Mechanisms of increase in mitral valve area and influence of anatomic features in double-balloon, catheter balloon valvuloplasty in adults with rheumatic mitral stenosis: a Doppler and two-dimensional echocardiographic study.

Abstract

To study the mechanism of increase in the mitral valve area (MVA) and the anatomic features of the mitral valve that may affect the results of catheter double-balloon valvuloplasty (CBV) in adult patients with mitral stenosis, Doppler and two-dimensional echocardiography was performed in 12 patients before and immediately after CBV. Immediately after CBV, there was an increase in the transverse diameter of the mitral valve orifice from 18 + 1.6 to 25 + 2.8 mm (mean -+ SD, p < .001). The anterior angles at the commissure increased from 33 ± 6 to 57 ± 20 degrees (p < .05) and the posterior angles from 36 ± 9 to 54 + 14 degrees (p < .05). The MVA was greater after CBV in patients with pliable mitral valves (2.6 0.7 cm2) compared with those with rigid mitral valves (1.9 ± 0.8 cm2; p = .08). After CBV, MVA was smaller in patients with calcification (2.1 ± 0.2 cm2) compared with those without (2.7 ± 0.5 cm2; p -. 10) and in those with subvalvular disease (2.0 ± 0.6 cm2) compared with those without (2.9 ± 0.9 cm2; p = .03). The MVA by Doppler ultrasound before CBV (1.0 ± 0.2 cm2) correlated well with MVA by cardiac catheterization (1.0 ± 0.3 cm2; r = .8, SEE = 0.2 cm2). After CBV, the correlation of MVA by Doppler ultrasound (2.0 + 0.5 cm2) with MVA by cardiac catheterization (2.4 ± 0.8 cm2) was poor (r = .3, SEE = 0.44 cm2). Doppler studies showed that new mitral regurgitation was produced in four patients (mild in three and moderate in one) and an increase of mitral regurgitation was produced in one patient. We conclude that (1) the increase in MVA by double-balloon CBV occurred along the natural planes of the commissures resulting in increased commissural angle opening; (2) severe calcification of the commissures with rigid valve leaflets was associated with the least increase in mitral valve area after CBV; calcification of the commissures, rigid valve leaflets, and subvalvular disease were associated with smaller increases in MVA, (3) new or an increase in mitral regurgitation occurred in over a third of the patients by Doppler, but in most patients the change was small, and (4) Doppler ultrasound provided a reasonable estimate of MVA before CBV but was of limited value in the estimation of the MVA immediately after CBV.

Influence of mitral valve morphology on double-balloon catheter balloon valvuloplasty in patients with mitral stenosis. Analysis of factors predicting immediate and 3-month results.

“…8 Mitral valve mobility may be affected by fusion at the commissures, leaflet thickening or calcification, and subvalvular disease. Early experience with surgical mitral commissurotomy showed that heavy calcification that produced an immobile valve resulted in little improvement in the mitral valve gradient.…”

Effect of percutaneous mitral balloon valvuloplasty on left atrial appendage function: Transesophageal echo study

“…9 Mitral valve area (MVA) is increased during balloon dilatation by commissural splitting. 10 Transoesophageal echocardiography (TEE) allows semi-invasive, highly accurate imaging of the functional efficiency of LAA by LAA Doppler and Doppler tissue imaging (DTI) flow profile 7 MS causes decreased LAA Doppler and DTI velocities in patients even with sinus rhythm. 4,11 Very few studies in the literature have evaluated the impact of PBMV on LAA function so far.…”

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary

“…Other factors include age, NYHA functional class, stenosis severity, LV end-diastolic pressure, cardiac output, and pulmonary artery wedge pressure (269,271,272,276). The underlying MV morphology is the factor of greatest importance in determining outcome (243)(244)(245)(246)269,272,273,276,277,(285)(286)(287)(288), and immediate postvalvotomy hemodynamics are predictive of long-term clinical outcome (271,273,276). Patients with valvular calcification, thickened fibrotic leaflets with decreased mobility, and subvalvular fusion have a higher incidence of acute complications and a higher rate of recurrent stenosis on follow-up.…”