Long-Term Efficacy of Percutaneous Mitral Commissurotomy for Restenosis After Previous Mitral Commissurotomy

Study Questions:

What are the results of percutaneous balloon mitral valvotomy (PBMV) for restenosis after prior surgical mitral commissurotomy or prior PBMV?

Methods:

A cohort of 163 consecutive patients who underwent PBMV because of restenosis after prior surgical commissurotomy (n = 121 closed-heart, n = 30 open-heart) or prior PBMV (n = 12) were prospectively studied at a single tertiary university hospital in France. Mean age was 48 ± 14 years; 62 patients (38%) had valve calcification, and restenosis was thought to be due to bicommissural fusion in all cases. PBMV was performed 16 ± 8 years after the prior intervention; a single- or double-balloon was used in 80 patients, and an Inoue balloon was used in 83 patients.

Results:

Good immediate results (valve area ≥1.5 cm2 with ≤2+ /4+ mitral regurgitation) were obtained in 135 patients (83%). The 20-year rate for cardiovascular survival without mitral surgery was 27.9 ± 4.7%, and for good functional results (cardiovascular survival without mitral re-intervention and in New York Heart Association [NYHA] functional class I or II) was 14.8 ± 3.9%. After good immediate results, 20-year rates for cardiovascular survival without surgery was 33.2 ± 5.5%, and for good functional results was 17.9 ± 4.7%. Multivariate predictive factors for poor late functional results after good immediate results were higher NYHA class (p = 0.01), atrial fibrillation (p = 0.0002), and higher mean mitral gradient after PBMV (p = 0.004).

Conclusions:

In patients with restenosis after surgical mitral commissurotomy or prior PBMV, the authors concluded that PBMV provides good immediate results in most cases. Among patients with good immediate results, one patient out of three remained free from surgery at 20 years, and one out of five had good functional results at 20 years. The authors concluded that these findings support the use of PBMV after previous intervention, particularly in selected patients with few symptoms and in sinus rhythm.

Perspective:

Rheumatic mitral stenosis is much less prevalent than it once was, but still is present. PBMV is the preferred current approach if intervention is warranted among patients with pure mitral stenosis, pliable and noncalcified leaflets, and insignificant mitral regurgitation. In this study, intervention was for the most part following surgical commissurotomy (151 of 163 patients, performed between 1986 and 1995) and it might not be possible to extrapolate results to patients with prior PBMV (representing only 12 of 163 patients studied). Among patients who underwent prior surgical commissurotomy, results of PBMV were generally favorable. However, some markers of worse outcome (higher NYHA class, atrial fibrillation) represent usual indications for intervention. It seems reasonable to consider PBMV among patients with mitral restenosis following a prior surgical or transcatheter/balloon intervention, but procedural experience and individualized decision making likely remain of greatest importance.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Prevalence, Tertiary Care Centers, France, Biological Markers, Patient Selection, Mitral Valve Insufficiency, Cardiology, Mitral Valve Stenosis, Cardiac Surgical Procedures, Angioplasty, New York


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