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Long-term (9 to 33 months) echocardiographic follow-up after successful percutaneous mitral commissurotomy
A Desideri1, O Vanderperren, A Serra
1Department of Medicine, Montreal Heart Institute, Quebec, Canada.
Insights
Percutaneous mitral commissurotomy offers lasting clinical improvement, but restenosis occurs in 21% of patients. Echocardiography helps predict restenosis and atrial shunting after the procedure.
Area of Science:
- Cardiology
- Interventional Cardiology
- Echocardiography
Background:
- Percutaneous mitral commissurotomy (PMC) is a treatment for mitral stenosis.
- Long-term outcomes and predictors of restenosis after successful PMC require further investigation.
Purpose of the Study:
- To assess late clinical and echocardiographic results after successful PMC.
- To identify predictors of restenosis and persistent atrial shunting post-PMC.
Main Methods:
- Prospective follow-up of 57 patients after PMC.
- Clinical assessment using New York Heart Association (NYHA) class.
- Echocardiographic evaluation including mitral valve area (MVA) and Doppler half-time method.
- Transthoracic color Doppler for atrial shunting detection.
Main Results:
- MVA increased post-PMC but decreased at follow-up (p<0.05).
- Echocardiographic restenosis (MVA ≤1.5 cm², >50% reduction) observed in 21% of patients.
- Atrial shunting persisted in 30% of patients at follow-up.
- Restenosis correlated with age, post-procedure MVA, and echocardiographic score; leaflet mobility and calcifications were predictive.
- Atrial shunting predictors included shunt magnitude, Bifoil balloon use, and post-procedure MVA.
- Sustained clinical improvement noted, with 75% of patients improving ≥1 NYHA functional class.
Conclusions:
- PMC provides durable clinical benefit, though restenosis is a significant concern.
- Echocardiographic parameters like leaflet mobility and calcifications predict restenosis.
- Atrial shunting can persist and is associated with specific procedural factors.
- Continued monitoring is essential to manage late outcomes after PMC.
Abstract:
Late results after successful percutaneous mitral commissurotomy were assessed by prospective clinical and echocardiographic follow-up. Fifty-seven patients were followed for a mean of 19 +/- 6 months (range 9 to 33) after the procedure. Mitral valve area (measured by Doppler half-time method) increased from 1.0 +/- 0.2 to 2.2 +/- 0.5 cm2 immediately after commissurotomy, and then decreased to 1.9 +/- 0.5 cm2 at follow-up (p less than 0.05), whereas gradient did not change after its immediate postcommissurotomy reduction. Echocardiographic restenosis (mitral valve area less than or equal to 1.5 cm2 with greater than 50% reduction of initial gain) was seen in 12 of 57 patients (21%). Atrial shunting, detected by transthoracic color Doppler in 61% of patients immediately after the procedure (color flow jet through atrial septum), persisted in 30% at follow-up. Restenosis by univariate analysis correlated with age, smaller valve area after the procedure, and higher echocardiographic score. Multivariate analysis identified leaflet mobility and calcifications as the components of a score that was predictive for restenosis. Magnitude of shunt (pulmonary-to-systemic flow ratio greater than 1.5), use of a Bifoil balloon (2 balloons on 1 shaft), and smaller valve area after the procedure were predictors by multivariate analysis of the persistence of atrial shunting. Clinical improvement persisted at long-term follow-up (mean New York Heart Association class 1.6 +/- 0.6 vs 2.6 +/- 0.6 before commissurotomy). Improvement of greater than or equal to 1 functional class was seen in 75% of patients (80% of those without and 58% of those with restenosis); patients with a shunt did not differ from the entire group.(ABSTRACT TRUNCATED AT 250 WORDS)