Degenerative Mitral Stenosis Versus Rheumatic Mitral Stenosis.

Mitral stenosis is classically caused by rheumatic disease (RMS). However, degenerative mitral stenosis (DMS) is increasingly encountered, particularly in developed countries with aging populations. The aim of this study was to compare clinical and echocardiographic characteristics between the 2 entities. One hundred fifteen patients with DMS were identified from an echocardiographic database in the United States and compared with 510 patients with RMS from Seoul, Korea. All subjects had a mitral valve area (MVA) ≤2.5 cm2 by continuity equation but were otherwise unselected. Patients with DMS were older and had more hypertension, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease than those with RMS. Atrial fibrillation was more common in RMS patients. Mean mitral valve gradient was slightly lower in DMS versus RMS (7.63 ± 3.67 vs 8.50 ± 4.23 mm Hg, p = 0.04) but MVA was strikingly higher in the DMS group (1.35 ± 0.41 vs 0.95 ± 0.38 cm2, p <0.0001). This appeared to be due to greater stroke volume in the DMS patients (70.4 ± 19.7 vs 55.7 ± 15.5 ml, p <0.0001). Indexed left atrial volume was greater in RMS (82.1 ± 40.3 vs 57.9 ± 21.4 ml, p <0.0001) while estimated pulmonary artery systolic pressure was greater in DMS (49.3 ± 16.5 vs 39.4 ± 13.6 mm Hg, p <0.0001). In conclusion, DMS patients are older and have more comorbidities than RMS patients. DMS presents with greater MVA relative to mean mitral valve gradient than RMS. This appears due to a higher stroke volume in DMS patients.

Stroke, thromboembolism and bleeding in patients with atrial fibrillation according to the EHRA valvular heart disease classification.

AIMS: We compared thromboembolic (TE) and bleeding risks in patients with atrial fibrillation (AF) according to the new 'Evaluated Heartvalves, Rheumatic or Artificial' (EHRA) valve classification. METHODS: Patients were divided into 3 categories: (i) EHRA type 1 corresponds to the previous 'valvular' AF patients, with either rheumatic mitral valve stenosis or mechanical prosthetic heart valves; (ii) EHRA type 2 includes AF patients with other valvular heart disease (VHD) and valve bioprosthesis or repair; and (iii) 'non-VHD controls' i.e. all AF patients with neither VHD nor post-surgical valve disease. RESULTS: Among 8962 AF patients seen between 2000 and 2010, 357 (4%) were EHRA type 1, 1754 (20%) were EHRA type 2 and 6851 (76%) non-VHD controls. EHRA type 2 patients were older and had a higher CHA2DS2-VASc and HAS-BLED scores than either type 1 and non-VHD patients. After a mean follow-up of 1264 ±â€¯1160 days, the occurrence of TE events was higher in EHRA type 2 than non-VHD patients (HR (95%CI): 1.30 1.09-1.54), p = 0.003; also, p = 0.31 for type 1 vs 2, p = 0.68 for type 1 vs non-VHD controls). The rate of major BARC bleeding events for AF patients was higher in either EHRA type 1 (HR (95%CI): 3.16(2.11-4.72), p < 0.0001) or type 2 (HR (95%CI): 2.19(1.69-2.84), p < 0.0001) compared to non-VHD controls. CONCLUSION: The EHRA valve classification of AF patients with VHD appears useful in categorizing these patients, in terms of TE and bleeding risks. This classification can be used in clinical practice for appropriate choices of oral anticoagulation therapy and follow-up.

3D Xplane Echocardiographic Technique for Validation of Mitral Leaflet Separation to Assess Severity of Mitral Stenosis.

BACKGROUND: Determining the severity of mitral stenosis (MS) is important for both prognostic and therapeutic implications. Mitral valve area (MVA) calculation techniques have more limitations. Mitral leaflet separation (MLS) is a precise and operator friendly alternative to planimetry. In contrast to previous researchers, we have used a novel 3D Xplane technique to validate MLS for assessing the severity of MS. 3D Xplane is superior for validation of MLS due to simultaneous real time acquisition of MLS in parasternal long-axis view and corresponding MVA by planimetry in parsternal short-axis view. METHODS: It was a prospective observational single center study. A total of 174 patients with MS were evaluated for MVA estimation by various echocardiographic modalities. Maximum leaflet separation and corresponding planimetered MVA were measured using novel 3D Xplane technique. RESULTS: With 3D Xplane technique, there was strong positive correlation between planimetered MVA and MLS (R = 0.925, P < 0.001), irrespective of coexisting MR (R = 0.886, P < 0.001) or AF (R = 0.912, P < 0.001). Receiver operating characteristic curves of MLS demonstrated AUC for mild and severe MS to be 0.966 and 0.995, respectively. MLS less than 8.62 mm predicted severe MS with 95.5% sensitivity and 94.7% specificity and MLS more than 12.23 mm predicted mild MS with 93.2% sensitivity and 91.4% specificity. CONCLUSION: In our study, a strong correlation between planimetered MVA and MLS was found using 3D Xplane technique. 3D Xplane thus validates and standardizes MLS by excluding errors due to temporal and spatial variations which are important limitations of 2D echocardiography.

Selection of patients for percutaneous balloon mitral valvotomy: is there a definitive limit for the Wilkins score?

AIM: The aim of this study was to determine the early and long-term results of percutaneous balloon mitral valvotomy (PBMV) in patients with Wilkins score (WS) between 9 and 11. METHODS: We performed a retrospective review of clinical records of patients with rheumatic mitral stenosis who underwent PBMV between November 1991 and March 2008. Follow-up was obtained by telephone interview and/or clinical records. The procedure was considered unsuccessful when post-procedure mitral valve area was <1.5 cm(2). RESULTS: We analyzed 124 patients, 108 (87.1%) of them women. Mean age at the time of repair was 46 ± 11 years and mean follow-up time was 10 ± 4 years. Before the procedure, 100 patients (80.6%) had WS ≤ 8 and 24 (19.4%) were in the "gray zone" (>8 and <11). Patients with WS ≤ 8 and patients in the gray zone had similar ages at first intervention (45 ± 11 vs. 49 ± 11 years; p=0.095) and follow-up time (10 ± 4 vs. 11 ± 5 years; p=0.55). There were no differences between groups in gender (women: 86% vs. 92%; p=0.735), or in baseline echocardiographic measurements (mitral valve area by planimetry 1.0 cm(2) [P25-P75: 0.9-1.1] vs. 0.9 [P25-P75: 0.8-1.2], p=0.514; pulmonary artery systolic pressure 53 mmHg [P25-P75: 45-63] vs. 50 [P25-P75: 44-54], p=0.823]; left atrial diameter >55 mm [16.5% vs. 13.6%, p=1.00]; mitral regurgitation [46.5% vs. 37.5%, p=0.428]) or baseline transmitral gradient (13 mmHg [P25-P75: 10-19] vs. 13 mmHg [P25-P75: 7-20]). Improvements in mitral valve area by planimetry and in hemodynamic gradient were similar in the two groups (0.91 ± 0.39 cm(2) vs. 0.84 ± 0.44 cm(2), p=0.55; 8.8 ± 5.3 mmHg vs. 7.3 ± 5.9 mmHg, p=0.275, respectively). There were no significant differences in major complications or success rates (4.0 vs. 12.5 p=0.131; 89.9% vs. 95.8%, p=0.69) or in need for urgent surgery or future reintervention (2.0 vs. 8.3%, p=0.168; 22% vs. 27.3%, p=0.594). In-hospital mortality occurred only in patients in the WS gray zone (2 [8.3%] vs. 0%, p=0.04), one death (4.2% vs. 0%, p=0.194) possibly being related to a higher WS (secondary to stroke) and the other as a consequence of peripheral vascular complication. Improvements in NYHA functional class soon after the procedure and during follow-up were similar in the two groups. Total mortality was similar in the two groups (3.1 vs. 8.7%, p=0.244). CONCLUSIONS: PBMV was a safe and effective procedure in patients in the WS gray zone. Optimal results can be achieved in these patients if they are carefully selected and operated at experienced centers.

New echocardiography-based classification of mitral valve pathology: relevance to surgical valve repair.

A new echocardiography-based classification of mitral valve pathology is proposed, the adoption of which may provide a uniform approach to the assessment of individual cases by the cardiologist, cardiac anesthesiologist, and surgeon. This type of approach may facilitate the planning and execution of valve repair techniques, with higher rates of success than are currently reported.

A classification system for stenosis from mitral valve Doppler signals using adaptive network based fuzzy inference system.

In this study, cardiac Doppler parameters were studied in 60 patients with mitral valve stenosis and compared with 41 ages and sex matched healthy controls. Firstly, the sonograms which represent the changes in Doppler frequency with respect to time were performed from mitral valve Doppler signals using short time Fourier transformation (STFT) method. Secondly, the envelopes of these sonograms and data set depicted from sonogram envelopes were acquired. Finally, the processed data set are applied to the proposed adaptive network based fuzzy inference system (ANFIS) model has potential in classifying the mitral valve Doppler signals. This result confirms that our technique contribute to the detection of mitral valve stenosis and our method offers more reliable information than looking at the sonogram on the Doppler screen and making a decision from the visual inspection. The proposed ANFIS model combined the neural network with adaptive capabilities and qualitative approach of fuzzy logic. The obtained results show that 98% correct classification was achieved, whereas two false classifications have been observed for the test group of 101 people.

Usefulness of three-dimensionally guided assessment of mitral stenosis using matrix-array ultrasound.

Two-dimensional (2-D) planimetry is limited by the technical demands, time, and observer variability required to locate the minimal orifice area, limiting the confident clinical reporting of mitral valve area (MVA). In 27 consecutive patients, MVA was determined independently by 2 observers using the conventional 2-D method and a new 3-D-guided method. Using a matrix-array probe, the valve was visualized in a long-axis view and a cursor steered to intersect the leaflet tips and provide a perpendicular short-axis plane viewed side-by-side. Two-dimensional and 3-D-guided methods allowed planimetry in 24 patients. Consistent with better orifice localization, 3-D guidance eliminated the overestimation of internal orifice diameters in the planimetered short-axis view relative to the limiting diameter defined by the long-axis view (for 3-D guidance, 0.73 +/- 0.20 vs 0.73 +/- 0.21 cm, p = 0.98, vs 0.90 +/- 0.27 cm in the 2-D short-axis view, p <0.01). Accordingly, mean values for the smallest orifice area by 3-D guidance were less than by 2-D imaging (1.4 +/- 0.5 vs 1.5 +/- 0.5 cm(2), p <0.01), changing the clinical severity classification in 11 of 24 patients (46%). The 2-D method also overestimated MVA relative to 3-D guidance compared with Doppler pressure halftime and (n = 6) Gorlin areas. Phantom studies verified no differences in resolution for the 2 acquisition modes. Three-dimensional guidance reduced intraobserver variability from 9.8% to 3.8% (SEE 0.14 to 0.06 cm(2), p <0.01) and interobserver variability from 10.6% to 6.1% (SEE 0.15 to 0.09 cm(2), p <0.02). In conclusion, matrix-array technology provides a feasible and highly reproducible direct 3-D-guided method for measuring the limiting mitral orifice area.

Classification of mitral insufficiency and stenosis using MLP neural network and neuro-fuzzy system.

Cardiac Doppler signals recorded from mitral valve of 60 patients were transferred to a personal computer by using a 16-bit sound card. The power spectral density (PSD) was applied to the recorded signal from each patient. In order to do a good interpretation and rapid diagnosis, PSD values classified using multilayer perceptron (MLP) and neuro-fuzzy system. Our findings demonstrated that 93.33% classification success rate was obtained from MLP, 90% classification success rate was obtained from neuro-fuzzy system. The classification results show that MLP offers best results in the case of diagnosis.

Increased plasma levels of soluble P-selectin in rheumatic mitral stenosis.

BACKGROUND: Previous studies have demonstrated that platelet activation occurs in peripheral blood of patients with rheumatic mitral stenosis (MS). However, in patients with MS, the plasma level of soluble P-selectin (a marker of platelet activation) remains unsettled. METHODS AND RESULTS: A total of 20 patients with symptomatic MS undergoing percutaneous transluminal mitral valvuloplasty (PTMV) were studied (group 1; 16 patients in permanent atrial fibrillation, and 4 patients in sinus rhythm). The plasma levels of soluble P-selectin in the femoral vein and artery, and right and left atria before PTMV and those in the peripheral venous blood at the 1-week and 4-week follow-ups after PTMV were determined by solid-phase, sandwich, enzyme-linked immunosorbent assay. The mitral valve area was calculated by means of the Doppler pressure half-time method. In addition, we measured plasma concentrations of soluble P-selectin in the peripheral venous blood samples obtained from 22 control patients (including 14 healthy volunteers in sinus rhythm [group 2] and 8 patients in permanent lone atrial fibrillation [group 3]). The plasma levels of soluble P-selectin were significantly elevated in group 1 patients (49.78 +/- 37.72 ng/mL) [mean +/- SD] compared with group 2 (25.52 +/- 15.38 ng/mL) and group 3 patients (32.17 +/- 14.18 ng/mL) [p < 0.005]. In group 1 patients, the plasma levels of soluble P-selectin in the left atrium did not significantly differ from those in the right atrium, femoral vein, or femoral artery (p = 0.05). The area of mitral valve increased significantly after PTMV (1.06 +/- 0.17 cm(2) vs 1.48 +/- 0.32 cm(2), p < 0.0001). The mean left atrial pressure fell significantly and immediately after PTMV (23.0 +/- 5.1 mm Hg vs 17.6 +/- 5.9 mm Hg, p < 0.0001). The peripheral venous plasma levels of soluble P-selectin obtained before PTMV did not significantly fall after PTMV (before, 49.8 +/- 37.7 ng/mL; 10 min after, 39.8 +/- 19.1 ng/mL; 1 week after, 46.1 +/- 20.8 ng/mL; and 4 weeks after, 41.2 +/- 15.9 ng/mL; p = 0.145). CONCLUSIONS: The venous plasma levels of soluble P-selectin in patients with moderate-to-severe MS were significantly higher than those in healthy volunteers or patients with lone atrial fibrillation. In addition, in patients with MS, there was no difference in the plasma levels of soluble P-selectin between the left and right atrial blood and between peripheral and atrial blood. Moreover, there was no change in soluble P-selectin levels as a result of PTMV.

Respuesta clínica y ecocardiografica en pacientes con estenosis mitral reumática sometidos a valvuloplastia mitral percútanea / Clinical answer and ecocardiografica in patient with subjected estenosis rheumatic mitral to valvuloplastia mitral percútanea

Este estudio se realizó con el objetivo de conocer los cambios clínicos y ecocardiográficos en pacientes con estenosis mitral reumática sometidos a valvuloplastia mitral percutánea en el Centro Nacional de Cardiología en el periodo de Septiembre del 2000 a Septiembre del 2002. Se realizó el procedimiento en 61 pacientes (52 femenino y 9 masculino), con edad promedio (15- 66 años) el 59 porciento con antecedentes de fiebre reumática, y el 78 porciento de amigdalitis. El 30 porciento presentó ritmo cardíaco de fibrilación auricular con anticoagulación, y el 9.8 porciento reportó complicaciones hemorrágicas. El área mitral prevalvuloplastia promedio 0.94cm gradiente diastólico máximo promedio de 22 mmHg, presión sistólica pulmonar de 56.26 mmHg. Clase funcional prevalvuloplastia III IV. Método: este procedimiento se realizó bajo anestesia local por punción de la vena femoral derecha se realizó cateterismo transeptal, después de dilatar el septum, se pasó el balón de Inoue, se llevó al ventrículo izquierdo, y colocó en la válvula mitral, donde se realizaron la separación de las comisuras, fracturas de las calcificaciones. Se valoró las complicaciones durante las valvuloplastia presentándose 1 embolia cerebral, Insuficiencia mitral 1, taponamiento cardiaco 2, hemorragia en el sitio de venopunción 5. Resultados: el área mitral posvalvuloplastia promedio 1.6cm2 DS 0.45, el gradiente diastólico máximo promedio de l3mmhg DS 4.98, presión sistólica pulmonar promedio 39.71mmhg DS 12.93, disminución del tamaño de la aurícula izquierda Capacidad funcional mejoró notablemente, encontrándose clase funcional I- II. Conclusiones: Se valoró que la valvuloplastia mitral percutánea es un procedimiento seguro, tiene excelentes resultados clínicos, evita la cirugía de recambio valvular...

[Early and long term results of mitral valvuloplasty]. / Resultats precoce et lointain de la valvuloplastie mitrale.

46 patients underwent Carpentier's mitral valve repair from 1986 through 2000. There were 15 males and 31 females. The mean age was 30 years. The cause of mitral regurgitation was rheumatic in all cases. According to Carpentier's classification, type II was present in 44% of patients, type III in 16% and type II-III in 40%. Left ventricular dysfunction was present in 10.8% of patients. Immediate echec of mitral valve repair occurred in 2.2% of cases. With a mean follow up of 79.6 months, late mortality was 12.2%. The overall result was excellent or good in 52.5% of cases, fair in 21.4% and poor in 26.2%. Deterioration of the result occurred in 18 patients (44% p Predictive factors of poor early and late results were age more than 40 years and a type III mitral regurgitation.

Effectiveness of percutaneous mechanical mitral commissurotomy using the metallic commissurotome in patients with restenosis after balloon or previous surgical commissurotomy.

Balloon mitral valvuloplasty has been reported to give equal or less positive results after previous commissurotomy than after a first procedure. Percutaneous mechanical mitral commissurotomy (PMMC) is a new technique that has not yet been evaluated in this subset of patients. Of 1,175 PMMC procedures (1,175 patients), 173 patients (14.7%) had previous commissurotomy; patients were older (40 vs 35 years of age, p <0.0001) and more often in atrial fibrillation (34% vs 21%, p = 0.0016) than were patients who had not undergone previous commissurotomy. The baseline transmitral gradient was lower (17 +/- 8 vs 19 +/- 8 mm Hg, p <0.002) and the echocardiographic Wilkins score was higher (8.7 +/- 1.9 vs 7.6 +/- 1.8, p <0.0001) for patients who underwent previous commissurotomy. Baseline mitral valve area was comparable between the 2 groups (0.96 +/- 0.21 vs 0.93 +/- 0.24 cm(2)). Immediate results were satisfactory, although slightly less favorable after previous commissurotomy, with a final mitral valve area of 2.01 +/- 0.30 versus 2.12 +/- 0.36 cm(2) (p <0.0001), and a residual transvalvular gradient of 5.0 +/- 3.6 versus 4.2 +/- 4.1 mm Hg (p = 0.003). The rates of procedural success (93%) and severe complications (4.7%) were comparable between the 2 groups. Thus, PMMC is an effective and safe technique for the treatment of mitral restenosis after previous commissurotomy.

Atrial endocardial changes in mitral valve disease: a scanning electron microscopy study.

BACKGROUND: The precise contribution of left atrial appendage (LAA) endocardial damage and dysfunction to the process of thrombus formation in patients with mitral valve (MV) disease, especially in the presence of atrial fibrillation (AF), has not as yet been clearly described. This may be important because the LAA is the usual site for thrombus formation. METHODS: The purpose of this study was to describe endocardial surface changes, through the use of scanning electron microscopy, in the left and right atrial appendages of patients with MV disease and the differences, if any, between patients with mitral stenosis and mitral regurgitation as well as between those with AF and sinus rhythm. Our second objective was to relate endocardial changes to plasma levels of von Willebrand factor (vWf), an established marker for endothelial damage. LAA specimens were obtained immediately after commencement of cardiopulmonary bypass from 35 patients (18 men; mean age 65 years, range 20 to 85) during surgery for MV repair or replacement. Right atrial appendage (RAA) specimens were similarly obtained as controls for individual patients. The specimens were fixed in 2.5% glutaraldehyde solution overnight, stored in Sorensen's phosphate buffer, and examined by means of scanning electron microscopy. Two independent observers documented the most advanced lesion in each specimen as follows: (1) "minimal" changes, with minimal disruption of the endocardium; (2) "intermediate" changes or prethrombotic lesions; and (3) "advanced" changes, with endocardial disruption and thrombotic lesions. Plasma levels of vWf were also measured (enzyme-linked immunosorbent assay) in all patients, and results were compared with those of age- and sex-matched healthy control patients. RESULTS: Advanced changes were more frequently seen in the endocardium of the LAA when compared with the RAA (31% vs 6%), whereas minimal changes were more frequently seen in the RAA compared with the LAA (23% vs 6%) (P =.00167). Similarly, the LAA from patients with mitral stenosis had a higher proportion of "advanced" endocardial changes when compared with patients with mitral regurgitation (67% vs 24%; P =.0066). The LAA in patients with AF had more "advanced" changes (39% vs 27%), but this was not statistically significant. Plasma vWf levels were significantly higher in patients with MV disease compared with healthy control patients (132 +/- 33 IU/dL vs 99 +/- 37 IU/dL; P =.0004) and in patients with advanced LAA changes compared with earlier changes (149 +/- 34 IU/dL vs 121 +/- 31 IU/dL; P =.042). CONCLUSIONS: Endocardial damage occurs in the atrial appendages of patients with MV disease. Potentially thrombogenic changes are more commonly seen in the LAA compared with the RAA and in patients with mitral stenosis compared with mitral regurgitation. These anatomic appearances may contribute to the risk of intra-atrial thrombus formation in patients with mitral valve disease, especially if AF is present.

Impact of tissue harmonic imaging on the assessment of rheumatic mitral stenosis.

We examined the effect of tissue harmonic imaging on the echocardiographic splitability score and valve area measurement of 40 patients with rheumatic mitral stenosis. Planimetered valve areas were unaffected by the use of harmonic imaging, but valve scores were increased, particularly in patients with scores <10.

Mitral balloon valvotomy for the treatment of mitral stenosis in octogenarians.

OBJECTIVES: To study the safety and benefit of mitral balloon valvotomy (MBV) in patients aged > or =80 years. SETTING: A tertiary cardiac centre DESIGN: A retrospective study of 20 octogenarians (mean age 83, range 80-89 years) in whom percutaneous MBV was performed as a definitive or palliative treatment for severe mitral stenosis. All were in New York Heart Association (NYHA) symptom class III or IV. Fourteen had been judged unfit for cardiac surgery. Hemodynamic data was recorded before and after MBV. Symptomatic outcome was documented at 1 month for all patients. Outcome at 1 year was available for 16 patients. RESULTS: Dilatation of the mitral valve was achieved in all patients without major complications. Mean mitral valve area increased 106% from 0.81 (+/-0.3) to 1.67 (+/- 0.8) cm2, transvalvular gradient decreased from 11.8 (+/- 4.8) to 5.6 (+/-2.9) mm Hg, cardiac output increased from 3.1 (+/- 0.6) to 4.1 (+/- 1.4) l/min (all P<.01). Eight of these 20 patients obtained a valve area > or =1.5 cm2, and 16 obtained an area > or = 1.2 cm2. One month after BMV, all patients were alive, and 16 of the 20 patients were improved by at least one NYHA class. This improvement was sustained in 7 of 16 patients followed up for 1 year. More severe mitral valve degenerative change, determined by echocardiography, was associated with poorer outcome. CONCLUSIONS: In this group of very old and frail patients, MBV was safe and resulted in significant immediate improvement. Sustained symptomatic benefit at 1 year was obtained in those with less extensive leaflet and subvalvular disease. In patients with severe degenerative valve disease on echocardiography, but unacceptable surgical risk, MBV offers short-term palliation.

Percutaneous mitral commissurotomy for restenosis after surgical commissurotomy: late efficacy and implications for patient selection.

OBJECTIVES: The results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy. BACKGROUND: Balloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy. METHODS: We studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 +/- 8 years after surgical commissurotomy. Mean age was 47 +/- 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121. RESULTS: Complications were death in 1 patient (0.4%) and mitral regurgitation >2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve area > or =1.5 cm2 without regurgitation >2/4). Predictors of poor immediate results in multivariate analysis were older age (p < 0.001), lower initial valve area (p = 0.01) and the use of the double-balloon technique (p = 0.015). In the 175 patients who underwent follow-up, 8-year survival without operation and in New York Heart Association class I or II was 48 +/- 5%, and 58 +/- 6% after good immediate results. In this latter group, poor late functional results were predicted by higher cardiothoracic index (p < 0.0001), previous open-heart commissurotomy (p = 0.05) and lower final valve area (p < 0.0001) in a multivariate Cox model. CONCLUSIONS: Percutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.

[Fundamentals and indications for mitral valve repair surgery]. / Fondements et indications de la chirurgie réparatrice dans les valvulopathies mitrales.

The concept of mitral valve repair is discussed, emphasizing the basic knowledge on which it relies, and the breakthrough it has produced in modern cardiac surgery. This concept challenges the myth of the artificial prosthesis, showing the superiority of autologous biological structures submitted to plastic repair. The foundations of valvular repair and the techniques that have contributed to its success are reviewed, and the advantages for the patients in terms of quality of life, and preservation of the left ventricular function are discussed.