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Percutaneous transvenous mitral commissurotomy using Inoue balloon in children less than 12 years
S S Kothari1, P Kamath, R Juneja
1Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi. kothari@medinst.ernet.in
Insights
Percutaneous transvenous mitral commissurotomy (PTMC) is a safe and effective treatment for severe rheumatic mitral stenosis in children. Using a smaller balloon size than recommended may be equally effective and safer, with comparable outcomes and low complication rates.
Area of Science:
- Pediatric Cardiology
- Interventional Cardiology
- Rheumatic Heart Disease
Background:
- Rheumatic mitral stenosis frequently affects children globally.
- Percutaneous transvenous mitral commissurotomy (PTMC) outcomes in pediatric populations are not extensively documented.
- Severe mitral stenosis significantly impacts pediatric cardiac function.
Purpose of the Study:
- To evaluate the safety and efficacy of PTMC using the Inoue balloon in children aged 7-12 years with severe rheumatic mitral stenosis.
- To compare outcomes between children receiving the recommended balloon size (RBS) versus a smaller maximum balloon size (MBS).
Main Methods:
- Forty-five children with severe rheumatic mitral stenosis underwent PTMC with the Inoue balloon.
- Patients were divided into two groups: Group I (MBS = RBS) and Group II (MBS < RBS).
- Hemodynamic parameters (PAW, diastolic gradient, MVA) and complications were assessed.
Main Results:
- PTMC significantly reduced pulmonary artery wedge pressure and mean diastolic gradient, increasing mitral valve area (MVA).
- Final MVA and complication rates (mitral regurgitation, atrial shunting) were comparable between groups, irrespective of balloon size.
- No procedural deaths, systemic embolisms, or cardiac tamponades occurred.
Conclusions:
- PTMC is a safe and effective intervention for severe rheumatic mitral stenosis in children under 12.
- Utilizing a smaller balloon size than RBS may be equally effective and potentially safer, with similar clinical outcomes.
- Long-term follow-up showed a low incidence of restenosis.
Abstract:
Rheumatic mitral stenosis in some parts of the world afflicts even young children. Percutaneous transvenous mitral commissurotomy (PTMC) using Inoue balloon in these children is not well reported. Forty-five children (aged 7-12 years, mean 11.0 +/- 1.2 years) with severe rheumatic mitral stenosis (mitral valve area [MVA] 0.64 +/- 0.14 cm2) underwent PTMC. The pulmonary artery wedge pressure (PAW) decreased from 24.3 +/- 8.6 to 14.7 +/- 7.2 mmHg (P < 0.0001) and mean diastolic gradient decreased from 24.3 +/- 7.7 to 7.9 +/- 5.9 mmHg with the final MVA of 1.63 +/- 0.45 cm2 (P < 0.0001). Complications included significant mitral regurgitation (MR) in three children and atrial shunting in two patients. No procedural death, systemic embolism, and cardiac tamponade were encountered. Twenty-four children had maximum balloon size (MBS) same as recommended balloon size (RBS) derived according to the height (group I) and 21 children had MBS 1-3 mm less than RBS (group II). Despite the lesser maximum balloon size, the final results were comparable in both groups (MVA group 1.66 +/- 0.44 vs. group II 1.61 +/- 0.48 P = NS). The incidence of significant MR (2 and 1 in group I and group II, respectively) was similar. On follow-up of 20.4 +/- 16.3 months (range 3-56 months), one child developed restenosis. We conclude that PTMC is safe and effective in children less than 12 years of age. However, the smaller balloon size than the RBS derived from height may be equally effective and possibly safer.