Asian Cardiovasc Thorac Ann 1998;6:285-287
© 1998 Asia Publishing EXchange Pte Ltd
Closed Mitral Valvotomy Versus Balloon Valvuloplasty: A Comparison of 100 Cases
Raju S Iyer, MCh,
Rajnish Jain, MD1,
Manoj Padmanabhan, MCh,
Abha Chandra, MCh,
Sanjeev Agarwal, DM2,
Raja Sekhar, DM2,
Dilip Dronamraju, FRCS
Department of Cardiothoracic Surgery
1 Department of Anaesthesiology
2 Department of Cardiology Sri Venkateswara Institute of Medical Sciences Tirupati, India
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For reprint information contact: Raju S Iyer, MCh Department of Cardiothoracic Surgery Sri Venkateswara Institute of Medical Sciences Tirupati 517507, Andhra Pradesh, India Tel: 91 8574 51222 Fax: 91 8574 28803
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ABSTRACT
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From January 1995 to December 1996, 50 patients with mitral stenosis underwent surgical valvotomy and another 50 had balloon mitral valvuloplasty. Balloon valvuloplasty was performed by the Inoue technique and surgical closed mitral valvotomy was carried out through a standard anterolateral thoracotomy with transventricular repeated Tubbs or finger dilatation. Functional status, left atrial mean transmitral gradient, mitral valve area, and left atrial size were recorded. No significant difference was found between the values of these parameters in the 2 groups of patients at the end of the study.
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INTRODUCTION
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Treatment of rheumatic mitral stenosis ranges from conservative medical management to closed mitral valvotomy (CMV), open mitral valvotomy, and the more recent balloon mitral valvuloplasty (BMV). Improvement of symptoms after CMV was demonstrated many years ago.1–3 Refinements in technique and the routine use of a metal dilator have produced sustained clinical improvement at low risk. Percutaneous BMV evolved from balloon valvuloplasty for pulmonary valve stenosis. A successful outcome after either procedure is usually defined as a mitral valve area greater than or equal to 1.5 cm 2 with no more than grade 1 mitral regurgitation, without a left-to-right shunt, and with a ratio of pulmonary to systemic blood flow greater than or equal to 1.5:1.4 This prospective study was designed to compare the results of CMV with BMV performed over a period of 2 years.
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PATIENTS AND METHODS
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From January 1995 to December 1996, 100 consecutive patients with mitral stenosis who were suitable for either CMV or BMV were alternately assigned to one or other procedure. Echocardiography and cardiac Doppler studies were performed with a Sonos 1500 system (Hewlett-Packard, Rockville, MD, USA). The mitral valve orifice area was determined by the pressure half-time method on Doppler echocardiography. Fifty patients underwent CMV by standard transventricular Tubbs dilatation with or without finger dilatation and 50 had BMV by the Inoue balloon (Toray Medical, Tokyo, Japan) technique.
Patients undergoing BMV were managed by cardiologists in the cardiac care unit and those undergoing CMV were managed in the postoperative intensive care unit. Post-operative echocardiography was performed on the 3rd post-procedure day, with follow-up echocardiography after 6 months and one year. On follow-up, the patients were also assessed for cardiac rhythm, New York Heart Association functional class, medication, and the presence or progression of the same or other valvular lesions. Results were compared by the Student t test.
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RESULTS
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Of these100 patients, 60 were female and 40 were male. Patients over the age of 30 years accounted for 42% whereas 20% were below 20 years. The preoperative clinical characteristics of each group are shown in Table 1
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There was a fall in the mean and peak transmitral gradients in both groups of patients determined by Doppler echocardiography 3 days after the procedure (Table 2). Transmitral peak gradients were in the ranges of 12 to 28 mm Hg before CMV and 14 to 28 mm Hg before BMV. They decreased significantly after both procedures to range between 6 and 15 mm Hg. However, there was no significant difference attributable to the type of procedure. Left atrial size was between 35 and 45 mm before dilatation and decreased by a mean of 7 ± 2 mm at the end of 6 months and by 10 ± 2 mm 1 year after the procedure, irrespective of the method of dilatation.
At the 1-year follow-up, 40 of the 50 patients who had CMV were in sinus rhythm and 10 were in atrial fibrillation; 45 were in New York Hear Association functional class I and 5 were in class II. All of these patients were taking oral digoxin and diuretics and none had progression of the mitral stenosis or a new valvular lesion. Of the patients undergoing BMV, 42 were in sinus rhythm and 8 were in atrial fibrillation at follow-up; 46 were in New York Heart Association functional class I and 4 were in class II. All were taking oral digoxin and diuretics and 3 patients who had valve replacements were taking oral anticoagulants.
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DISCUSSION
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A number of previous studies of CMV and BMV have been reported. Ravkilde and Hansen5 analyzed 35 years of follow-up of 240 patients and found that CMV offered good long-term palliation of the symptoms of isolated mitral stenosis in patients without signs of irreversible organ damage and with pliable valves. John and Bashi,6 in a study of CMV in 367 patients over 40 years of age, reported that this procedure was the most effective palliative operation. In their study, atrial fibrillation was present in 38% of patients and mitral valve calcification in 24%. They stated that with the increased need for cost containment in healthcare, CMV assumes a greater significance. Beg and Reyazuddin7 reported favorable results after CMV in 45 cases of mitral stenosis in childhood and adolescence. The majority of their patients presented with dyspnea and palpitations. In a study by Gautam and Coulshed, 8 better long-term survival was noted for mitral valvotomy with the Tubbs dilator compared to finger splitting, and the presence of calcification at the time of valvotomy adversely affected survival. They concluded that CMV gave good results before the onset of atrial fibrillation and congestive cardiac failure, and that all patients should have anti-coagulation.
In a randomized comparative study of the immediate and long-term results of BMV and CMV, both procedures were found to be comparable in respect of postoperative functional status, restenosis, and mitral valve areas.9 Another report concluded that optimal results of BMV can be expected in patients with sinus rhythm and pliable valves with no severe subvalvular disease identified by echocardiography who undergo dilatation with large effective balloon dilating areas.10 Patients with sub-optimal results were more likely to have severe valve leaflet thickening and calcification on echocardiography. Reporting cardiac catheterization after 8 months of follow-up in 92 patients, Turi and colleagues 11 found sustained improvement in a young population (mean age, 27 years) with a mean echo score of 7 and no difference in early or intermediate results between balloon valvuloplasty and closed or open commissurotomy.
Three mechanisms account for the results of balloon valvuloplasty: commissural splitting; stretching of the commissural orifice; and cracking of valve leaflet calcification. Radiographic analysis of 15 operatively excised valves subjected to balloon dilatation demonstrated primarily commissural splitting, whereas an intraoperative study of the effects of balloon dilatation demonstrated a significant early benefit from commissural stretching.12,13 Because fusion of the commissures is the typical etiology of mitral stenosis in young patients, commissural splitting provides exceptional results.14
In spite of the initial optimistic pronouncement that BMV would significantly improve care for rheumatic valve disease in developing countries, the low cost and equally good results of CMV make it the procedure of choice in many parts of the world where valvular heart disease is prevalent, and ours is no exception.15 At the end of our study, there was no major difference in the results of either procedure, although the duration of hospital stay was appreciably less in the BMV patients. Seven patients in the failed BMV group had to be switched over to the surgical procedure, of whom 3 had to undergo a valve replacement. None in the CMV group needed a valve replacement. Mitral valve orifice area, left atrial size, functional status, and the transmitral peak gradients in both groups showed remarkable improvement at the 1-year follow-up with no patient having recurrent mitral stenosis. BMV is a costly but less invasive procedure and development of cheaper (possibly reusable) technology in the field of BMV would help solve this vexing problem for third world countries.
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ABSTRACT
INTRODUCTION
