Introduction: Mitral stenosis is a prevalent valvular disease in developing countries. Percutaneous mitral balloon valvuloplasty (PMBV) is the gold standard treatment. The main objective of this study was to assess the initial results of PMBV in patients with mitral stenosis during 16 years (2002-2018) in Mashhad, Iran. Materials and Methods: From April 2002 to March 2018, 770 patients underwent PMV in department of cardiology. PMV was performed by the antegrade transseptal method using the Inoue balloon. Results: The obtained success rate was 97%. In this study, the valve area increased from 0.9±1.1 to 1.8±0.2 cm2 (

Ali Eshraghi

Arash Gholoobi

Feraeshteh Ghaderi

Hourak poorzand

Javad Ramezani

Mahdi Zahedi

Mahmoud Mohammadzadeh Shabestari

Mohammad Abbassi Teshnizi

Directory of Open Access Journals

 *Corresponding author: Mahdi Zahedi, Ischemic Disorders Research Center, Golestan University of Medical Sciences, Gorgan, Iran. Tel and Fax: 05138022711; Email: dr_zahedi@hotmail.com  © 2018 mums.ac.ir All rights reserved.  This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.     Immediate Results of Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis Mahdi Zahedi1*, Mahmoud Mohammadzadeh Shabestari2, Ali Eshraghi2, Mohammad Abbassi Teshnizi2, Arash Gholoobi2, Hourak poorzand2, Feraeshteh Ghaderi2, Javad Ramezani2 1 International Cardiologist, Ischemic Disorders Research Center, Golestan University of Medical Sciences, Gorgan, Iran 2 International Cardiologist, Atherosclerosis Prevention Research Center, Mashhad University of Medical Sciences, Mashhad, Iran A R T I C L E  I N F O  A B S T R A C T Article type: Original Article  Introduction: Mitral stenosis is a prevalent valvular disease in developing countries. Percutaneous mitral balloon valvuloplasty (PMBV) is the gold standard treatment. The main objective of this study was to assess the initial results of PMBV in patients with mitral stenosis during 16 years (2002-2018) in Mashhad, Iran. Material and Methods: From April 2002 to March 2018, 770 patients underwent PMV in department of cardiology. PMV was performed by the antegrade transseptal method using the Inoue balloon. Results: The obtained success rate was 97%. In this study, the valve area increased from 0.9±1.1 to 1.8±0.2 cm2 (P<0.0001). There was no case of peri-procedural death or cardiac tamponade. Additionally, 0.25% of the patients required mitral valve replacement. Severe mitral regurgitation occurred in 0.9% of the subjects. There was no case of cerebrovascular accident, transient ischemic attack, embolic myocardial infarction, or cardiac perforation. Supraventricular tachycardia occurred in 2.59% of the patients. Conclusion: The PMBV by the Inoue technique is a feasible and easy procedure with a short crossing times and low complications. Article history: Received: 10 Aug 2018 Revised: 24 Oct 2018 Accepted: 30 Oct 2018  Keywords:  Inoue Technique Mitral Stenosis Percutaneous Mitral Balloon Valvuloplasty   ►Please cite this paper as: Zahedi M, Mohammadzadeh Shabestari M, Eshraghi A, Abbassi  Teshnizi M, Gholoobi A, Poorzand H, Ghaderi F, Ramezani J. Immediate Results of Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis. J Cardiothorac Med. 2018; 6(4): 374-377.  IntroductionMitral stenosis (MS) is a prevalent valvular disease in developing countries. Acute rheumatic fever is the leading cause of this disorder (1). In 1982, the first percutaneous mitral valvuloplasty (PMV) was performed on a 33-year-old man with severe MS by a Japanese surgeon named Inoue. The initial report was published in 1984 (2).  The splitting of fused commissures is the mechanism, by which PMV and surgical techniques reduce stenosis (3). The hemodynamic outcomes of PMV and surgical commissurotomy in several randomized trials. However, surgical patients had more peri-procedural complications (4-6). Therefore, the surgical technique has been supplanted by PMV (7). The main objective of this study was to assess the initial results of PMV in patients with MS during 16 years (2002-2018) in Mashhad, Iran.  Materials and Methods Patient Selection for Balloon Valvuloplasty From April 2002 to March 2018, 770 patients underwent PMV in department of cardiology, Mashhad Iran. Echocardiographic examination was performed on the day before the procedure.  Planimetry by two-dimensional echocardio-graphy was the reference measurement used to calculate mitral valve area.   Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis  Zahedi M et al.   J Cardiothorac Med. 2018; 6(4): 374-377.  375    Table1. Wilkins Scoring System for Mitral Valvuloplasty Grade Leaflet Mobility Valve Thickening Calcification Subvalvular Thickening 1 Highly mobile Minimal thickening Single area of brightness Minimal chordal thickening 2 Reduced mobility Thickened tips Scattered areas at leaflet margins Chordal thickening up to one-third 3 Basal leaflet motion only Entire leaflet thickened Brightness extends to mid leaflets Distal third of chordae thickened 4 Minimal motion Marked leaflet thickening Extensive leaflet brightness Extensive thickening to papillary muscles A desirable score is 8 or lower.  A Wilkins score (table 1) of less than 8 was considered to be predictor of favorable outcomes. PMV was recommended for symptomatic patients with moderate to severe MS (i.e., valve area <1 cm2/m2 of body surface area or <1.5 cm2 in normal-sized adults) and with favorable valve morphology. Furthermore, asymptomatic patients with very severe MS (<1 cm2) with favorable valve anatomy or AF rhythm were included. Patients with moderate or greater MR or LA appendage thrombus were excluded. We assessed initial Results of PMV in patients with mitral stenosis during16 years (2002-2018) in Mashhad, Iran.  Techniques PMV was performed by the antegrade transseptal method using the Inoue balloon (8).  The procedure was performed using a transfemoral approach through a 9F and 5F catheter sheath in the vein and artery, respectively, with patients under conscious sedation. After the bolus administration of 1000 U heparin, right heart catheterization was performed. Thereafter, right atriography was carried out to determine the optimal puncture site using a Brockenbrough needle. Transseptal cardiac catheterization was performed using standard Brockenbrough technique. While the Brocken-brough catheter was slowly flicked up from the superior vena cava into the atrial septum, it was advanced through the atrial septum.  Then, a coiled-tip guidewire was inserted into the left atrium through the Brockenbrough sheath. In addition, 9000 U heparin was administered to reduce the risk of a thromboembolic event during the manipulation of catheters and wires in the left atrium. In the next step, the Inoue balloon catheter was advanced over the coiled-tip wire. Once the balloon catheter had crossed the atrial septum, the catheter was placed in the left atrium, and it formed a loop with the tip facing toward the mitral valve orifice. The tip of the balloon was inflated with 1 to 2 ml of contrast material, allowing blood flow to carry the balloon tip through the left ventricle. Once the balloon catheter had been inserted into the left ventricle, its distal portion was inflated with contrast material. The catheter was then pulled back until resistance was met.  After each dilatation, the left atrial and ventricular pressures were simultaneously measured through the middle part of the Inoue catheter and the pigtail catheter, respectively. The balloon size was increased in 1-mm increments until the pressure gradient decreased or substantial worsening of mitral regurgitation (MR) occurred.  Statistical analysis Quantitative variables were expressed as mean standard deviation. Good immediate results of percutaneous mitral commissurotomy were defined by the composite endpoint used in previous studies (9, 10), which associates a mitral valve area 1·5 cm2 with no regurgitation >2/4. Comparison of variables before and after the procedure used the Paired T test. A p value < 0.05 was considered clinically significant. .  All statistical analyses were performed using Statistical Package of Social Science (SPSS) software (version 24, IBM Corporation).  Results Immediate results All patients had Wilkins score of less than 8. The immediate results of the procedure are demonstrated in Table 2. Good immediate results that were defined above were obtained in 97% of the patients. There was no case of peri-procedural death or cardiac tamponade. Additionally, mitral valve replacement was required in 0.25% of the subjects. Severe MR (Sellers' grade=3) occurred in 0.9% of the participants.  There was no case of cerebrovascular accident, transient ischemic attack, embolic myocardial infarction, or cardiac perforation. Supraventricular tachycardia was reported in 2.59% of the patients.  The improvement in valve function, as assessed by planimetry, is shown in Table 2, with a valve area increasing from 0·9±1.1 to 1·8±0.2 cm2 (P<0·0001).  90% of patients who were undergone angiography had huge collateral branch from left circumflex artery to left atrium.    Zahedi M et al.  Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis 376  J Cardiothorac Med. 2018; 6(4): 374-377.                                                     Table2. Immediate results after Percutaneous Mitral Valvuloplasty (n=770) Variable Mean±SD [range] or n=770 (%) Good results 747 (97%) Mitral valve area (Pre) 0·9±1.1 Mitral valve area (Post) 1·8±0.2 Hospital mitral valve replacement 2 (0.25%) Severe Mitral Regurgitation 7 (0.9) Cerebrovascular accident 0 Transient ischemic stroke 0 Cardiac perforation 0 Atrial Septal Defect (>1.5mm) 2 (0.25%) Vascular repair/transfusion 4 (0. 5%) Supraventricular tachyarrhythmia 20 (2.59%) Embolic myocardial infarction 0 Death 0  DiscussionSymptomatic patients with moderate to severe MS (i.e., valve to body surface area ratio less than 1 cm2/m2 or <1.5 cm2 in normal-sized adults) and with favorable valve morphology, as well as no or mild MR and no evidence of left atrial thrombus should undergo PMV. Even mild symptoms such as a subtle decrease in exercise tolerance are an indication for intervention because the procedure relieves symptoms and improves long-term outcome with a low procedural risk (11).  PMV is the gold standard treatment option in patients with MS. Surgical intervention is now reserved for patients, who require intervention and are not candidates for PMV (12). In the present study, it was explained that the Inoue balloon technique is a safe procedure. According to the literature, this technique is feasible and in association with short crossing time and low complication rates (13-15). Regarding the results of the current study, the success rate was 97%. Given the evidence, the success rate in the total population is 79.6%, a result that fits within the reported range (73-99%) (16-18). It is confirmed that PMV is associated with less morbidity, shorter length of hospital stay, avoidance of the discomfort and other problems associated with thoracotomy, while the cost of surgery is at least twice that of balloon Valvotomy (19).  The immediate results of PMV appeared to be very similar to closed and open surgical commissurotomy (4-7). However, operative mortality following surgical commissurotomy (2.97%) was higher than that reported after PMV (0.05%) (20, 21). In other reports, the complications associated with PMV consisted of cerebral embolism and cardiac perforation in approximately 1% of patients.  Furthermore, the prevalence of severe MR that requires operation was 2% (22). In this study, there was no case of cerebrovascular accident, transient ischemic attack, embolic myocardial infarction, or cardiac perforation. Other studies reported that approximately 5% of patients were discharged with a small, residual atrial septal defect.  Nevertheless, this defect closes or decreases in size in most of the cases. Rarely, the atrial septal defect is large enough to cause right-sided heart failure. This complication most often is seen in conjunction with an unsuccessful mitral valvotomy (22). In the present study, 0.25% of the patients left the hospital with an atrial septal defect. Another complication is supraventricular tachycardia, which occurred in 2.59% of the participants.  Conclusion PMV is the gold standard treatment option for patients with MS. The Inoue balloon technique is a feasible and easy procedure with a short crossing time and low complication rates.  Acknowledgments The authors would like to appreciate the Research Deputy of Mashhad University of Medical Sciences, Iran, for the financial support.  The authors would also like to thank the Vice Chanceller of Research of Gorgan University of Medical Sciences, Gorgan.  Conflict of Interest  The authors declare no conflict of interest.  References 1. Marcus RH, Sareli P, Pocock WA, Barlow JB. The spectrum of severe rheumatic mitral valve disease in a developing country. Correlations among clinical presentation, surgical pathologic findings, and hemodynamic sequelae. Ann Intern Med. 1994; 120:177-83. 2. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg. 1984; 87:394-402. 3. McKay RG, Lock JE, Safian RD, Come PC, Diver DJ,   Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis  Zahedi M et al.   J Cardiothorac Med. 2018; 6(4): 374-377.  377   Baim DS, et al. Balloon dilation of mitral stenosis in adult patients: Postmortem and percutaneous mitral valvuloplasty studies. J Am Coll Cardiol. 1987; 9:723-31. 4. Bakaeean B, Kabiri M, Iranfar H, Saberi MR, Chamani J. Binding effect of common ions to human serum albumin in the presence of norfloxacin: investigation with spectroscopic and zeta potential approaches. J Solut Chem. 2012; 41:1777-801. 5. Patel JJ, Shama D, Mitha AS, Blyth D, Hassen F, Le Roux BT, et al. Balloon valvuloplasty versus closed commissurotomy for pliable mitral stenosis: a prospective hemodynamic study. J Am Coll Cardiol. 1991; 18:1318-22. 6. Ben Farhat M, Ayari M, Maatouk F, Betbout F, Gamra H, Jarrar M, et al. Percutaneous balloon versus surgical closed and open mitral commi-ssurotomy: seven-year follow-up results of a randomized trial. Circulation. 1998; 97:245-50. 7. Reyes VP, Raju BS, Wynne J, Stephenson LW, Raju R, Fromm BS, et al. Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med. 1994; 331:961-7. 8. Feldman T, Henmann HC, Inoue K Techniques of percutaneous transvenous mitral commissurotomy using the Inoue balloon catheter. Curhet Cardiowsc Diag. 1994; 28:26-34. 9. Vahanian A, Michel PL, Cormier B, Vitoux B, Michel X, Slama M, et al. Results of percutaneous mitral commissurotomy in 200 patients. Am J Cardiol. 1989; 63:847-52. 10. Iung B, Cormier B, Ducimetiere P, Porte JM, Nallet O, Michel PL, et al. Immediate results of percutaneous mitral commissurotomy: a predictive model on a series of 1514 patients. Circulation. 1996; 94:2124-30. 11. Lembcke A, Durmus T, Westermann Y, Geigenmueller A, Claus B, Butler C, et al. Assessment of mitral valve stenosis by helical MDCT: comparison with transthoracic Doppler echocardiography and cardiac catheterization. Am J Roentgenol. 2011; 197:614-22. 12. Sohrabi T, Hosseinzadeh M, Beigoli S, Saberi MR, Chamani J. Probing the binding of lomefloxacin to a calf thymus DNA-histone H1 complex by multi-spectroscopic and molecular modeling techniques. J Mol Liquids. 2018; 256:127-38. 13. Ribeiro PA, Fawzy ME, Arafat MA, Dunn B, Sriram R, Mercer E, et al. Comparison of mitral valve area results of balloon mitral valvotomy using the Inoue and double balloon techniques. Am J Cardiol. 1991; 68:687-8. 14. Bassand JP, Schiele F, Bernard Y, Anguenot T, Payet M, Ba SA, et al. The double-balloon and Inoue techniques in percutaneous mitral valvuloplasty: comparative results in a series of 232 cases. J Am Coil Cardiol. 1991; 18:982-9. 15. Abdullah M, Halhn M, Rajendran V, Sawyer W, Zaibag MA. Comparison between single (Inoue) and double balloon mitral valvuloplasty: immediate and short-term results. Am Hearr J. 1992; 123:1581-8. 16. Palacios IF, Sanchez PL, Harrell LC, Weyman  AE, Block PC. Which patients benefit from percutaneous mitral balloon valvuloplasty? Prevalvuloplasty and postvalvuloplasty variables that predict long-term outcome. Circulation. 2002; 105:1465-71. 17. Herrmann HC, Ramaswamy K, Isner JM, Feldman TE, Carroll JD, Pichard AD, et al. Factors influencing immediate results, complications, and short-term follow-up status after Inoue balloon mitral valvotomy: a North American multicenter study. Am Heart J. 1992; 124:160-6. 18. Tousi SH, Saberi MR, Chamani J. Comparing the Interaction of cyclophosphamide monohydrate to human serum albumin as opposed to holo-transferrin by spectroscopic and molecular modeling methods: evidence for allocating the binding site. Protein Pept Lett. 2010; 17:1524-35. 19. Arora R, Nair M, Kalra GS, Nigam M, Khalilullah M. Immediate and long-term results of balloon and surgical closed mitral valvotomy: a randomized comparative study. Am Heart J. 1993; 125:1091-4. 20. Commerford PJ, Hastie T, Beck W. Closed mitral valvotomy: actuarial analysis of results in 654 patients over 12 years and analysis of preoperative predictors of long-term survival. Ann Thorac Surg. 1982; 33:473-9. 21. Reid CL, Otto CM, Davis KB, Labovitz A, Kisslo KB, McKay CR. Influence of mitral valve morphology on mitral balloon commissurotomy: immediate and six-month results from the NHLBI balloon valvotomy registry. Am Heart J. 1992; 124:657-65. 22. Jneid H, Cruz-Gonzalez I, Sanchez-Ledesma M, Maree AO, Cubeddu RJ, Leon ML, et al. Impact of pre-and postprocedural mitral regurgitation on outcomes after percutaneous mitral valvuloplasty for mitral stenosis. Am J Cardiol. 2009; 104:1122-7.            

Immediate Results of Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis

http://jctm.mums.ac.ir/article_11825_bc82690018bc6377c8cdb39011898436.pdf

Immediate Results of Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis

Abstract

Similar works

Full text

Available Versions

Directory of Open Access Journals