Comparison of Long-Term Outcome After Mitral Valve Replacement or Repeated Balloon Mitral Valvotomy in Patients With Restenosis After Previous Balloon Valvotomy

doi:10.1016/j.amjcard.2006.12.088

The American Journal of Cardiology

Volume 99, Issue 11, 1 June 2007, Pages 1571-1574

https://doi.org/10.1016/j.amjcard.2006.12.088 Get rights and content

Symptomatic mitral stenosis (MS) develops in 7% to 21% of patients after percutaneous mitral balloon valvotomy (PMV). Treatment options for these patients are surgical mitral valve replacement (MVR) or repeated PMV. However, no comparisons were made between these 2 procedures regarding long-term outcome. This retrospective study compares the long-term outcome of 888 patients with symptomatic MS after MVR or repeated PMV who underwent PMV from April 1988 to December 2003. Thirty-two patients subsequently underwent repeated PMV, and 59 patients underwent MVR for symptomatic MS. Mean follow-up was 85 ± 43 months with a maximum follow-up of 15 years. Patients with MVR have more unfavorable clinical characteristics, including a higher incidence of atrial fibrillation and severe mitral regurgitation. Event-free survival was similar between the 2 groups up to 40 months after the procedure; 3-year event-free survival rates were 96.6% for MVR patients and 90.0% for repeated PMV patients (p = 0.215). However, after 40 months, the outcome was more favorable for MVR. Comparing MVR versus PMV, 6-year event-free survival rates were 93.0% versus 75.9% (p = 0.036), and 9-year event-free survival rates were 90.4% versus 36.0% (p <0.001). In conclusion, the long-term outcome of patients with symptomatic MS after previous PMV was more favorable after MVR than after repeated PMV. These data suggest that MVR may be the preferred mode of therapy in patients with unfavorable valve morphologic characteristics and no co-morbid disease.

Section snippets

Patients

Eight hundred eighty-eight patients underwent PMV in our institution from April 1988 to December 2003. Of these, we identified 32 patients who underwent repeated PMV for symptomatic restenosis (repeated-PMV group) and 59 patients who underwent MVR (MVR group) during the same period. Criteria for choosing MVR or repeated PMV in patients with restenosis were at the discretion of the attending physician. Clinical outcome (such as repeated procedure, stroke, readmission for heart failure, and

Pre- and postprocedural characteristics of patients

Baseline characteristics of both groups of patients are listed in Table 1. Repeated PMV was performed at 72.7 ± 34.3 months after initial PMV and MVR at 57.6 ± 35.2 months after initial PMV. Patients in the repeated-PMV group were generally younger than those in the MVR group (42 ± 11 vs 50 ± 10 years, p = 0.001) and had a lower incidence of atrial fibrillation (29% vs 55%, p = 0.02). Pre- and postprocedural echocardiographic parameters are listed in Table 2. There was a significant increase in

Discussion

The present study compares MVR with repeated PMV in patients with mitral restenosis after previous PMV for whom long-term follow-up >10 years could be analyzed. Data show that MVR is associated with better long-term event-free survival and remains superior to repeated PMV for up to 15 years after surgery. These data suggest that MVR may be the preferred mode of therapy for patients who are expected to benefit during a long period. The strength of this study is the availability of data for

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Cited by (27)

Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement vs Percutaneous Mitral Valvuloplasty
2024, Canadian Journal of Cardiology
This study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm²).
From the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm² < MVA ≤ 1.5 cm² and MVA ≤ 1.0 cm², respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention.
Among 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012).
PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.
La présente étude visait à comparer les issues cliniques liées à la valvuloplastie mitrale percutanée (VMP) à celles du remplacement de la valve mitrale (RVM) pour corriger la sténose mitrale (SM) sévère, selon les critères les plus récents (surface valvulaire mitrale [SVM] ≤ 1,5 cm²).
À partir des 3140 patients inscrits au registre multicentrique Mitral Stenosis With Rheumatic Etiology (MASTER), nous avons inclus dans notre analyse les patients atteints d'une SM sévère ayant subi une VMP ou un RVM entre janvier 2000 et décembre 2021, à l’exclusion de ceux ayant auparavant subi une intervention ou une chirurgie valvulaire, qui étaient atteints d’une ou de plusieurs autres dysfonctions valvulaires ou qui présentaient une thrombose de l’atrium ou de l’auricule gauche. La SM modérée à sévère était définie comme une SVM > 1,0 cm² et ≤ 1,5 cm², alors que la SM très sévère était définie comme une SVM ≤ 1,0 cm². Le critère d’évaluation principal composite comprenait le décès d’origine cardiovasculaire (CV) et l’hospitalisation pour insuffisance cardiaque. Le critère d’évaluation secondaire composite comprenait les éléments du critère principal et la réintervention.
Parmi les 442 patients de l’analyse (âge moyen de 56,5 ± 11,9 ans, dont 77,1 % de femmes), les personnes dans le groupe ayant subi une VMP (n = 260) étaient plus âgées, présentaient plus de troubles concomitants et avaient des valeurs plus élevées pour le score échographique, la taille des cavités cardiaques gauches et la pression ventriculaire systolique droite que les personnes du groupe ayant subi un RVM (n = 182). Au cours d’un suivi d’une durée moyenne de 6,9 ± 5,2 ans, l’analyse avec appariement et pondération selon la probabilité inverse n’a montré aucune différence entre les groupes pour le critère principal d’évaluation, mais la fréquence du critère d’évaluation secondaire était plus faible dans le groupe ayant subi un RVM (p = 0,010). L’analyse par sous-groupes des patients présentant une SM modérée à sévère ou très sévère n’a révélé aucune différence entre les groupes pour le critère d’évaluation principal. Chez les patients atteints d’une SM modérée à sévère, le groupe ayant subi un RVM a obtenu des résultats plus favorables pour le critère d’évaluation secondaire (p = 0,012).
Le type d’intervention (VMP ou RVM) n’exerçait pas d’influence sur la mortalité d’origine CV chez les patients atteints d’une SM modérée à sévère ou très sévère. Toutefois, en raison du taux de réintervention précoce plus élevé dans le groupe de patients atteints d’une SM modérée à sévère ayant subi une VMP, il semble que le RVM soit préférable en l’absence d’une morphologie pour laquelle la VMP est manifestement adaptée.
The 40th Anniversary of Percutaneous Balloon Valvuloplasty for Mitral Stenosis: Current Status
2022, Structural Heart
Citation Excerpt :
This in turn may contribute to persistent atrial fibrillation and restenosis after PBMV. Overall, the literature is equivocal on whether PBMV or surgery has superior outcomes in patients with restenosis62,63; in general, event-free survival is lower with the former, driven by higher need for reintervention, but in the setting of favorable valve anatomy, PBMV remains reasonable as the procedure of choice. Concomitant valve disease, whether aortic or tricuspid, has special implications.
Percutaneous balloon mitral valvuloplasty (PBMV), once the most complex of percutaneous cardiac procedures and essentially the first adult structural heart intervention, set the stage for a host of new technologies. Randomized studies comparing PBMV to surgery were the first to provide a high-level evidence base in structural heart. The devices used have changed little in 40 years, but the advent of improved imaging and the expertise gained in interventional cardiology has provided some additional procedural safety. However, with the decline in rheumatic heart disease, PBMV is being performed in fewer patients in industrialized nations; in turn, these patients have more comorbidities, less favorable anatomy, and thus a higher rate of procedure-related complications. There remain relatively few experienced operators, and the procedure is distinct enough from the rest of the structural heart intervention world that it has its own steep learning curve. This article reviews the use of PBMV in a variety of clinical settings, the influence of anatomic and physiologic factors on outcomes, the changes in the guidelines, and alternative approaches. PBMV remains the procedure of choice in patients with mitral stenosis with ideal anatomy and a useful tool in patients with less than ideal anatomy who are poor surgical candidates. In the 40 years since its first performance, PBMV has revolutionized the care of mitral stenosis patients in developing countries and remains an important option for suitable patients in industrialized nations.
Mitral Stenosis: Patient Selection, Hemodynamic Results, Complications, and Long-Term Outcome with Balloon Mitral Commissurotomy
2016, Practice of Clinical Echocardiography
Immediate results of redo percutaneous mitral valvuloplasty
2013, Annales de Cardiologie et d'Angeiologie
La dilatation mitrale percutanée (DMPC) est devenue le traitement de choix du rétrécissement mitral et a prouvé son efficacité en cas de resténose mitrale après commissurotomie chirurgicale. Cependant, cette technique, coûteuse, n’est pas dénuée de complication et sa réussite n’est pas garantie. Les indications d’une tentative de redilatation mitrale percutanée (re-DMPC) ne sont pas bien établies. D’où l’idée d’étudier les résultats immédiats de la re-DMPC.
Le but de ce travail est d’évaluer les résultats immédiats de la re-DMPC chez des patients présentant une resténose mitrale et d’analyser les différents éléments cliniques et paracliniques permettant de déterminer les facteurs prédictifs de succès de la re-DMPC afin de mieux sélectionner les candidats à une nouvelle tentative de DMPC.
Étude rétrospective à partir d’une série de 40 procédures de re-DMPC par ballon d’Inoué succédant à une procédure antérieure initialement réussie, colligées dans le service de cardiologie de l’hôpital Habib Thameur de Tunis entre 1996 et 2011 chez qui nous avons recensé les données des examens cliniques et paracliniques.
L’âge moyen de nos patients était de 43 ± 11 ans [23 ; 63]. De la population, 87,5 % étaient de sexe féminin (cinq hommes et 35 femmes). Le délai moyen entre deux procédures était de 8 ± 4 ans [1 ; 15]. Le succès procédural immédiat défini par une surface mitrale supérieure ou égale à 1,5 cm² et une fuite mitrale inférieure ou égale à grade 2 a été obtenu chez 31 patients (77,5 %). Une insuffisance mitrale (IM) sévère a été observée chez trois patients (7,5 %). Un accident vasculaire cérébral ischémique est survenu chez un patient (2,5 %). Aucun cas de décès ni de tamponnade n’a été noté. Le stade III ou IV de NYHA, une IM pré-procédurale, une hypertension artérielle pulmonaire et un score global de Padial supérieur à 10 ont été retenus comme facteurs prédictifs d’échec. Plus le score global de Wilkins est élevé (> 8), plus il est prédictif d’échec. Les deux composantes du score de Wilkins : la mobilité valvulaire et l’appareil sous-valvulaire (ASV) ainsi que le paramètre remaniement de l’ASV du score de Padial considérés séparément sont également prédictifs d’échec. Seul une surface auriculaire gauche inférieure ou égale à 25 cm² était liée à un risque élevé d’IM sévère.
La redilatation mitrale percutanée est une alternative thérapeutique à la chirurgie qui est efficace et promettant des résultats immédiats intéressants. L’analyse des paramètres cliniques et surtout échographiques aident à prédire le succès du geste, ce qui permettra une meilleure sélection des candidats à la re-DMPC.
Percutaneous mitral valvuloplasty (PMV) has emerged as the procedure of choice in treatment of mitral stenosis and has proved effectiveness in cases of mitral restenosis after surgical commissurotomy. However, this technique is costly, is not devoid of complication and success is not guaranteed. Indications of an attempted redo percutaneous mitral valvuloplasty (redo-PMV) are not well established. Hence the idea to study the immediate results of (re-PMV).
The purpose of this study is to evaluate the immediate results of the re-PMV in patients with mitral restenosis and analyze the different clinical and laboratory findings to determine predictors of success of re-PMV to better selection of candidates for a new attempt PMV.
Retrospective study from a series of 40 procedures of re-PMV with the Inoue balloon succeeding a successful initial procedure, collected in the cardiology department of Habib Thameur hospital of Tunis between 1996 and 2011, in which we identified the data of clinical and paraclinical examinations.
The mean age of patients was 43 ± 11 years [23; 63]. Of the population, 87.5% were female (five men and 35 women). The average time between the two procedures was 8 ± 4 years [1; 15]. The immediate procedural success defined by a mitral valve area greater or equal to 1.5 cm² and a grade less than or equal to 2 mitral regurgitation was obtained in 31 patients (77.5%). A severe mitral regurgitation (MR) was observed in three patients (7.5%). A cerebrovascular stroke occurred in one patient (2.5%). No death or cardiac tamponade were noted. Class III or IV of NYHA, a pre-procedural MR, pulmonary hypertension and an overall score of Padial greater than 10 were retained as predictors of failure. More the overall score of Wilkins is high (> 8), more it is predictive of failure. The two components of the Wilkins score: valvular mobility and subvalvular apparatus (SVA) and the parameter of the redesign of the SVA score of Padial considered separately are also predictive of failure. Only a left atrial area less than or equal to 25 cm² was linked to high risk of severe MR.
Redo percutaneous mitral valvuloplasty is a therapeutic alternative to surgery that is effective and promising interesting immediate results. Analysis of clinical and mainly echographic parameters is useful for predicting the success of the gesture, which will allow a better selection of candidates for re-PMV.
Guidelines on the Management of Valvular Heart disease (Version 2012)
2013, Revista Espanola de Cardiologia
Rheumatic Mitral Valve Disease
2009, Valvular Heart Disease: A Companion to Braunwalds Heart Disease Expert Consult - Online and Print

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Valvular heart diseaseComparison of Long-Term Outcome After Mitral Valve Replacement or Repeated Balloon Mitral Valvotomy in Patients With Restenosis After Previous Balloon Valvotomy

Section snippets

Patients

Pre- and postprocedural characteristics of patients

Discussion

J Thorac Cardiovasc Surg

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Valvular heart disease
Comparison of Long-Term Outcome After Mitral Valve Replacement or Repeated Balloon Mitral Valvotomy in Patients With Restenosis After Previous Balloon Valvotomy