Early Percutaneous Mitral Commissurotomy vs. Conventional Management in Asymptomatic Moderate Mitral Stenosis

Study Questions:

What are the long-term outcomes of early preemptive percutaneous mitral commissurotomy (PMC) versus a conventional (CONV) treatment strategy?

Methods:

From 1997 to 2007, the investigators prospectively enrolled 244 consecutive asymptomatic patients (191 women, ages 51 ± 11 years) with moderate rheumatic mitral stenosis (MS), who were potential candidates for early PMC. The treatment groups were not randomly assigned, and the choice of early PMC or CONV treatment for each patient was at the discretion of the attending physician. The primary endpoint was defined as the composite of cardiovascular mortality, cerebral infarction, systemic embolic events, and PMC-related complications. Event-free survival curves were constructed with Kaplan–Meier estimates and compared by the use of the log-rank test.

Results:

In the PMC group, there were no procedure-related deaths, and mitral valve area was increased from 1.26 ± 0.11 to 2.07 ± 0.28 cm2 immediately after PMC (p < 0.001). During a median follow-up of 8.3 years, there were three cardiovascular deaths and five cerebral infarctions in the PMC group (n = 106) compared with 16 cardiovascular deaths, 12 cerebral infarctions, and seven systemic embolic events in the CONV group (n = 138). The estimated actuarial 11-year event-free survival rate was 89 ± 4% in the PMC group and 69 ± 5% in the CONV group (p < 0.001), but was not significantly different in those without atrial fibrillation and previous embolism (86 ± 5% in the PMC group and 79 ± 6% in the CONV group at 11 years; p = 0.28). For the 62 propensity score-matched pairs, the risk of the cardiovascular endpoint was significantly lower in the PMC than in the CONV group (hazard ratio, 0.327; 95% confidence interval, 0.112-0.954; p = 0.041).

Conclusions:

The authors concluded that in asymptomatic patients with moderate MS and favorable valve morphology, the clinical benefits of early PMC may outweigh the risks associated with early intervention.

Perspective:

This study suggests that early PMC was associated with a significant reduction in the composite event rate of cardiovascular mortality, cerebral infarction, systemic embolic events, and PMC-related complications. Since early PMC is associated with improved long-term event-free survival, it may be considered as a therapeutic option to further improve clinical outcomes in selected asymptomatic patients with moderate MS, but prospective randomized trials are indicated to further confirm the efficacy of early PMC.

Clinical Topics: Valvular Heart Disease, Vascular Medicine

Keywords: Incidence, Risk, Stroke, Rheumatic Heart Disease, Follow-Up Studies, Patient Selection, Cerebral Infarction, Cardiology, Mitral Valve Stenosis, Embolism, Mitral Valve


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