Independent clinical and echocardiographic predictors of restenosis after percutaneous mitral balloon commissurotomy followed for 24 years

BACKGROUND: Mitral valve stenosis (MVS) is one of the most common structural heart diseases in developing countries, primarily due to rheumatic disease. Percutaneous mitral balloon valvuloplasty (PMBV) has been, since its introduction in 1984, the preferred option of treatment for such disease. However, restenosis is presented with an approximate incidence of 20%. Echocardiographic scoring of the mitral apparatus has been the main tool used to indicate and foresee the possible result of the procedure. The objective of this study was to enlight risk factors of mitral valvular restenosis in a significant number of patients submitted to percutaneous mitral balloon commissurotomy for the treatment of mitral stenosis (MS), particularly when secondary to rheumatic heart disease. METHODS: This study reports the vast experience of a single center high volume tertiary institution where 1.794 consecutive patients were treated with PMBC between 1987 and 2011. The primary endpoint was to determine the independent predictors of this untoward event, defined as loss of over 50% of the original increase in maximum valve area (MVA) or MVA< 1.5 cm2. RESULTS: Mitral valve restenosis was observed in 26% of the cases (n=483). Mean population age was 36 years old, with most patients being female (87%). Mean follow up duration was 4.8 years. At multivariate analysis independent pre-procedural predictors of restenosis were: left atrial diameter (HR: 1.03, 95% ci: 1.01-1.04, p<0.01), pre procedure maximum gradient (HR: 1.01, 95% ci: 1.00-1.03, p=0.02) and higher wilkins scores (HR: 1.37, 95% ci: 1.13-1.66, p<0.01). CONCLUSION: In the very long term follow-up, mitral valve restenosis was observed in a quarter of the population undergoing PMBC. Preprocedure echocardiographic findings, including left atrial diameter, maximum valve gradient and high Wilkins scores were found to be the only independent predictors of this deleterious event.

Long-term follow-up in patients with rheumatic mitral stenosis and severe pulmonary artery hypertension submitted to percutaneous mitral balloon commissurotomy

BACKGROUND: Percutaneous balloon mitral commissurotomy (PMBC) is an attractive therapeutic approach in patients with mitral stenosis. The aim of this study was to assess the immediate and long-term clinical, echocardiographic and haemodynamic outcomes of PMBC in patients with severe pulmonary hypertension (PH). METHODS: Among all procedures (in more than two decades of experience), PMBC was performed from 1987 until 2011 at a single-center in 147 patients who had significant PH defined as baseline pulmonary artery mean pressure (PAMP) (systolic pulmonary pressure > 75 mmHg). All-cause mortality, need for mitral valve replacement (MVR) or new PMBC, and valve restenosis were evaluated during follow-up yearly. RESULTS: Mean age was 33.8 ± 12.8 years and 83.6% (123 patients) were women. Primary success was achieved in 89.8% of the patients (132 patients). Mitral valve area (MVA) increased from 0.83 ± 0.17 cm2 to 2.03± 0.35 cm2 (p<0.001), and at 20-years, mitral valve area was 1.46± 0.34 cm2 (p=0.235). Systolic pulmonary artery pressure decreased from 87.0 ± 6.0 mmHg to 60.0 ± 0.9 mmHg (p<0.001) The rates of all-cause mortality, need for MVR, new PMV, and valve restenosis were 0.67%, 20.0%, 8.78% and 30.4%, respectively, in long-term follow- up (mean 15.6 ± 4.9 years). CONCLUSIONS: PMBC is a safe and effective technique for the treatment of patients with mitral stenosis and PH. A significant decrease in pulmonary pressure was observed after commissurotomy. Although there was a gradual decrease of MVA at long-term follow-up, most patients remained asymptomatic and without major adverse events.

Immediate and long-term predictor score of success after percutaneous mitral balloon commissurotomy

BACKGROUND: Percutaneous mitral balloon commissurotomy (PMBC) remains the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis (MS) and suitable anatomy. The objective of this study was to propose a new score for the prediction of immediate and late success. METHODS. This is a retrospective, single-center, single-arm registry encompassing all 1915 consecutive patients with rheumatic mitral stenosis recruited and referred to PMBC between August 3rd 1987 and July 19th 2010. All data were previously collected and recorded in a dataset. Clinical status was determined according to the New York Heart Association (NYHA) classification. Long-term outcome was a composite of incidence of major adverse cardiac events (cardiovascular death, new PMBC or mitral valve repair surgery) up to 24 years of clinical follow-up (from 1988 until December 3rd, 2011), including cardiovascular death, need for new PMBC, or mitral valve replacement surgery. RESULTS. Mean patient age was 36.8 ± 12.9 years, most (86.4%) were female, and Wilkins score was between 9-11 in 49.1% of patients. In the multivariate analysis, the predictors of immediate success were age (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-0.99; p=0.01), left atrium size (OR, 0.96; 95% CI, 0.93-0.99; p=0.01), mean pre-procedure mitral gradient (OR, 0.93; 95% CI, 0.89-0.96; p<0.001), intermediate Wilkins score 9-11 (OR, 0.62; 95% CI, 0.40- 0.94; p=0.02), and high Wilkins score ≥12 (OR, 0.35; 95% CI, 0.16-0.76; p<0.01). For prediction of late events, age (hazard ratio [HR], 0.98; 95% CI, 0.97-0.98; p<0.001), New York Heart Association class III-IV (HR, 1.50; 95% CI, 1.18-1.92; p<0.001), left atrium size (HR, 1.02; 95% CI, 1.02-0.04; p<0.01), and high Wilkins score ≥12 (HR, 2.02; 95% CI, 1.30-3.15; p<0.01) were significant. Two nomograms were developed using significant predictors from the model (one for immediate results and another for long-term results). CONCLUSIONS: In this large population, not only the Wilkins score, but also clinical and hemodynamic features, seem to be relevant in predicting immediate and late success for patients with rheumatic MS who underwent PMBC.

Independent clinical and echocardiographic predictors of restenosis after percutaneous mitral balloon commissurotomy followed for 24 years

INTRODUCTION: Mitral valve stenosis (MVS) is one of the most common structural heart diseases in developing countries, primarily due to rheumatic disease. Percutaneous mitral balloon valvuloplasty (PMBV) has been, since its introduction in 1984, the preferred option of treatment for such disease. However, restenosis is presented with an approximate incidence of 20%. Echocardiographic scoring of the mitral apparatus has been the main tool used to indicate and foresee the possible result of the procedure. OBJECTIVE: The objective of this study was to enlight risk factors of mitral valvular restenosis in a significant number of patients submitted to percutaneous mitral balloon commissurotomy for the treatment of mitral stenosis (MS), particularly when secondary to rheumatic heart disease. METHODS: This study reports the vast experience of a single center high volume tertiary institution where 1.794 consecutive patients were treated with PMBC between 1987 and 2011. The primary endpoint was to determine the independent predictors of this untoward event, defined as loss of over 50% of the original increase in maximum valve area (MVA) or MVA < 1.5 cm2. RESULTS: Mitral valve restenosis was observed in 26% of the cases (n = 483). Mean population age was 36 years old, with most patients being female (87%). Mean follow up duration was 4.8 years. At multivariate analysis independent pre-procedural predictors of restenosis were: left atrial diameter (HR: 1.03, 95% ci: 1.01-1.04, p < 0.01), pre procedure maximum gradient (HR: 1.01, 95% ci: 1.00-1.03, p = 0.02) and higher wilkins scores (HR: 1.37, 95% ci: 1.13-1.66, p < 0.01). CONCLUSION: In the very long term follow-up, mitral valve restenosis was observed in a quarter of the population undergoing PMBC. Preprocedure echocardiographic findings, including left atrial diameter, maximum valve gradient and high Wilkins scores were found to be the only independent predictors of this deleterious event.

Long-term follow-up in patients with rheumatic mitral stenosis and severe pulmonary artery hypertension submitted to percutaneous mitral balloon commissurotomy

INTRODUCTION: Percutaneous balloon mitral commissurotomy (PMBC) is an attractive therapeutic approach in patients with mitral stenosis. OBJECTIVE: The aim of this study was to assess the immediate and long-term clinical, echocardiographic and haemodynamic outcomes of PMBC in patients with severe pulmonary hypertension (PH). METHODS: Among all procedures (in more than two decades of experience), PMBC was performed from 1987 until 2011 at a single-center in 147 patients who had significant PH defined as baseline pulmonary artery mean pressure (PAMP) (systolic pulmonary pressure > 75 mmHg). All-cause mortality, need for mitral valve replacement (MVR) or new PMBC, and valve restenosis were evaluated during follow-up yearly. RESULTS: Mean age was 33.8 ± 12.8 years and 83.6% (123 patients) were women. Primary success was achieved in 89.8% of the patients (132 patients). Mitral valve area (MVA) increased from 0.83 ± 0.17 cm2 to 2.03 ± 0.35 cm2 (p < 0.001), and at 20-years, mitral valve area was 1.46 ± 0.34 cm2 (p = 0.235). Systolic pulmonary artery pressure decreased from 87.0 ± 6.0 mmHg to 60.0 ± 0.9 mmHg (p < 0.0001). The rates of all-cause mortality, need for MVR, new PMV, and valve restenosis were 0.67%, 20.0%, 8.78% and 30.4%, respectively, in long-term follow- up (mean 15.6 ± 4.9 years). CONCLUSIONS: PMBC is a safe and effective technique for the treatment of patients with mitral stenosis and PH. A significant decrease in pulmonary pressure was observed after commissurotomy. Although there was a gradual decrease of MVA at long-term follow-up, most patients remained asymptomatic and without major adverse events.

Novel prognostic score for immediate and late success after percutaneous mitral balloon commissurotomy in patients with mitral stenosis

INTRODUCTION: Percutaneous mitral balloon commissurotomy (PMBC) remains the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis (MS) and suitable anatomy. OBJECTIVE: The objective of this study was to propose a new score for the prediction of immediate and late success. METHODS: This is a retrospective, single-center, single-arm registry encompassing all 1915 consecutive patients with rheumatic mitral stenosis recruited and referred to PMBC between August 3rd 1987 and July 19th 2010. All data were previously collected and recorded in a dataset. Clinical status was determined according to the New York Heart Association (NYHA) classification. Long-term outcome was a composite of incidence of major adverse cardiac events (cardiovascular death, new PMBC or mitral valve repair surgery) up to 24 years of clinical follow-up (from 1988 until December 3rd, 2011), including cardiovascular death, need for new PMBC, or mitral valve replacement surgery. RESULTS: Mean patient age was 36.8 ± 12.9 years, most (86.4%) were female, and Wilkins score was between 9-11 in 49.1% of patients. In the multivariate analysis, the predictors of immediate success were age (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-0.99; p = 0.01), left atrium size (OR, 0.96; 95% CI, 0.93-0.99; p = 0.01), mean pre-procedure mitral gradient (OR, 0.93; 95% CI, 0.89-0.96; p < 0.001), intermediate Wilkins score 9-11 (OR, 0.62; 95% CI, 0.40-0.94; p = 0.02), and high Wilkins score ≥12 (OR, 0.35; 95% CI, 0.16-0.76; p < 0.01). For prediction of late events, age (hazard ratio [HR], 0.98; 95% CI, 0.97-0.98; p < 0.001), New York Heart Association class III-IV (HR, 1.50; 95% CI, 1.18-1.92; p < 0.001), left atrium size (HR, 1.02; 95% CI, 1.02-0.04; p < 0.01), and high Wilkins score ≥12 (HR, 2.02; 95% CI, 1.30-3.15; p < 0.01) were significant. Two nomograms were developed using significant predictors from the model (one for immediate results and another for long-term results). CONCLUSIONS: In this large population, not only the Wilkins score, but also clinical and hemodynamic features, seem to be relevant in predicting immediate and late success for patients with rheumatic MS who underwent PMBC.

Preditores de sucesso imediato e seguimento de muito longo prazo após valvoplastia mitral percutânea com balão em pacientes com estenose mitral reumática / Predictors of immediate success and very long-term follow-up after percutaneous mitral balloon valvuloplasty in patients with rheumatic mitral stenosis

INTRODUÇÃO: A valvoplastia mitral percutânea por balão (VMP) ainda permanece como tratamento preferencial para pacientes com estenose mitral reumática sintomática grave e com anatomia favorável. Este estudo tem o objetivo de analisar os resultados a longo prazo após VMP. MÉTODOS: Trata-se de uma análise retrospectiva unicêntrica de todos os 1.582 pacientes com estenose mitral grave que foram submetidos VMP com sucesso entre 1987 e 2011. O desfecho primário foi o combinado de mortalidade por todas as causas, necessidade de cirurgia valvar mitral ou necessidade de repetição de VMP até o seguimento de 23 anos. RESULTADOS: Entre os 1.582 pacientes consecutivos submetidos a VMP, o sucesso imediato foi alcançado em 90,9% (1.438 pacientes). Os preditores independentes de sucesso agudo incluíram tamanho do átrio esquerdo (OR: 0,96; IC 95%: 0,93-0,99; p = 0,045), escore de Wilkins ≤ 8 (OR: 1,66; IC95%: 0,48-0,93; p = 0,02) e idade (OR: 0,97, IC 95%: 0,96-0,99, p = 0,006). A teste c-estatístico calculada para prever o sucesso foi de 0,68. Não houve diferença significativa com relação às taxas de sucesso ao longo dos anos. Quando dividida em tercis com base na experiência do operador, uma maior taxa de sucesso foi observada no segundo tercil quando comparado com os outros dois grupos (32,0% vs. 46,5% vs. 21,5%, p = 0,046). O seguimento a longo prazo (média de 15,6 ± 4,9 anos) foi obtido em 79,1% dos casos de sucesso. A incidência do desfecho primário foi de 19,1% (IC 95%: 17,0-21,1). A mortalidade global, necessidade de cirurgia valvar mitral ou a repetição de VMP foi de 0,6% (IC 95%: 0,3-1,2), 8,3% (IC 95%: 7,0-9,9) e 10,0% (IC 95%: 8,5-11,7), respectivamente. Um total de 93,1% de todos os 1.252 pacientes após VMP com sucesso teve uma melhora na classe funcional NYHA após o primeiro ano do procedimento. Destes, apenas 13,0% desenvolveram a NYHA III-IV durante todo o período de acompanhamento (23 anos)...(AU)

Artéria Coronária Direita Originada da Artéria Descendente Anterior: Uma Rara Anomalia Coronariana / Anomalous Origin of the Right Coronary Artery from the Mid-Left Anterior Descending Artery: A Rare Coronary Anomaly

A artéria coronária única é anomalia rara, que pode estar associada à isquemia miocárdica e morte súbita. Apresentamos o caso de uma mulher jovem, com quadro de angina atípica, cujo cateterismo revelou artéria coronária direita que se originava do terço médio da artéria descendente anterior, uma variante da artéria coronária única.

A single coronary artery is a rare anomaly that may be associated with myocardial ischemia and sudden death. We present a case of a young woman with atypical angina whose coronary angiography revealed a right coronary artery originating from the mid left anterior descending artery, a variant of the single coronary artery.

Dados ecocardiográficos prognósticos na estenose aórtica importante assintomática / Echocardiographic prognostic data in asymptomatic severe aortic stenosis

A estenose aórtica é a valvopatia mais frequente nos países desenvolvidos e uma das principais doenças valvares nos países em desenvolvimento. trata-se de um problema clínico de importância socioeconômica crescente, uma vez que a população mundial tem se tornado proporcinalmente mais idosa, dada a maior expectativa de vida. Na história natural da doença, o surgimento dos sintomas se correlaciona com piora significativa no prognóstico e a substituição valvar aórtica é o único procedimento capaz de alterar a sobrevida desses pacientes...