Percutaneous transvenous mitral commissurotomy for mitral stenosis patients with markedly severe mitral valve deformity: Immediate results and long-term clinical outcome

None of our patients developed cardiac tamponade defect and the low incidence of significant mitral reor systemic embolism. The low incidence of mitral gurgitation is noteworthy. regurgitation (7%) is similar to that reported in other series.6g7 We believe this is related to stepwise dilatation Roy SB. Bharia ML. Lozaro EJ, Ramalingawamy V. Juvenile mitral stenosis performed in each patient, with meticulous attention in1. India. L*mcrt 1963:2:1193-1195. being paid to measuring gradients and auscultating for 2. Lock JE, Khaliullah M, Shrivartava S, Bahl V, Keane JF. Percutaneous cathein rheumatic mitral stenosis. N Engl J Med 19X5:313: mitral regurgitation before each increment in balloon ter commissurotomy size. This is easily done with the same balloon in the 3.1508-1515. Al-Zaibag M, Ribeiro PA, Al-Kasab S, Al-Faigh MR. Percutaneous double balInoue technique.* The only patient who developedsevere loon mitral valvotomy for patients with revere mitral stenosis. Circuforion 1987; mitral regurgitation had a less than ideal valve on 4778-784. 4. Arora R. Nti M, Rajagopal S, Sethi KK, Mohan JC. Nigam M. Khalilullah M. echocardiographic assessmentbefore balloon valvotomy. Percutaneous balloon mitral valvuloplasty in children and young adults with The reported incidence of atria1 septal defects after rheumatic mitral stenosis. Am Ham J 1989:118:883-887. 5. Shrivastava S. Dcv V, Vasan RS, Dac GS. Rajani Y. Percutaneous mitral valvuballoon mitral valvotomy varies between 9% and loplasly in juvenile mitral stenosis. Am J Car&[ 1991:123:892 894. 53%.9,‘0The incidence is lower with the Inoue technique 6. Fawzy ME, .Mimish L, Awad M, Galal 0. El-I&b F, Khan B. Mitral halloon (10% to 25%).6,7Our series had an incidence of only valvolomy in children with Inoue balloon technique; immediate and intermediate Hea/? J 1994;127:1559-1562. 2.3%, and there was no case of echocardiographically 7.termBahlresult.VK. AmChandra S. Kothari SS. Talwar KK. Sharma S. Kaul U. Raiani M. demonstrable shunt 48 hours after balloon valvotomy. Wasti HS. Percutaneous transvcnous commissurotomy using lnoue cathetcrin juvemitral stenosis. Carher Cardiowxc Diagn 1994;(suppl 2):82 -86. This low incidence with the Inoue technique is related 8.nileInoue K, Owaki T, N&unum T, Kitamma F. Miya&to N. Clinical application to the fact that the septum is not dilated with a balloon of tmnsvenous mitral commissurotomy by a new balloon catheter. J l?umr Curand the deflated profile of the balloon is smaller than the diovaw Surg 1%34;R7:394-l02. 9. O’Shea JP, Abascal VM, Marshall JI:, Wilkins GT. ‘Ilwmas JD. Long term percylindrical balloons. sistence of atnal scptal defects following percutaneous mitral valvuloplas~y: a We conclude that balloon valvotomy of the mitral Doppler echocardiographic follow up study (abstr). Circhtim 1988;78(suppl valve with the Inoue technique is a safe and effective Il):II-I. 10. Castle P. Block PC, O’Shea 1. Palacios IF. Auial septal defect after pcrcuraprocedure for treating juvetile rheumatic MS. The neous mitral valwloplasty: immediate rewlts and follow-up. J Am CON Cordial almost complete absence of iatrogenic atria1 septal 1990;15:13cH%1304.

Percutaneous Transvenous Mitral Commissurotomy for Mitral Stenosis Patients With Markedly Severe Mitral Valve Deformity: Immediate Results and Long-Term Clinical Outcome Yuki Yoshida, MT, Shigeru Kubo, MT, Shunichi Tamaki, MD, and Kanji Inoue, MD ince percutaneous transvenous mitral commissurotomy (PTMC) with the Inoue balloon catheter techS nique was introduced in 1984,’ the efficacy and safety of this treatment have been established as a result of extensive clinical trials.2A Mitral stenosis patients with markedly severe valve deformity are generally treated with mitral valve replacement.However, if thesepatients are at high risk for open heart surgery, PTMC may become the only available treatment. The purpose of this study was to assessthe efficacy and safety of PTMC for mitral stenosis patients with markedly severe valve deformity. ... Among 58 consecutive patients with PTMC from November 1989 to March 1994 at Takeda Hospital, 17 patients (10 men and 7 women, aged 23 to 76 years) had markedly severevalve deformity, defined as echocardiographic severity score 212.5 Nine of the 17 patients (53%) were at high surgical risk, and surgical treatment From the Deportment of Clinical Laboratory, the Deportment of Cardiology, and the Deportment of Cardiovascular Surgery, Takeda Hospital, Higashiiru, Nishmotoin, Shiokoii dori, Shimcgyo-ku, Kyoto 600, Japan. vowscript received February I 7, 1995; revised maw script received and accepted May 26, 1995.

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was considered contraindicated: ejection fraction 535% in 4 patients, pulmonary fibrosis in 1, severeliver function disturbance in 2, and renal failure and severe liver function disturbance in 2. Of the 17 patients, 15 (88%) had atrial fibrillation, 1(6%) had pacemakerrhythm (VVI pacing), and 1 (6%) had normal sinus rhythm. Grade 1 mitral regurgitation according to the criteria of Sellers et al6 was present in 8 patients (47%), grade 2 was present in 3 (18%), and grade 3 was present in 1 premoribund patient (6%). Five patients (29%) had mitral restenosis after open or closed mitral commissurotomy. Thrombi confined to the left atria1appendageor left atrial posterior wall documented by transesophagealechocardiography were presentin 3 patients. PTMC was performed by the Inoue balloon catheter system as previously described by Inoue et al.’ All patients underwent diagnostic catheterization, baseline hemodynamic measurements,and 2-dimensional and Doppler echocardiography before and after PTMC. The degree of mitral valve deformity was assessedaccording to the echocardiographic scoring system.5The total echocardiographic score was derived from an analysis of mitral leaflet mobility, subvalvular thickening, leaflet thickening, and leaflet calcification, which were graded from 0

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1.5, 1995

TABLE I Hemodynamic,

Clinical, MVA

Patient 1 2 3 A 5 6 7 a 9 10

11 12 13 14 15

16 17 CO sured

and Echocardiographic

(cm2)

Results CO (L/min)

LAP (mm Hg)

Before

After

Before

After

Before

After

Follow-Up

-

3.2 4.1 1.7 2.9 3.9 A.1 3.8 6.8

1 3

1 3

IV

III

IV

IV

1

1

1

1

0 1 0 0 2

1 1 2 1 2

Ill Ill IV IV

II II II Ill

Ill Death Death II Death

II

II

II

III Ill

1 1

1 1

IV II

II II Ill

II III

2 0 0 1 2 1

2 1 0 1 2 1

IV

IV

IV

II

pressure; MR = mitral functional class.

regurgitation;

Before

After

Follow-up

0.9 0.7 0.5 0.6 0.7

1.3

1.0

1.4

0.8

1.2 0.9 1.2 1.4

1.1 Death Death 1.2 Death 1.2 1.1 1.2

12 24 9 7 21 a

1.4

-

30 32 20 20 38 11 23 20 33

12 14

21 4.0 1.7 2.8 3.4 4.0 3.5 A.5

0.7 1.3 1.5 1.3 1.2 1 .o

Death 1.3 1 .o 1 .o

38 20 20 27 22 21

30 12 16 20 10 14

3.8 5.5 2.2 A.0

0.4 0.6 0.7 0.6 0.5 0.7 1 .o 0.7 0.7 0.6 - cardiac output by 2.dimensional

1.1

1.1 1.1 1.3

measured by the thermodilution method; echocardiography; NYHA = New York

NYHA

MR [grade]

After

Before

10

3.9 6.2 3.0 A.5

LAP = leh atria1 Heart Association

to 4. The total echocardiographic score is 0 to 16, and higher scoresrepresenta more severely deformed valve. The mitral valve areawas measuredby direct planimetry.* In patients with left atrial thrombi, the location of the catheter was continuously monitored by transesophagealechocardiographyduring PTMC. Complete success was defined as a final valve area 21.5 cm2 and a gain in mitral valve area of 225%. Incomplete successwas defined as a final valve area of 21.0 and cl.5 cm2, with a gain in mitral valve area of 225%. Hemodynamic failure was defined as a final valve area of cl.0 cm2 or a gain in mitral valve areaof R5%.9 Restenosisat follow-up was defined as a reduction of X50% of the gain in mitral valve area produced by valve dilatation. Measurementsbefore and after PTMC were compared using the Wilcoxon signed-rank test for nonparametric data. A probability value co.05 was considered significant. The technical success rate of PTMC was 100%. Table 1 lists the results of PTMC. In this study, neither emergency surgery was required nor cardiac tamponade occurred as a complication of the PTMC procedure. PTMC could be performed without embolic complications in 3 patients with thrombi in the left atrium, documented by ‘transesophageal echocardiography. Color Doppler echocardiography showed the presence of small atria1left-to-right shunts in 6 patients (35%). After PTMC, the degree of mitral regurgitation increased by 1 grade in 3 patients (18%), by 2 grades in 1 (60/c),and remained unchanged in 13 (76%). The mitral valve area significantly increased, from 0.69 + 0.17 to 1.20 + 0.2 cm* (p ~0.01). As a result of valve dilatation, mean mitral transvalvular pressuregradient was reduced from 15.1 + 6.0 to 6.6 + 2.5 mm Hg (p
MVA

I

-

Death -

III

Ill

III

Ill III Ill

II II II

II II

= mitral

valve

area

mea-

15 patients and hemodynamic failure in the remaining 2 patients. Thirteen of the 17 patients (76%) had symptomatic improvement. Three patients improved from New York Heart Association grade IV to III, 7 from grade III to II, 2 from grade IV to II, and 1 from grade II to I. Symptoms in 4 patients (24%) did not worsen. One patient underwent mitral valve replacement 2 days after PTMC. Late deaths occurred in 4 patients (24%): 2 cardiac and 2 noncardiac deaths. Eight patients who had been followed up in our hospital were free of cardiovascular events for up to 57 months. In 8 patients who were followed up by echocardiography, the mitral valve area was 0.75 + 0.14 cm* before and 1.26 + 0.15 cm2 immediately after PTMC, and 1.15 f 0.11 cm* at follow-up. No restenosis occurred for a mean followup period of 27.0 + 14.5 months. ... Whether patients with severevalve deformity should be subjectedto mitral valve replacementor PTMC is an issue of clinical interest.‘c-I2 The hemodynamic results of PTMC for patients with a markedly deformed valve were incomplete. However, most of these patients had improvement in clinical symptoms after PTMC, and symptomatic improvements tended to be greater in patients with more serious symptoms before PTMC. This suggeststhat symptomatic improvements can be expected, even when the gain of valve area is incomplete in patients with high-grade mitral stenosis and serious symptoms. Therefore, if the patient does not want to undergo open heart surgery for various reasons,PTMC is considered to be worth performing to improve clinical symptoms becauseit can be very safe and its physical burden and the time required for the procedure are comparable to those for diagnostic cardiac catheterization. The long-term results of PTMC are now under investigation, and the precise mechanism and the predictors of mitral restenosis on long-term follow-up remain unclear.In this study,the gain in valve areaobtained

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407

by PTMC was lessoptimal in patients with a more severe clinically useful in treating the mitral stenosis patient valve deformity, and there was the tendency toward a with a markedly severe valve deformity. mild decreasein mitral valve area at follow-up examiK, Owaki ‘I‘, Qkamura 1‘. Kitamurd F. Miyamoto K. Clinical application nations. Therefore, mitral restcnosisis expectedto occur of1. Inoue transvenous mitral commissumtomy by a new ballwn catheter. J Thomc Curin these patients after several years. If restcnosis results di0w.w swg 1984:x7:394402. (PTMC). from refusion of the commissures,repeat PTMC may be 2. Inouc K. Hung JS. Percutaneous transvenous mitral comGswrotomy I:ar East expcrirncz. In: Topol EJ. cd. Tertbwk of Interventional Cardiology. effective. However. if restenosisoccurs mainly because The Ict ti. Pbiladelpbia: WR Saunders. 11r)O:8X7-8’99. of a markedly restricted opening of the anterior leaflet 3. Nobuyoshi M. Hamacaki N. Kimura T. Nosaka II. Yokoi H, Yasumoto H, Horidue to inexorable.progressof the fibrotic process,mitral uchi Il. Nakashima II. Shindo T. Tori T. Miyamoto AT. Inoue K. Indications, cornplicatwns. and short-term clinical outcome of percutaneous transvcnous mitral comvalve surgery should be recommended.As a last resort, missurotomy. Cinularim 1989:80:782-792, emergency PTMC was performed in 3 premoribund pa- 4. Hung JS. Chem MS. Wu JJ, Fu .M. Ych KH, Wu YC, Cbemg WJ. Chua S, 1.e CR. Short- and long-term results ofcathetcr ballwon percutaneous transvc~~ous mitral tients. These patients escaped the critical state after commiswrotomy. Am J Curdiol 1991:67:8.54-X62. PTMC, and 1 of the 3 patients underwent mitral valve 5. Wilkins GT, Weyman AE, Aba.xal VM. Block PC, Palacious II:. Percutaneous variables replacement several days later. This limited experience balloon dilatation of the mitral valve: an analysis of echcrardiogaphic to outcome and the mechanism of dilatation. Rr Heart J 1988:60:299-30X. shows that if the clinical and hemodynamic state con- 6.related Sellers KD, Levy MJ, Amplatz K. Lillehei CW. Left retrograde cardioangiopratraindicates open heart surgery,PTMC may be available phy in acquired cardiac disease. Am J Cardin/ lY64;14:4374l7. as a bridge to open heart surgery after hemodynamic im- 7. lnoue K. Ilung JS, Chen CK. Chcng TO. Mitral stenosis. Inoue balltxm catbcter technique. In: Chcng T0, cd. Percutaneous Balloon Valvuloplasty New York: provements.Three of the 9 patients at surgical high risk Igaku-Shoin Medical Publishers. 1992:237-279. died during follow-up, but the remaining 6 patients have 8. Cben C, Abascal VM. Echocardiographic evaluation. In: Cheng TO, ed. PercuUalloon Valvolopla~ty. iGw York: I&u-Shoin Medical Publishers, 1992: continued to improve clinically without restenosis.Our tzmcous I 27--I X4. data show that clinical improvement has been sustained 9. I.efwre T, Bonan R, Serra A, Crepeau J, Dyrda I, Rctitclerc R. Leclerc Y. Vanfor several years even in these patients. When rcsteno- dcrperren 0. Waters D. Percutaneous mitral valvuloplasty in surgical high risk J Am Cob Cardiol I~Nl:l7:348-3.51. sis occurs in thesepatients, PTMC may be repeatedwith patients. 10. Palacins IF. Block PC, Wilkins CT. Weyman AL. Follow-up of patients underequally successful results. going percutaneous mitral halloon valvotomy. Analysis of factors detcrmining In conclusion, to evaluate the efficacy and safety rcstenoais. Gin-rtlrrriun 19X9:79:573-579. 11. Feldman T. Carroll JD, Isner JM, Chisholm RJ. Ilolmcs DIZ. Massumi A. of PTMC for mitral stenosis patients with markedly Pichard AD. Hcrrmann HC. Stcrtzcr SH. O‘Xeill U’W. Dorros G, Sundram P. severe valve deformity, we performed PTMC in 17 Rashore TM. Ramawamy K. Jones LS, Inoue K. Effect of valve deformity on and mitral regurgitation after Inoue balloon commissurotomy. Circulnriun patients with severe mitral stenosis assessedby echo- resultc 1992:X5: 18t%l87. cardiography (echo score 212). This study demon- 12. Feldman T, Carroll JD. Valve deformity and halloon mechanics in lzwzutastrates that PTMC can be performed safely and is ncoub transwnous mitral commtssurotomy. Am Heart J lo()l: 121:16?8-1633.

Clinical Significance of High-Frequency, Low-Amplitude Electrocardiographic Signals. and QT Dispersion in Patients Operated on for Tetralogy of Fallot Luciano Daliento, MD, Francesca Caneve, MD, Pietro Turrini, MD, Gianfranco Buja, MD, Andrea Nava, MD, Ornella Milanesi, MD, Giovanni Stellin, MD, and Giulio Riuoli, MD merit of Cardiovascular Surgery of the University of Padua. We retrospectively studied43 nonconsecutivepatients (mean age 2 SD. 25.4 + 1.2years) who underwent total the most important mechanism of sudden death.‘,* The repair of teualogy of Fallot by right epicardial ventricuaim of this study was to assessthe usefulnessof signal- lotomy at a mean age of 8.7 f 6.9 years. Mean duration averagedelectrocardiography and QT dispersion as non- of postsurgical follow-up was 16.5 f 4.2 years. All invasive investigations for risk stratification of danger- patients consented to a routine examination, including ous ventricular arrhythmias in patients operated on for electrocardiography,Holter monitoring, signal-averaged electrocardiography, and echocardiographic evaluation. tetralogy of Fallot. ... Examinations took place in the Division of Cardiology Between 1979 and 1989,234 patients were operated of Padua University in 1994. on for total repair of tetralogy of Fallot in the DepartDuring echocardiographic or hemodynamic study, none of the patients showed a significant residual intraventricular shunt (QP/QS >l.S), a right ventricular pressure ti5 mm Hg, or a poor right and/or left ventricular From tnc @epar:ments of Cord:olagy, PeGlaws, and Cardiovascvlar Surgery, Universiy o( PaaJa. Ialy. THIS stu4 was scnporiec! by function (mean value of right ventricular end-diastolic the Research Project “‘ATMA.” Natlana; Council far Research, R-me. volume, calculated by Simpson’s rule: 1114 39.2 mVm2; and Veneto Region, Venice, Itaiy. Cr 3allwto’s cwrcnt address s. right ventricular ejection fraction: 51 f 9.5%; left venluciano Miento, MD, Ca&ra ai Cardiologla, Policllnlco Lmvertricular end-diastolic volume, calculated by the monositaria, via Giustinian:, 2, 35 128 “adova, I!aly Manuscript racelved planar method of Green: 62 -e 18 ml/m*; left ventricular jarwary 4, 1992; revisac mawscript recewcd and accept& Apr;l 26 199.5 ejection fraction: 60 f 8%. entricular arrhythmias, recorded by 24-hour ambulatory monitoring in patients following total repair V of tetralogy- of Fallot, are frequent and are considered

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