Journal of the Saudi Heart Association (2010) 22, 125–132
King Saud University
Journal of the Saudi Heart Association www.ksu.edu.sa www.sha.org.sa www.sciencedirect.com
REVIEW ARTICLE
Mitral balloon valvuloplasty Mohamed Eid Fawzy
*
October 6 University Medical School, Cairo, Egypt Received 7 April 2010; accepted 28 April 2010 Available online 11 May 2010
KEYWORD Mitral balloon valvuloplasty
Abstract Percutaneous mitral balloon valvuloplasty (MBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, MBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of MBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0– 0.5%), cerebral accident (1–2%), mitral regurgitation (MR) requiring surgery (1.6–3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with MBV and surgical commissurotomy. Restenosis after MBV ranges from 4% to 70% depending on the patient selection, valve morphology, and duration of follow-up. Restenosis was encountered in 31% of the author’s series at mean follow-up 9 ± 5.2 years (range 1.5–19 years) and the 10, 15, and 19 years restenosis-free survival rates were (78 ± 2%) (52 ± 3%) and (26 ± 4%), respectively, and were significantly higher for patients with favorable mitral morphology (MES 6 8) at 88 ± 2%, 67 ± 4% and 40 ± 6%), respectively (P < 0.0001). The 10, 15, and 19 years event-free survival rates were (88 ± 2%, 60 ± 4% and 28 ± 7%, respectively, and were significantly higher for patients with favorable mitral morphology (92 ± 2%, 70 ± 4% and 42 ± 7%, respectively (P < 0.0001). The effect of MBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of MBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed. ª 2010 King Saud University. All rights reserved.
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[email protected] 1016-7315 ª 2010 King Saud University. All rights reserved. Peerreview under responsibility of King Saud University. doi:10.1016/j.jsha.2010.04.013
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Contents 1.
2.
3.
4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2. Echocardiographic evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3. Immediate hemodynamic results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4. Complications of balloon mitral valvuloplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Long-term follow-up and predictors of restenosis and event-free survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Mitral restenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Event-free survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Regression of severe pulmonary hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Regression of significant tricuspid regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Effect of mitral valvuloplasty on left ventricular function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6. Effect of MBV on left atrial size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7. Effect of MBV on the incidence of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mitral balloon valvuloplasty in special circumstances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Mitral balloon valvuloplasty for restenosis after previous surgical or balloon valvuloplasty . . . . . . . . . . . . . . . 3.2. Mitral balloon valvuloplasty during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Mitral balloon valvuloplasty in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. Comparison of mitral balloon valvuloplasty with surgical commissurotomy . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
1.1. Techniques
Mitral stenosis is a progressive disease that leads to heart failure and is finally fatal unless mechanical intervention enlarges the mitral valve orifice to permit adequate cardiac output at a tolerable left atrial pressure. Starting over 50 years ago a variety of surgical techniques were developed; first closed commissurotomy followed by open commissurotomy after the introduction of the cardiopulmonary bypass (Harken et al., 1949; John et al., 1983). Mitral balloon valvuloplasty was introduced in 1984 by the Japanese surgeon Inoue, who developed the procedure as a logical extension of surgical closed commissurotomy (Inoue et al., 1984). Since then, balloon valvuloplasty has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis. The mechanism by which both procedures reduce stenosis is the same and involves mechanical dilatation of fused commissures (McKay et al., 1987). Several randomized trials reported similar hemodynamic results with balloon valvuloplasty and surgical commissurotomy. However, periprocedural complications in surgical patients were somewhat higher (Patel et al., 1991; Turi et al., 1991; Reyes et al., 1994; Arora et al., 1993; Farhat et al., 1998). Both forms of commissurotomy eliminate the risks common to prosthetic valves, which include primary valve failure, thromboembolism, and endocarditis. The purpose of this review is to summarize the immediate and long-term results up to 19 years of MBV, its complications, and elucidate the effect of MBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation. Also, the applications of MBV in specific clinical situations as in children, during pregnancy, and for restenosis following previous surgical or balloon commissurotomy, are discussed.
The transseptal technique is the most common technique used to perform MBV. The technique consists of advancing a catheter over the wire across the interatrial septum after transseptal puncture, enlarging the opening and advancing one large balloon (Inoue balloon) or two smaller balloons (double-balloon technique) across the mitral orifice and inflating them within the orifice. Although acute and short-term outcomes differ little between these two techniques (Abdullah et al., 1992; Park et al., 1993), complications such as death, left ventricular perforation, and stroke appear to be less common with the Inoue balloon. The multiple advantages of the Inoue balloon (Fawzy et al., 1996), include low profile of the device, the elimination of the stiff guide wire (minimizing the risk of LV perforation), easy maneuverability, and the stepwise dilation (gradual increase of balloon size on sequential inflations). 1.2. Echocardiographic evaluation Echocardiography is the mainstay of the noninvasive evaluation of mitral stenosis. The transthoracic echocardiography provides an evaluation of the valvular apparatus, mitral valve area (MVA), left atria dimension, and associated valve lesions. Doppler echo provides hemodynamic evaluation including mean mitral gradient, MVA, assessment of concomitant tricuspid regurgitation (TR) and estimation of pulmonary artery pressure. The morphologic evaluation of the mitral valve is semiquantilated using echocardiographic score (echo score). The scoring system evaluates leaflet thickening, mobility, calcification, and subvalvular involvement on a scale of 0–4, as described (Wilkins et al., 1988). The mitral valve morphology is considered favorable if the mitral echocardiographic score (MES) is 68. Transesophageal (TEE) echo should be performed
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before MBV for patients with atrial fibrillation or prior history of systemic embolism or very obese patient where the left atrium was not properly visualized. We do not recommend TEE as routine procedure before MBV (Fawzy et al., 2009).
surgery (0.9–2%), mitral regurgitation of some degree (15%), and atrial septal defect detected by dolor Doppler (20–23%) which, however, closes or decreases in size in most patients (Fawzy et al., 1996, in press; Ishikura et al., 1990).
1.3. Immediate hemodynamic results
2. Long-term follow-up and predictors of restenosis and event-free survival
The left atrial pressure, mean mitral gradient, and pulmonary artery systolic pressure decreased significantly after MBV with corresponding increase in MVA. In the National Heart, Lung Blood Institute Balloon Valvotomy Registry of 736 patients (Reid et al., 1992), the MVA by echocardiographic assessment was 1.09 ± 0.29 cm2 before the procedure and increased to 1.8 ± 0.15 cm2 after the procedure. In the author’s series, 547 consecutive patients (Fawzy et al., 2009) the echocardiographic MVA was 0.92 ± 0.17 cm2 before the procedure, and increased to 1.95 ± 0.29 cm2 after the procedure. A significant inverse relationship was found between the echo score and post-procedure MVA where mitral valve morphology was found to be a strong predictor of post-procedure mitral opening (Wilkins et al., 1988; Fawzy et al., 2007). However, good results could also be obtained in cases with relatively high echo score.
2.1. Mitral restenosis The restenosis rate after MBV has been reported as 39% at 7 years (Hernandez et al., 1999) and was lower (31%) at 19 years in our younger population (mean age 31.5 ± 11 years) (Fawzy et al., 2007, 2009; Ben Farhat et al., 2001) and was 20% in subgroup of patients with MES 6 8. The actuarial freedom from restenosis rates for this population were 78 ± 2% at 10 years, 52 ± 3% at 15 years, and 26 ± 5% at 19 years and were significantly higher for patients with optimal morphology (Fawzy et al., 2007) (echo score 68), namely 88 ± 2% at 10 years, 67 ± 4% at 15 years, 40 ± 6% at 19 years (Fig. 1). The predictors of being free from restenosis were a low echo score (P < 0.0001) and post-procedure MVA P 2.0 cm2 (Fawzy et al., 2007, 2009; Ben Farhat et al., 2001; Iung et al., 1999).
1.4. Complications of balloon mitral valvuloplasty 2.2. Event-free survival In general, MBV is a safe procedure with high success rate, particularly if the patients chosen have optimal valve morphology as determined by echo score. When the reported rates of complications of MBV are viewed in aggregate, complications appear to occur at approximately the following rates: mortality (0–0.5%), cerebrovascular accident (CVA) (0.5–2%), cardiac tamponade (0.7–1%), mitral regurgitation requiring
Iung et al. (1999) reported an event-free survival (survival with freedom from redo MBV, MVR, cardiac death, NYHA functional class III or IV) rate of 61% at 10 years in 528 patients with successful PMBV (mean age, 49 years). Palacios et al. (2002) (879 patients with successful MBV mean age, 55 years) reported a rate of 38% at 12 years for patients with echo score
Figure 1 Freedom from restenosis by Kaplan–Meier estimates for all patients and for patients with MES 6 8. Numbers at the bottom represent patients alive and uncensored at each year of follow-up.
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68 and 22% for patients with echo score >8. Event-free survival rates at 10, 15, and 19 years were 88%, 60%, and 28% respectively, in our relatively younger patients and were significantly higher for patients with MES 6 8 (92%, 70%, 42%, respectively; P < 0.0001). The predictors of event-free survival were low echo score and baseline A.F (P < 0.0001 and P = 0.014, respectively) (Fig. 2) (Fawzy et al., 2007, 2009). 2.3. Regression of severe pulmonary hypertension Pulmonary hypertension frequently complicates mitral stenosis and may significantly influence the clinical findings and prognosis of this condition. The increase in pulmonary arterial pressure is often out of proportion to the degree of left atrial hypertension, reflecting a major increase in pulmonary vascular resistance (Wood, 1954; Walston et al., 1973; Fawzy et al., 1996, 2004). To elucidate the effect of MBV on severe pulmonary hypertension, the author (Fawzy et al., 2004) studied 559 consecutive patients with severe MS undergoing successful MBV. Patients were allocated to three groups on the basis of their pulmonary artery stystolic pressure (PASP) at cardiac catheterization prior to MBV; group A (n = 345; 62%) had mild pulmonary hypertension (PASP < 50 mmHg); group B (n = 183; 33%) had moderate pulmonary hypertension (PASP 50–79 mmHg); and group C (n = 31; 5%) had severe pulmonary hypertension (PASP P 80 mmHg). Immediately following valvuloplasty, the PASP normalized in group A, in group B and C, pulmonary hypertension decrease slightly with further substantial regression occurred overtime (Fig. 3) (Fawzy et al., 1996, 2004; Dev and Shrivastava, 1991) and severe pulmonary hypertension normalized over 6–12 months in patients with successful PMBV and follow-up MVA P 2.0 cm2 (Fawzy et al., 1996, 2004; Dev and Shrivastava, 1991).
Figure 3 Mean pulmonary artery systolic pressure estimated by Doppler echocardiography for group A, B, C at baseline and at follow-up over 12 months.
2.4. Regression of significant tricuspid regurgitation Significant tricuspid valve regurgitation (TR) is a common finding in patients with severe MS and in the majority of cases, it is functional, resulting from right ventricular and tricuspid annular dilation caused by long standing pulmonary hypertension. Although earlier reports suggested that TR can resolve once the diseased mitral valve is replaced (Braunwald et al., 1967; Pluth and Ellis, 1968), the results of later studies are contradictory (Carpentier et al., 1974; Breyer et al., 1976). We and other investigators demonstrated regression of significant TR after successful MBV in relatively young patients (mean age
Figure 2 Kaplan–Meier event-free survival estimates (alive and free of redo MBV, MVR, NYHA III or IV) for all patients and for patients with MES 6 8. Numbers at the bottom represent patients alive and uncensored at each year of follow-up.
Mitral balloon valvuloplasty 25 ± 10 years) with severe MS and concomitant significant pulmonary hypertension (70 ± 22 mmHg) (Breyer et al., 1976; Hannoush et al., 2004; Skudicky et al., 1994; Song et al., 2003). On the other hand, Sagie et al. (1994) reported no regression of TR in relatively older patients (mean age 57 ± 15 years) with severe MS and mild pulmonary hypertension (46 ± 15 mmHg). We demonstrated that severe pulmonary hypertension is a strong predictor of regression of severe TR after MBV (Hannoush et al., 2004). 2.5. Effect of mitral valvuloplasty on left ventricular function In most cases of mitral stenosis, the left ventricular contractility is normal. However, in about one third of patients with mitral stenosis left ventricular systolic function is reduced. Preload reduction – caused by limited mitral inflow – and increased afterload – precipitated by reflex vasoconstriction secondary to decreased cardiac output, act in concert to reduce ejection performance (Gash et al., 1983; Fawzy et al., 1996). We have demonstrated normalization of impaired LV systolic function after successful MBV in patients with severe MS (Fawzy et al., 1996). 2.6. Effect of MBV on left atrial size Significant reduction of LA size following successful mitral Valvotomy was demonstrated by several investigators (Takarada et al., 1992; Rittoo et al., 1993; Chen et al., 1992; Stefadouros et al., 1999). To demonstrate the effect of MBV on left atrial size, 205 consecutive patients (mean age 31 ± 11 years) were studied by the author (Stefadouros et al., 1999). LA size at baseline and at mean follow-up of 31 ± 21 months after successful MBV (post-procedure MVA P 1.5 cm2, MR 6 214) were analyzed. LA anteroposterior dimension decreased in 87% of the patients (from 48.7 ± 7 mm to 42 ± 6.6 mm; P < 0.0001) whereas in 13%, it remained unchanged or even increased. Similarly, LA volume was decreased in 93.5% of patients (from 92 ± 29 cm3 to 61 ± 24 cm3; P < 0.0001) whereas in the remaining 6.5% of patients it remained unchanged or even increased. LA anteroposterior dimension returned to normal in 29.2% of patients in sinus rhythm and in none for the patients with AF. Multiple linear stepwise regression analysis was used to identify predictors of regression of LA size after MBV. The variables included in the analysis were gender, age, baseline anteroposterior LA dimension, baseline and post-procedure echo MVA, echo score, and baseline A.F. Only two of these variables (baseline anteroposterior LA dimension and baseline AF were shown to be predictors of regression of LA dimension (P < 0.001) (Stefadouros et al., 1999). 2.7. Effect of MBV on the incidence of atrial fibrillation We demonstrated favorable effect of MBV on the long-term incidence of chronic AF (8.9%) in patients with severe MS (Fawzy et al., 2006) in comparison with the historical controls (29%) of patients with severe MS and similar baseline characteristics who were not submitted to intervention (Diker et al., 1997). The predictors of AF were age, large LA > 40 mm, small MVA (61.5 cm2) at follow-up (Fawzy et al., 2006).
129 3. Mitral balloon valvuloplasty in special circumstances 3.1. Mitral balloon valvuloplasty for restenosis after previous surgical or balloon valvuloplasty The outcome of MBV for mitral restenosis after surgical or balloon commissurotomy has been addressed by several investigators (Medina et al., 1990; Serra et al., 1993; Jang et al., 1995; Lau et al., 1996; Iung et al., 2000a,b; Fawzy et al., 2005). In a series studied by the author comparing immediate and long-term results of MBV in patients undergoing MBV as initial procedure (524 patients) versus those undergoing repeated MBV for restenosis (56 patients) (Fawzy et al., 2005) no death or technical failure were encountered in either group, and mitral regurgitation >2/4 occurred in 2% of the patients in both groups. Good immediate results (defined as post-procedure MVA P 1.5 cm2 and MR < 2/4) were obtained in 93% of patients undergoing MBV for restenosis vs. 96% in those with de novo MS (P = 0.4). Actuarial freedom from restenosis rates at 10 years were 58% vs. 68% in de novo MS (P = 0.18). Ten years event-free survival rates (survival with freedom from MVR, reintervention, cardiac death, functional class III or IV) were 54% vs. 80% for de novo MS. The predictors of event-free survival were age, echo, score, and baseline atrial fibrillation (P = 0.002, P < 0.0001, P = 0.01, respectively). We concluded that MBV is safe and provides good immediate results in patients with restenosis. Long-term results were inferior compared to de novo mitral stenosis but still satisfactory, since more than half of the patients remained improved at 10 years enabling the operation or reoperation to be deferred (Fawzy et al., 2005). 3.2. Mitral balloon valvuloplasty during pregnancy Pregnancy induces hemodynamic disturbances, mainly by increasing the intravascular volume by 30–50% over nonpregnant levels, the process commencing from the 6th week onwards and reaching a plateau towards the third trimester. This hemodynamic burden, in conjunction with the physiological increase of heart rate in pregnancy, results in an increase in transmitral gradient and left atrial pressure which may lead to acute pulmonary edema even in patients with moderate mitral stenosis (Szekely et al., 1973; Elkayam and Bitar, 2005). Although patients with cardiac disease are generally expected to experience a symptomatic increase by one NYHA class during pregnancy, this functional assessment may at times be deceptive because some patients either over- or under-estimate their symptoms, or limit their physical activity during pregnancy. However, when clinical assessment is complemented by accurate echocardiographic evaluation, the pregnancy outcome in such patients is usually predictable. Thus, without intervention, the maternal mortality for patients with mitral stenosis who are in NYHA classes I and II is 0.4% and significantly higher (6.8%) for those in NYHA classes III and IV, particularly during labor and delivery (Szekely et al., 1973; Hameed et al., 2001; Silversides et al., 2003). Although both, surgical commissurotomy and mitral balloon valvuloplasty have been shown to yield similarly favorable immediate and long-term results, the maternal mortality associated with the former procedure has been reported to be between 1.7% and 3.1%, as compared with no mortality with mitral balloon
130 Valvuloplasty (Szekely et al., 1973; de Souza et al., 2001). Moreover, surgical commissurotomy is associated with significantly higher fetal mortality ranging from 5% to 33% (Elkayam and Bitar, 2005; de Souza et al., 2001) whereas only one fetal death has so far been reported complicating mitral balloon Valvuloplasty during pregnancy (Presbitero et al., 1996). MBV should be avoided if possible during the first trimester and should be performed by experienced operators with adequate abdominal and pelvic shielding with minimum radiation exposure (De Andrade et al., 2001). Exposure can be reduced by minimizing fluoroscopy time by using echocardiography and Doppler, instead to obtain information on cardiac function and degree of MR (Fawzy et al., 2001). The use of the Inoue balloon catheter seems to be preferred over a double-balloon technique, because it takes less time to perform thus subjects the fetus to less radiation (Fawzy et al., 2001). The author studied the immediate and long-term results of MBV in 23 pregnant patients using the Inoue balloon technique (Fawzy et al., 2001). The procedure was successful in all cases: the gradient fell from 15.7 ± 5.5 mmHg to 5 ± 1.6 mmHg and the MVA increased from 0.9 ± 0.2 cm2 to 2.0 ± 0.36 cm2. There were no maternal or fetal deaths and all patients delivered at full term by vaginal delivery. At follow-up (mean 5.1 ± 2.8 years range 1–9 years) of the 24 babies born alive (one pregnancy resulted in twins), one died subsequently at one week of age from sudden infant death syndrome and another died at 8 months of age from severe pneumonia. All the remaining 22 children had normal growth (Fawzy et al., 2001). 3.3. Mitral balloon valvuloplasty in children MBV in children appears to be safe and effective similar to adult patients (Fawzy et al., 2005). The author studied 30 children and followed them up to 13 years. The Inoue balloon technique was used in all. The procedure was successful
M.E. Fawzy (post-procedure MVA P 1.5 cm2, MR 6 2.4) in 28 patients (93%). The mitral mean gradient decreased from 16 ± 4.5 mmHg to 6 ± 3 mmHg and the MVA increased from 0.8 ± 0.14 cm2 to 2.0 ± 0.3 cm2. No death or systemic embolism was encountered, cardiac tamponade occurred in one patient and none of these patients develop severe MR. At longterm follow-up, there was no significant difference between children and adult patients in the incidence of restenosis and event-free survival (Fig. 4). The valve morphology rather tan the patient age was the main determinant of valve restenosis (Fawzy et al., 2005). 3.4. Comparison of mitral balloon valvuloplasty with surgical commissurotomy MBV is associated with less morbidity, shorter hospital stay, avoidance of the discomfort and other problems associated with thoracotomy, while the cost of surgery is at least twice that of balloon Valvotomy in the United States (Arora et al., 1993). The immediate results appear to be very similar to closed and open surgical commissurotomy (Patel et al., 1991; Turi et al., 1991; Reyes et al., 1994; Arora et al., 1993; Farhat et al., 1998) while operative mortality from closed commissurotomy was 2.97% (Commerford et al., 1982) was higher than that reported after PMBV (0.05%) Fawzy et al., in press; Reid et al., 1992. The only long-term, though relatively small (30 patients in each group), randomized study comparing surgical closed, open, or percutaneous commissurotomy, has been reported by Farahat et al. (1998) in young population with pliable, noncalcified valves. The 7-year results were better for open and percutaneous procedures than for closed commissurotomy as assessed by a higher event-free survival (93%, 90%, and 50%, respectively), better follow-up MVA (1.8, 1.8, and 1.3 cm2) and lower restenosis rate (6%, 6%, and 37%). In long-term surgical series (John et al., 1983; Commerford et al., 1982; Rihal et al., 1992). Hickey et al. (1991) reported
Figure 4 Freedom from restenosis by Kaplan–Meier estimates for group A (children and adolescent) and group B (adults). Numbers at the bottom represent patients alive and uncensored at each year of follow-up.
Mitral balloon valvuloplasty on 103 patients with closed commissurotomy (mean age 38 years) event-free rate from mitral valve replacement of 78% at 10 years and 47% at 20 years. (Rihal et al., 1992) reported on 267 patients (mean age 43 years) event-free rate from MVR 57% at 10 years and 24% at 20 years. In our series, the combined event-free rates after MBV is 88% at 10 years, 60% at 15 years, and 28% at 19 years were not worse than those of surgical series. 4. Conclusions Mitral balloon valvuloplasty, which is the procedure of choice in the treatment of rheumatic mitral stenosis, has excellent immediate and long-term results in patients with favorable mitral valve morphology but those with less favorable anatomy may still have reasonably good hemodynamic and symptomatic relief. This technique is associated with less morbidity and long-term results are better than the historical reported surgical results. The long-term outcome can be predicted from baseline clinical and valvular characteristics. MBV is safe and effective when treating patients with MS and severe pulmonary hypertension, the latter condition being normalized over 6– 12 months after successful MBV. Severe TR regresses after successful MBV in the presence of severe pulmonary hypertension. Severely impaired LV systolic function normalized after successful MBV. The result of MBV in children is similar to those in adults and the valve morphology is strong predictor of good immediate and long-term results. MBV is safe and effective during pregnancy with no untoward effect on the fetus. References Abdullah, M., Halim, M., Rajendran, V., Sawyer, W., Al Zaibag, M., 1992. Comparison between single (Inoue) and double balloon mitral valvotomy: immediate and short-term results. Am. Heart J. 123, 1581–1588. Arora, R., Nair, M., Kalaca, G.S., et al., 1993. Immediate and longterm results of balloon and surgical closed and open mitral valvotomy: a randomized comparative study. Am. Heart J. 125, 1091–1094. Ben Farhat, M., Betbout, F., Gamra, H., et al., 2001. Predictors of long-term event free survival of freedom from restenosis after percutaneous balloon mitral commissurotomy. Am. Heart J. 142, 1072–1079. Braunwald, N.S., Ross Jr., J., Morrow, A.G., 1967. Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement. Circulation 35 (Suppl. 1), 63–69. Breyer, R.H., McClenthan, J.H., Micharlis, L.L., et al., 1976. Tricuspid regurgitation: a comparison of non-operative management, tricuspid annuloplasty, and tricuspid valve replacement. J. Thorac. Cardiovasc. Surg. 72, 867–874. Carpentier, A., Deloche, A., Hanania, G., et al., 1974. Surgical management of acquired tricuspid valve disease. J. Thorac. Cardiovasc. Surg. 67, 53–65. Chen, C.R., Cheng, T.O., Chen, J.Y., Zhou, Y.I., Mei, J.M., Ma, T.Z., 1992. Long-term results of percutaneous mitral valvotomy with the Inoue balloon catheter. Am. J. Cardiol. 70, 1145–1148. Commerford, P.J., Hastie, T., Beck, W., et al., 1982. Closed mitral valvotomy: actuarial analysis of results in 654 patients over 12 years and analysis of pre-operative predictors of long-term survival. Ann. Thorac. Surg. 33, 473–479. De Andrade, J., Maldonado, M., Pontes Jr., S., Elmec, R.A., Eduardo, M.R., De Sousa, J., 2001. The role of mitral valve balloon
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