01). Although percutaneous mitral valvotomy resulted in an increase in mitral valve area in each patient, a suboptimal result, as defined by a postprocedure mitral valve area of 1.0 cm2 or less, an increase in area of 25% or less, or a final mitral gradient of 10 mm Hg or more occurred in 21 of the 60 procedures (35%). Multivariate analysis of 16 variables was performed to determine which factors might predict this result. Patients with a suboptimal result were more likely to have severe valve leaflet thickening or immobility and an extreme degree of subvalvular thickening and calcification on echocardiogram. Other factors that predicted a suboptimal result were a smaller effective balloon dilating area and the presence of atrial fibrillation. Thus optimal immediate hemodynamic results can be obtained in the majority of patients undergoing percutaneous mitral valvotomy. Optimal results may be expected in patients in normal sinus rhythm, with pliable mitral leaflets, and with no severe subvalvular disease identified by echocardiography, who undergo dilation with large effective balloon dilating areas.

Mitral balloon valvuloplasty for mitral restenosis after surgical commissurotomy.

Mitral balloon valvuloplasty was performed in 14 patients with recurrent mitral stenosis 16.9 +/- 1.8 years (range 6 to 30) after surgical commissurotomy. There were 13 women and 1 man with a mean age of 55 +/- 4 years (range 23 to 73). Mitral balloon valvuloplasty resulted in an increase in mitral valve area from 0.8 +/- 0.1 to 1.7 +/- 0.2 cm2 (p = 0.001), a decrease in mean mitral diastolic pressure gradient from 15 +/- 2 to 7 +/- 1 mm Hg (p = 0.001) and an increase in cardiac output from 3.4 +/- 0.3 to 3.9 +/- 0.3 liters/min (p = 0.03). No deaths, strokes, vascular complications or conduction abnormalities were observed. Mitral regurgitation developed or increased in severity in seven patients (50%). There was no evidence of significant left to right shunt through the atrial septal puncture site after mitral balloon valvuloplasty. A good result (defined as a mitral valve area greater than 1.0 cm2, an increase in mitral valve area greater than 25% and a mean gradient less than 10 mm Hg) was achieved in 9 (64%) of the 14 patients. A subgroup of four patients who had a superior result (increase in mitral valve area of 1.7 +/- 0.2 versus 0.5 +/- 0.1 cm2 in the other 10 patients, p = 0.004) was identified. These patients had less echocardiographic evidence of rheumatic mitral valve damage and were the only patients who had sinus rhythm. They were also younger, less debilitated and had a lower grade of fluoroscopic valve calcification compared with the other patients. Thus, mitral balloon valvuloplasty is a safe and effective procedure for patients with recurrent mitral stenosis after surgical commissurotomy.(ABSTRACT TRUNCATED AT 250 WORDS)