IMMEDIATE OUTCOME OF PERCUTANEOUS

TRANSVENOUS MITRAL C OMMISSUROTOMY (F.|MC)

SYED AZTZUL FIASUE', MD. ASHRAF UDDIN CHOWDHURY', MD.
TOUFIgUR RAHMAN3, KHONDOKER
gAMRUL rSt/,M4

Abstract
To assess the immediate haemodgnamic and- echocard.tographic outconrc
oJ-percutaneous
transuenous mttral commisstLrotomy (wMC) in a populatton u;iere'rheumatic
mitrai sienosis r:s uery
common, a prospectfue study tuas done in National Institute oJ Cardiouctsculor
Diseases, Ohaki-
Bangladesh, during the pertod oJ May 2o04 to ,hprtl 20o5. fifig pattents
toith rheumatic mitral
stenosis toho undenlrcnt WMC tuere eua\uated" clinica1tg and bg- eliocardiography.
Mean age oJ the
sttrJy population was 30.42 x 1o.25 gears. Mean lefi ot tat piussure as ,icord-ed-
bg cathiter"tuas
32'95 t B'25 mm Hg in pre YIMC group u:hite afi.er PTMC it usas lb.BB + Z.os mm
Hg. Mean aorttc
pressure tncreased.from go.Bs x 2.28 mm Hg to g6.gb x 2.22 mm
Hg afi.er the piced.ure. Ajter
PTMC mean nitrar uaLue area tncreasedJrom o.8r t o. j5 cm2 to r.B2
echocardiograplul. Mitral ualoe gradient recluced" to
i o.zs i*;r;;;;;;; ;u
t 2.78 mm Hg Jrom 26.23 t b.69 mm Hg
-io.2s
afi'er WMC. LeJt atrtr:tl size also d-ecreasedJrom 47.21 + 6.g9 mm to 3i.b'x 7.64 l-rLl'r.. Complications
u)ere uncommon euen in pati'ents u-:ith high echocardiographic score.
?TMC is a uery effectiue cLnd"
saJe procedure atrelieuing the hemodynamic effects oJrheimattcmitral
stenosrs . tnproperly selected
patients complications are also uery minimum-

Introduction >grade 1, left atrial thrombus, Wilkins-Weyman echo

The standard treatment for patients with severe score >12 and significant calcification in valve
symptomatic rheumatic mitral stenosis who do not commissures. Informed consent was taken before the
have anatomy requiring valve replacement has been procedure. All patients who had valvotomy were
either open or closed surgical commissurotomy. The entered into the study. All procedures were done
intr^oduction of a percutaneous balloon technique, through right femoral vein via the transeptal puncture.
as first described by Inoue et al--l in 19g4 was a Inoue double balloon was used (Fig-l). Each balloon
blessing for many mitral stenosis patients. mMC was used several times after proper sterilization.
is an excellent technique for properly selected Echo scoring was done according to Wilkins_Weynnan
patients. A simple separation of fused, pliable
echo scoring system. Four parameters of scoring system
leaflets by blunt pressure of a balloon introduced
are leaflet mobility, leaflet thickening. subvalvular
through the femoral vein, produces good valvular
thickening and va\rrlar calcification. ffre totat score is
functi---on2. This technique was devJloped with a
derived fiom analysis of the parameters, which are graded
view to achieve an equivalent effect without Iiom 0 (normal) to 4 according to specified criteria.
thoracotomy by using the expansile force of the
balloon. And aiso native valve is preserved not Successful PIMC was defined as resultant mitral
replaced by metallic valve. Since iti introduction valve area > 1.52 and more than 5O%o increase in mitrat
PTMC has been used with mixed success with valve area.
decreasing number of complications3-5.
Echocardiography was done both before and after the
In this present report, short term outcome of fifty procedure to evaluate left atrial size, mitral valve area,
patients who underwent the procedure in NICVD,
Dhaka, between May 2OO4 to April 2OOb, is described.
T]t I valve gradient and mitral regurgitation (Fig. II_
III). During the procedure left atiiaipressure anci
aortic pressure were recorded both before and afler
Methods balloon dilatation. Any complication during or after
Patients with symptomatic severe mitral stenosis who valvotomy were also recorded. patients were evaluated
underwent PIMC were included in the study. patients clinically and by echocardiography about 3_5 days after
were included in the study after physical examination procedure and at discharge from hospital.
and echocardiographic evaluation. All baseline data
were recorded. Exclusion criteria for the study were Follow-up informations were obtained at regular
mitral regurgitation >grade l, aortic regurgitation interval after hospital discharge. Data regarding long
term follow-up are not presented in this report.
I. Professor of Cardiologr, National Institute of Cardiovascular Diseases.
Dhaka
2. Assistant Registrar, National Institute of Cardiovascular Diseases, Dhaka
3. Assistant Registrar, National Institute of Cardiovascular Diseases, Dhaka
4. Assistant Professor, National Institute of Cardiovascular
Diseases, Dhaka

Bangladesh J Medicine 2OO4; tlc 4S_4g

Immediate Outcome of Percutaneous Transvenous Mitral RJM Vol. 15 No. 2

Fig 1 : Manipulatton oJ Inoue balloon catleter. 1. T he

balloon catlleter, uith a stdfening canrnula inserted, is
arluctnced ouer ttrc guirle usire and pusled into Lefi atium-
Tlrcn cannula is remoued. 2 . The catheter is iserted into
the Lefi Dentrtcle (LV). 3. In ttrc LV, onlg the distal haLJ oJ
the balloon is iryflated. It is pulled to brtng into contact (b)
u:ithttrc LV sirle oJmitralualue. 4. Tlrc balloonis inJlated
toJttlt extent qt tte mitral ori.fce and therebg separates Fig.-2 : 2-D ectacardiographic image oJ seuere mitral
lheJused commissures. stenosis : (a) bejore PTMC, (b) afier PTMC

(a) b)
Fig.3 : Color Doppler (a) and Spectral Doppler (b) image of seuere mitral stenosls

46
 BJM VoI. 15 No. 2 Immediate Outcome of Percutaneous Transvenous Mitral

Results Echocardiographic findings:

Pati.entpoptilation: Echocardiography was done 1 day before valvotomy
Fifty patients undergoing pfMC were included in this and 3 days after, to compare the outcome of the
study. Among them majority (Zgo/o) were female procedure. Symptomatic severe mitral stenosis
(Table- 1). Highest number (44o/o) of patients belonged patients who did not have any exclusion criteria were
to 25-34 years age group(Fig-IVJ. selected for PTMC. Patients with MR grade nil to one
and AR grade nil to one were also included for the
Table-I procedure. Patients with high grade MR or AR or with
B as eltne de mog r aphtc char act_eris tics severe calcification of mitral valve or with lelt atrial
thrombus were excluded. Most patients had echo score
Parameters Features S8, although some patients had echo score between
Age 9-10 were also included for valvotomy (Table-2).
o Mean age 30.42 t 10.25 years Before PfMC mean mitral valve area was O.81 rO. I5
o Range 13-55 years cm2 (range O.5- 1 .2 cm2; . After valvotomy mean mitral
valve area was 1.82+ O.2b crn2 (range 1.4-2.b crrl2)
Sex (Table-3).
o Male 11 (22o/o) Mean mitral valve gradient was 26.23+5.69 mm Hg
o Female 3g e8o/o) (range 37-6O mm) before the procedure, which reduced
to 10.23 +2.78 mm Hg (range 4-18 mm) after
valvotomy.
za
20 Mean left atrial size was 42.21 +6.g9 mm (range 37-
0)
.o 15 60 mm). After PTMC mean left atrial size reducecl 1o
E
10 31.5 +7.64 mm (range20-46 mmJ.
z tr
Ejection fraction was also recorded before and after
0 valvotomy. There was no significant change in ejection
<15 15-24 25-34 35_44 45_54 >55 fraction after the procedure.
Age
Fig. 4 : Age distrtbutton oJ IrtMC patients
Table-III
nfYIIA status : Hae nuf,gnamic p ctramefer s
Pateints were classified in 4 groups according to NyHA
classification before pIMC (Table-2). Majority of
Parameters Pre PTMC Post PTMC P vah.re
patients belonged to NYHA class III before mMC. MVA (cm2) 0.81t0.15 t.82=O.25 <0.01
There was sl.rnptomatic improvement in all patients MVG (mm Hg 26.23x.5.69 10.23t2.78 <0.0I
after PTMC. LA size (mm) t 6.99 31.5 x 7.64
47.2I <0.O5
Table-II l,A pressure 32.95t8.25 15.88t7.05 <0.0s
B aseline cltnical and echocardiographic characterisrbs (mm H$
Aortic pressure 90.85x2.28 96.gbx.2.22 <0.05
Pararneter Number (Percent)
RHD status *MVA-mltral valve area, MVG- mitral
valve gradient. LA_
oMS 33 (66%) ieft atrium
o MS with MR<Grade2 17 (34o/o)
Cardiac cath findings :
NYHA status During P|MC left atrial pressure was recorded. Mean
o Class I-II 20 (4Oo/o)
left atrial pressure before the procedure was 32.95
+8.25 mm Hg (range 14-42 mrn). After valvotomy left
o Class III-IV 30 (60010) atrial pressure reduced to a mean of l5.gg +7.05 mm
Wilkin's Echo score Hg (range 6-4O mm) (Table-3).
c 4-6 20 (4Oo/o) Aortic pressure was recorded via a pigtail catheter
o 7-8 placed in root of the aorta. Mean aortic pressure was
23 (460/o)
90.85 t 2.28 mlrn Hg before valvotomy and it was 96.95
o 9-10 7 (l4o/o) t 2.22 mm Hg after the procedure.

47
Immediate Outcome of Percutaneous Transvenous Mitral BJM Vol. 15 No. 2

Complications : haemodlmamic and clinical effects at a very short time

Complications during the procedure was very few. Only and without much complications. The cost is even
1 patient developed haemopericardium, which was lowered by repeated use of single balloon without
managed surgically. Four patients developed MR3grade any adverse effects. PIMC is a very safe procedure if
2, which was managed conservatively. Local vascular done with expert hand after proper patient selection
compllcation at the femoral puncture site was more and major surgery like valve replacement can be
common (l4o/o). This includes pain, haematoma and avoided which is a big burden for a patient both
haemorrhage (Table-4). economically and psychologically.

References
Table-tV 1. Inoue K. Owaki T, Nakamura T et al. Clinical
application of transvenous mitral commissurotomy
Complicatiora by a new Balloon catheter. J Thorac Cardiovasc Surg
1984: 87: 394-402.
Complication Number (percentage)
c Inoue K, Nakamura T, Kitamura F, Myamoto N :
Haemopericardium 1 (2o/o)
Nonoperative mitral commissurotomy by a new
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Local vascular complication 7 (14o/o) Kveselis DA. Rocchini AP, Beekman R et al. Balloon
angioplasty for congenital and rheumatic mitral
Discussion stenosis. Am J Cardiol 1986; 57:348-35O.
Although very uncommon in western world, rheumatic Babic UU, Pecic P, Djurisic Z el al. Percutaneous
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disabling heart disease whose main victims are poor Percutaneous balloon valvotomy in a patient with
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6
the modern treatment facilities. Valve replacement Percutaneous catheter commissurotomy in
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with pure mitral stenosis or mitral stenosis with mild I5 1 5- I5 IB.
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as they can undergo IrIMC procedure at a very low Percutaneous double balloon mitral valvotomy for
cost. The cost is further reduced by multiple use of rheumatic mitral valve stenosis. Lancet l986; 1:
one Inoue balloon catheter after proper sterilization. 757 -761.

Inoue and colleagues had showed that PTMC act in B. McKay CR, Kawanishi DT. Rahimtoola SH. Catheter
the same way as surgical commissurotomy by opening balloon valvuloplasy of the mitral valve in adults
the fused commissuresl. Since then a number of using a double balloon technique : early
reports showed the efficacy of this procedures-e. haemodynamic resuslts. JAMA 1987; 257: 1753-
Fawzy and colleagues had showed that mitral 176 I.
valvotomy had excellent long term results in properly I The National Heart, Lung, and Blood Institute
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surgical commissurotomy have the same mechanism, experience with balloon mitral commlssurotomy:
one can expect that these two methods will share NHLBI balloon vaivuloplasty registry report on
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Conclusion
clinical and echocardiographic results after
Rheumatic mitral stenosis is predominantly a disease successful mitral balloon valvotomy and predictors
of lower socioeconomic society. PIMC is a very cheap of long term outcome. Eur Heart J 2005:25:1647'
and effective procedure to obtain very good 7652.