Mitral Valve Stenosis – ABC CARDIOL

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Beyond the Appendage: Left Atrial Wall Thrombosis in Rheumatic Mitral Stenosis

Bernardo Resende et al. Tomás Carlos Rogério Teixeira Lino Gonçalves

A 61-year-old woman with a history of rheumatic valvular heart disease and permanent atrial fibrillation (AF), chronically anticoagulated with rivaroxaban, presented with acute ischemic stroke and bilateral upper-limb ischemia. Neuroimaging revealed an acute infarction in the right middle cerebral artery territory and a subacute infarction in the left posterior cerebral artery territory (). Doppler ultrasound confirmed arterial occlusion in both upper limbs ().

Transesophageal echocardiography demonstrated marked left atrial (LA) enlargement, dense spontaneous echocardiographic contrast within the left atrial appendage (LAA), and reduced appendage flow velocities, without evidence of an organized thrombus (). The mitral valve exhibited features consistent with chronic rheumatic disease, with an estimated valve area of 1.0 cm² (). Notably, two- and three-dimensional imaging identified a large mural thrombus adherent to the LA wall, extending along the lateral and posterior walls and measuring approximately 4 × 0.8 cm (; Supplementary Videos 1-3).

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Review Article

My Approach to Wilkins-Block score in rheumatic mitral stenosis

Nayana Flamini Arantes Gomes et al. Fernanda de Azevedo Figueiredo Estela Fófano Rodrigues Carolina Kuchenbecker Soares Maria Carmo Pereira Nunes

Abstract

Mitral stenosis (MS) is the main clinical expression of chronic rheumatic heart disease. In symptomatic patients with severe MS and favorable anatomy, percutaneous mitral balloon valvuloplasty (PMBV) is the first-line therapeutic strategy. For the proper selection of candidates, the Wilkins-Block echocardiographic score was developed to characterize mitral valve morphology and predict eligibility for the procedure. This score includes four structural domains: leaflet mobility, valve thickening, degree of calcification, and subvalvular apparatus involvement, grading each parameter from 1 to 4 points, resulting in an overall range of 4 to 16 points, in increasing order of anatomical severity. The Wilkins score has become a widely validated tool, showing a consistent correlation with the immediate and long-term outcomes of PMBV. Among the limitations of the score, the absence of commissural anatomy assessment stands out, a variable recognized as a relevant prognostic determinant due to its strong association with the occurrence of post-procedure mitral regurgitation, considered the most frequent and clinically significant complication of PMBV. With the accumulation of clinical and technical experience, the indications for PMBV have been progressively extended to include patients with less favorable anatomical profiles. In these contexts, selection must be particularly rigorous, incorporating not only morphological criteria derived from echocardiographic evaluation, but also clinical aspects, in order to ensure satisfactory results and minimize the risk of complications.

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Review Article

My Approach to Three-Dimensional Echocardiography in Mitral Stenosis: How and When?

Alexandre Costa Souza et al. Marcus Vinicius Silva Freire de Carvalho Marco André Moraes Sales

Abstract

Three-dimensional echocardiography has become an essential tool in the assessment of mitral stenosis, allowing detailed anatomical analyses and reliable measurements, even in complex anatomies or extensive calcification. Based on daily clinical experience in an imaging laboratory, this article offers a practical guide for image acquisition and optimization, multiplanar reconstruction, and three-dimensional planimetry, focusing on technical adjustments, the use of tools such as rotation and cropping, and strategies for integrating the method into the routine workflow of cardiovascular imaging centers.

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Case Report

Lutembacher Syndrome Associated With Pulmonary Hypertension: The Importance of Early Diagnosis for Enabling Surgical Treatment

Ana Luiza Caldeira Lopes et al. Maria Estefânia Bosco Otto Bianca Corrêa Rocha de Mello Michelle Bruna da Silva Sena Wagner Luis Gali

Introduction

Lutembacher syndrome (LS) is defined by the simultaneous presence of an atrial septal defect (ASD) and mitral stenosis (MS). Although it is a rare condition, its clinical significance lies in the considerable hemodynamic impact and the potential for early progression to irreversible pulmonary hypertension (PH).

The exact prevalence of LS remains unknown. However, for estimation purposes, MS is considered the most frequent manifestation of rheumatic fever (RF) in young women, and the prevalence of RF in developing countries ranges from 5 to 10 cases per 1,000 children. Furthermore, the incidence of congenital ASD in patients with MS is estimated at 0.6% to 0.7%.

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Case Report

Cerebral Thromboembolism as a Primary Manifestation of Severe Rheumatic Mitral Stenosis: A Clinical Case from Guayaquil, Ecuador

Patricia Delgado Cedeño et al. Estefania Carolina Arteaga Herrera Cesar Joao Tumbaco Mite Elsie Valdivieso Valenzuela … Boris Barreno Vera Karen Llimaico Del Pin

Abstract

Mitral stenosis (MS) is a valvular disease that predominantly affects women, with rheumatic fever being the most prevalent etiological cause. The hemodynamic consequences of rheumatic MS may include left atrial (LA) pressure overload and dilation, atrial fibrillation (AF), secondary pulmonary hypertension, heart failure, atrial thrombosis, and systemic thromboembolism. Echocardiography is the gold standard for diagnosing, quantifying severity, and evaluating the hemodynamic impact of MS.

We present the case of a 41-year-old female patient who arrived at the emergency department with a 6-hour history of dysarthria and right hemiparesis. Cardiovascular examination revealed sinus rhythm and a diastolic murmur with an opening snap at the mitral focus. Imaging studies revealed severe MS with LA dilation and a patent foramen ovale without hemodynamic impact. The patient underwent percutaneous balloon mitral valvuloplasty, which resulted in an increase in mitral valve area (MVA), a reduction in pulmonary pressure, and significant functional improvement.

Cerebral thromboembolism can be the first manifestation of severe MS, even in patients with sinus rhythm. Anticoagulation is crucial for those with severe atrial dilation to reduce the risk of embolic events. This case highlights the importance of early diagnosis and appropriate treatment based on clinical guidelines, as they improve patient quality of life and reduce the risk of future complications. It also serves as a reminder that stroke may be the sentinel event in silent but severe mitral valve pathology.

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Case Report

Dysfunctional Mitral Bioprosthesis Treated using Transapical Approach with Inovare Transcatheter Valve: A New Alternative to Conventional Surgery

Williams Roberto Lata Gacho et al. Jaime Paula Pessoa Linhares Filho Henrique Barbosa Ribeiro Roney Orismar Sampaio … José Onório Almeida Palma Fonseca Márcio Silva Miguel Lima

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Case Report

Rheumatic Mitral Valvopathy and Papillary Fibroelastoma An Unusual Association

Rafael Macedo Mustafé et al. Elinthon Tavares Veronesi Carlos Manuel Almeida Brandão Márcio Silva Miguel Lima

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ABCIC

Case Report

Lutembacher Syndrome: Case Report and Literature Review

Susan Caroline Azevedo Aredes et al. Gabriela da Silva Scopel Stella de Souza Carneiro Josana Azevedo Aredes … Aline Valério de Lima Patrick Ventorim Costa

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Original Article

Serum Thiol Levels and Thiol/Disulfide Homeostasis in Patients with Rheumatic Mitral Valve Disease and Healthy Subjects

Ahmet Korkmaz et al. Birsen Doğanay Funda Basyigit Cem Çöteli … Abdulkadir Yildiz Tugba Gursoy Umit Guray Ozgul Ucar Elalmis

Abstract

Background

Rheumatic mitral valve disease (RMVD) is the most common presentation of rheumatic heart disease (RHD). Inflammation and fibrosis processes also play significant roles in its pathogenesis. Recent studies showed that thiols and thiol-disulfide are promising novel oxidative stress markers.

Objectives

The present study aimed to evaluate differences in the serum thiol and thiol-disulfide levels in patients with RMVD and the control group.

Methods

Ninety-two patients with RMVD were enrolled in the study. Fifty-four healthy subjects, age, and gender-matched with the study group, were also included in the study as a control group. This study investigated thiol levels in patients with RMVD and the control group. P-values lower than 0.05 were considered statistically significant.

Results

The patients with RMVD presented higher systolic pulmonary artery pressure (SPAP) and left atrial (LA) diameter levels than the control group. Native thiol (407±83 μmol/L vs. 297±65 μmol/L, p<0.001) and total thiol (442±82 μmol/L vs. 329±65 μmol/L, p<0.001) levels were higher in the control group. Disulfide (16.7±4.9 μmol/L vs. 14.8±3.7 μmol/L, p=0.011) levels were higher in the group of patients with RMVD. A positive correlation was found between disulfide/native and disulfide/total thiols ratio with SPAP, LA diameter, and MS severity. Disulfide/total thiols ratio was significantly higher in patients with severe MS than with mild to moderate MS patients.

Conclusions

To the best of our knowledge, this is the only study of its kind that has evaluated thiol/disulfide homeostasis as a novel predictor, which was more closely related to RMVD and the severity of MS.

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Ebstein’s anomaly, noncompaction cardiomyopathy, and mitral valve stenosis

Anderson da Costa Armstrong et al. Gustavo Volpe Tiago Augusto Magalhães Dinani Armstrong Marcelo Nacif

A 29-year-old woman who was previously diagnosed with Ebstein’s anomaly was referred for magnetic resonance imaging of the heart due to progressively worsening dyspnea on exertion.

Cardiac magnetic resonance images (Siemens Essenza 1.5T) showed right atrial dilation and low insertion of the tricuspid valve septal leaflet. The patient also presented with increased left ventricular trabeculation characteristic of noncompaction cardiomyopathy and signs of posterior mitral leaflet restriction secondary to probable rheumatic valvular disease.

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Original Article

Histopathological Characterization of Mitral Valvular Lesions from Patients with Rheumatic Heart Disease

Nayana F. A. Gomes et al. Marcelo A. Pascoal-Xavier Livia S. A. Passos Thiago Mendonça Nunes Paula … João Marcelo de Souza Aguiar Felipe Vieira Guarçoni Maria Cecília Landim Nassif Claudio Leo Gelape Renato Braulio Paulo Henrique N. Costa Luiz Guilherme Passaglia Raquel Braga Martins Walderez O. Dutra Maria Carmo P. Nunes

Abstract

Background:

The underlying mechanisms by which rheumatic heart disease (RHD) lead to severe valve dysfunction are not completely understood.

Objective:

The present study evaluated the histopathological changes in mitral valves (MV) seeking an association between the pattern of predominant valvular dysfunction and histopathological findings.

Methods:

In 40 patients who underwent MV replacement due to RHD, and in 20 controls that underwent heart transplant, histological aspects of the excised MV were analyzed. Clinical and echocardiographic data were also collected. Histological analyses were performed using hematoxylin-eosin staining. Inflammation, fibrosis, neoangiogenesis, calcification and adipose metaplasia were determined. A p value<0.05 was considered to be statistically significant.

Results:

The mean age of RHD patients was 53±13 years, 36 (90%) were female, whereas the mean age of controls was 50±12 years, similar to the cases, with the majority of males (70%). The rheumatic valve endocardium presented greater thickness than the controls (1.3±0.5 mm versus 0.90±0.4 mm, p=0.003, respectively), and a more intense inflammatory infiltrate in the endocardium (78% versus 36%; p=0.004), with predominance of mononuclear cells. Moderate to marked fibrosis occurred more frequently in rheumatic valves than in control valves (100% vs. 29%; p<0.001). Calcification occurred in 35% of rheumatic valves, especially among stenotic valves, which was associated with the mitral valve area (p=0.003).

Conclusions:

Despite intense degree of fibrosis, the inflammatory process remains active in the rheumatic mitral valve, even at late disease with valve dysfunction. Calcification predominated in stenotic valves and in patients with right ventricular dysfunction.

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Editorial

Transseptal, Transcatheter Mitral Valve-In-Valve Replacement: Ready for Prime Time Treatment of Bioprosthetic Valve Failure in Brazil?

Dimytri Alexandre Alvim de Siqueira et al. Auristela Isabel de Oliveira Ramos Fausto Feres

Structural Bioprosthetic Valve Deterioration, Failure and Redo Valve Surgery

Bioprosthetic valves are the device of choice for older patients who require left heart valve replacement, and recent data indicate that bioprostheses are also increasingly used in patients less than 65 years of age who undergo aortic or mitral valve surgeries. Although numerous observational studies have shown excellent survival and freedom from valve-related complications, ultimately all bioprosthetic heart valves are prone to fail. The term structural valve deterioration (SVD) includes permanent, irreversible intrinsic changes of the valve (i.e. leaflet tears, calcification, pannus formation or fibrosis); other pathological causes of bioprosthetic valve dysfunction (i.e. thrombosis, endocarditis) are potentially reversible. When significant hemodynamic compromise (severe regurgitation or stenosis) ensues and/or there is a clinical event related to SVD (reintervention, death), the term bioprosthetic valve failure (BVF) is now suggested.

Redo surgical valve replacement is currently indicated for the majority of patients with bioprosthetic SVD. The risk of redo mitral surgery remains much higher than the risk of first mitral valve replacement (MVR). Advanced age, female gender, preoperative NYHA class, reduced left ventricular ejection fraction (LVEF), pulmonary hypertension and the number of prior operations have all been identified as predictors of mortality. Moreover, adhesions from previous surgery substantially increases bleeding complications. In a study with 260 patients enrolled in the European Redo Cardiac Operation Database (RECORD), in-hospital mortality was 9.2% after redo MVR. A high incidence of postoperative complications, such as low cardiac output syndrome (17.3%), need for circulatory support (9.2%), acute renal failure (16.5%) and need for transfusion (25%) was reported. Similarly, a contemporary study from the Society of Thoracic Surgery (STS) with 11,973 patients revealed that mitral reoperation (n=1096) was associated with higher operative mortality (11.1%) in comparison with the first MVR or repair (6.5%). Despite the paucity of data about redo MVR in Brazil, it is well-known that rheumatic heart disease with valvular involvement is the most frequent indication for cardiac valve surgery in young patients. Since BVF is influenced by age – in patients less than 40 years of age, for example, 15-year freedom from reoperation can be as low as 36%-, patients in our country require multiple reinterventions with increasing risks, substantial impact on their quality of life and costs to the healthcare system.

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Unexpected Mass in the Left Atrium

Tatiana Guimarães et al. Rui Plácido Ana Catarina Quadros José Marques da Costa Fausto J. Pinto

A 60-year-old Caucasian female with a history of rheumatic mitral stenosis, permanent atrial fibrillation and chronic lymphocytic leukemia was admitted due to decompensated chronic heart failure. The transthoracic echocardiogram depicted a severe mitral stenosis (anatomic valve area of 0.9 cm²), mild mitral regurgitation, aneurysmatic left atrium and mildly compromised left ventricular ejection fraction. Given the indication for mitral valve replacement, coronary angiography was performed, revealing an abnormal vascularized mass at the level of the left atrium beyond normal coronary arteries (Panel A). For better characterization an angio-CT was requested. A well-delimited, 7x4x3cm left atrial homogeneous, slight hyperdense mass was observed along the lateral portion of the atrial roof (Panel B and C). The patient underwent both surgical mass resection and mitral valve replacement with an uneventful recovery. The pathological analysis showed a multifocal left atrial wall and pericardial fat infiltration with CD20+, CD5 +, bcl-2+, cyclin D1+, CD10- and CD23- lymphoid cells, in addition to a left atrial adherent thrombus (Panels D-I). These findings were compatible with lymphocytic lymphoma/chronic lymphocytic leukemia and the patient remains clinically stable.

Secondary or metastatic tumors are much more common than primary tumors of the heart. A recent necropsy study revealed that cardiac metastases in patients with leukemia and lymphomas may be present in 25% of patients. Despite being mostly clinically silent, cardiac imaging improvements and availability has led to increased incidental recognition and awareness.

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Artigo Original

Study of breathing pattern and thoracoabdominal movement in mitral valve disease

Satiko Shimada Franco et al. Paula Nubiato Bardi Max Grinberg Maria Ignêz Zanetti Feltrim

BACKGROUND: patients with mitral valve disease can progress to having pulmonary congestion, which increases the work the respiratory muscles. This overload can change the breathing pattern with a predominance of rib cage displacement or presence of paradoxical movements. OBJECTIVE: a) to study the breathing pattern and thoracoabdominal movement of patients with mitral valve disease; b) to study the effect of body position on breathing parameters; and c) to correlate pulmonary hypertension with lack of coordination of thoracoabdominal movement. METHODS: the breathing pattern and thoracoabdominal movement of patients with mitral valve disease were assessed using respiratory inductive plethysmography during quiet breathing in the dorsal decubitus and sitting positions for two minutes. The variables assessed were tidal volume, breathing time and thoracoabdominal movement. RESULTS: of the 65 patients selected, 10 were excluded, 29 were in the mitral stenosis group and 26 in the mitral regurgitation group. Tidal volume, pulmonary ventilation and mean inspiratory flow significantly increased in the sitting position, with no difference between the groups. The thoracoabdominal movement remained coordinated in all groups and positions; except for five patients in the dorsal decubitus position, who lacked coordination (three in the mitral stenosis group; two in the mitral regurgitation group). A significant correlation with pulmonary artery pressure values was observed (r = 0.992; p = 0.007). CONCLUSION: No difference in breathing pattern or thoracoabdominal movement was found between patients with mitral stenosis and regurgitation. The sitting position increased tidal volume without altering breathing times. The lack of coordination of the thoracoabdominal movement in the dorsal decubitus position was associated with pulmonary hypertension.

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Case Report

Association between immunological diseases and their similar clinical manifestations

Alexandre de Matos Soeiro et al. Maria Carolina Feres de Almeida Tarso Augusto Duenhas Accorsi Guilherme Sobreira Spina … Carlos Vicente Serrano Jr Flávio Tarasoutchi

We report on a 30-year-old female patient, with biological mitral valve prosthesis due to symptomatic mitral stenosis and a history of acute myocardial infarction and generalized tonic-clonic seizure episodes, visual hallucinations, cerebral thromboembolic events and, at present, chorea and acute carditis. The patient was diagnosed with active rheumatic fever (RF), systemic lupus erythematosus (SLE) and Antiphospholipid syndrome (APS). The combination of three unusual diagnoses in the same patient makes this a unique case, modifying patient treatment and prognosis.

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Case Report

Giant atrial myxoma mimicking severe mitral stenosis in young patient

Eric Paiva Vilela et al. Leonardo Moura Danielle Pepe Edson Nunes … Fabio Erthal Erika Campana

The echocardiogram of a twenty-year-old man, previously healthy, suffering from paroxysmal nocturnal dyspnea and fatigue after moderate exertion that intensified over a period of about ten days, showed the left atrium myxoma working as severe mitral stenosis.

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Artigo Original

Immediate and late results of percutaneous mitral valve repair in patients with mitral stenosis

Luiz Francisco Cardoso et al. Carlos Vinetou Ayres André Moreira Bento Flávio Tarasoutchi … Marcelo Luiz Vieira Max Grinberg

BACKGROUND: The analysis of immediate and long-term results of mitral valvoplasty by balloon catheter (MVRBC) are still lacking in literature, mainly in the national context. OBJECTIVE: To assess the immediate and late results of patients submitted to mitral valve repair by balloon catheter. METHOD: A total of 330 consecutive patients were followed-up by 47 ± 36 months (up to 126 months). Univariate and multivariate analyses assessed the factors associated with the success of the procedure, restenosis and late events (death or necessity of new intervention on mitral valve). Kaplan-Meier method estimated survival without events. RESULTS: The procedure was successful in 305 cases (92.4%). The mitral valve anatomy was the main predictor for immediate success for the procedure. During the procedure, restenosis occurred in 77 (23.3%) patients and was associated with smaller mitral valve area and with larger calcification before the process. In a mean period of 38 ± 26-month follow-up, 67 events occurred. The probability of survival without events was of 95% in one year, 75% in five years and 61% in ten years. The predictors of survival without events were: age, echocardiography score and immediate result of the procedure. CONCLUSION: Mitral valve repair by balloon catheter is an effective procedure, as 60% patients did not present events after the follow-up. The anatomical condition of the mitral valve and the patient’s age were the best predictors of survival without events, and should be taken into account when selecting patients for the mentioned procedure. (Arq Bras Cardiol 2010; 94(3):383-390)

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Artigo Original

Bleeding during oral anticoagulant therapy: warning against a greater hazard

Paulo de Lara Lavítola et al. Guilherme Sobreira Spina Roney Orismar Sampaio Flávio Tarasoutchi Max Grinberg

BACKGROUND: Bleeding is one of the main concerns in patients undergoing oral anticoagulation therapy. OBJECTIVE: To investigate the determinant causes of bleeding in patients undergoing oral anticoagulant therapy. METHODS: A total of 360 patients with atrial fibrillation (AF) undergoing oral anticoagulant (ACo) therapy, with a target INR of 2.0-3.5, were followed prospectively for a period of 48 ± 7.2 months. The patients were evaluated on average every 30 days and were investigated regarding the presence of associated pathology that could lead to bleeding. RESULTS: A total of 338 patients participated in the present study. Of these, 210 (62.13%) were females. Mitral stenosis was present in 218 patients (64.4%), a mitral biological prosthesis in 64 (18.9%) and mitral valve failure in 56 (16.5%) patients. Bleeding occurred in 65 patients (19.2%), being severe in 7 (10%) patients. In 38/65 patients, a new associated disease was identified, which facilitated bleeding. An associated disease was identified in 100% of the patients with bleeding within the therapeutic range, against 49.05% of associated disease diagnosis in those with an INR > 3.5 (p=0.001). CONCLUSION: The diagnosis of a local disease associated to the bleeding was frequent among those patients undergoing oral anticoagulant therapy (58.5%). There was an association between bleeding with an INR within the therapeutic range (INR=2.0-3.5) and the diagnosis of a pathology predisposing to bleeding (p<0.001). It is mandatory to investigate the cause of bleeding in patients undergoing oral anticoagulant therapy, especially if the INR is within the therapeutic range.

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Case Report

Permanent pacemaker implantation in a pregnant woman with rheumatic mitral valve disease

Rodrigo Barbosa Esper et al. Remo Holanda de Mendonça Furtado Flávio Tarasoutchi Guilherme Sobreira Spina … Max Grinberg Walkiria Samuel Ávila

We describe a rare case of permanent pacemaker implantation in a pregnant woman with rheumatic mitral valve disease previously undergoing percutaneous balloon valvuloplasty. She presented symptomatic advanced atrioventricular block of non-reversible cause and manifest in the third trimester of gestation.

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Anatomopathological Session

Case 3/2008: severe and rapidly progressive dyspnea in a woman with mechanical mitral valve prosthesis

Adriano Freitas Ribeiro et al. Michele Tavares Abrantes Marcelo Vieira Vera Demarchi Aiello

ANATOMOPATHOLOGICAL SESSION

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Artigo Original

Comparison of the inoue and single balloon techniques during long term percutaneous balloon mitral valvoplasty follow-up: analysis of risk factors for death and major events

Ivana Picone Borges et al. Edison Carvalho Sandoval Peixoto Rodrigo Trajano Sandoval Peixoto Paulo Sergio de Oliveira … Mario Salles Netto Ricardo Trajano Sandoval Peixoto Marta Labrunie Pierre Labrunie Ronaldo de Amorim Villela Aristarco Gonçalves Siqueira-Filho

OBJECTIVE: To analyze the long term evolution of patients undergoing percutaneous balloon mitral valvoplasty comparing the Inoue and Balt single balloon methods, and to identify predictors of death and major events (death, repeat balloon mitral valvoplasty or mitral valve surgery). METHODS: The follow-up for the single and Inoue balloon groups were 54 ± 31 (1 to 126) months and 34 ± 26 (2 to 105) months, respectively (p 50 years and an echocardiographic score > 8 were independent predictors of death; and an echocardiographic score > 8 and post operative mitral valve area 50 years, echocardiographic score > 8 and mitral valve area < 1.50 cm² after the procedure.

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Case Report

Percutaneous mitral valvuloplastry in a pregnant woman guided only by the transesophageal echocardiography

José A. Mangione et al. Salvador André Bavaresco Cristovão Gustavo Ithamar Souto Maior Henry Abensur

Mitral valve stenosis is the most common valve lesion in pregnancy. In spite of an optimized clinical treatment and a favorable valve anatomy according to Wilkins and Block score, in symptomatic patients, percutaneous intervention is shown to be of great importance. In these patients, avoiding x-ray exposure as much as possible is recommended so as to protect the fetus from the deleterious effects of ionizing radiation. In this case report, a 24-year old pregnant patient with severe mitral stenosis (valve area of 0.9 cm²) was successfully submitted to a TEE-guided percutaneous treatment, without the use of x-ray.

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Artigo Original

Comparison of open commissurotomy and balloon valvuloplasty in mitral stenosis: a five-year follow-up

Luiz Francisco Cardoso et al. Max Grinberg Pablo Maria Alberto Pomerantzeff Miguel Antonio Neves Rati … Caio Cesar Jorge Medeiros Marcelo Luiz Vieira Luiz Virgen Flávio Tarasoutchi

OBJECTIVE: To compare clinical and laboratory data in patients with mitral stenosis undergoing open commissurotomy or balloon valvuloplasty, who were followed up for 5 years. METHODS: Eighty-one patients were prospectively assessed prior to the procedure (PRE) and immediately after the procedure, in the immediate postoperative period (IPO), and followed up yearly for 5 years (PO12M, PO24M, PO36M, PO48M, and PO60M). They were randomized into the following 2 groups: GC (group undergoing open commissurotomy): 37 patients (32.4 ± 7.2 years; 89.2% females); and GV (group undergoing balloon valvuloplasty): 44 patients (32.9 ± 9.5 years; 90.9% females). The patients’ assessment comprised the following items: functional class, occurrence of events, electrocardiography, and Doppler echocardiography. RESULTS: A significant improvement in functional class occurred in most patients. Three patients in GC and in GV were in functional class III in PO60M. No difference in the mitral gradient was observed between the groups. A difference in the mean mitral valve areas was observed between the groups during the entire evaluation. No patients died. In regard to the IPO of GC, 3 patients had moderate mitral insufficiency (MI), and 3 had bleeding (1 was reoperated upon). In the IPO of GV, 4 patients had moderate MI, 1 had severe MI, 2 had cardiac tamponade, and 1 patient required surgery due to severe MI. Over 60 months, 9 GV patients evolved to moderate or severe MI, while 6 GC patients evolved to moderate or severe MI, and 2 other GC patients required surgery due to double mitral dysfunction. CONCLUSION: The rate of success in open mitral commissurotomy and balloon mitral valvuloplasty was 100%, and the rate of complications was low. During follow-up, a mild elevation in mitral gradient and a drop in mitral valve area were observed in both groups.

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Artigo Original

Comparison between percutaneous balloon valvuloplasty and open commissurotomy for mitral stenosis

Luiz Francisco Cardoso et al. Miguel Antonio Neves Rati Pablo Maria Alberto Pomerantzeff Caio Cesar Jorge Medeiros … Flávio Tarasoutchi Eduardo Giusti Rossi Walkiria Samuel Ávila Max Grinberg

PURPOSE: To compare immediate and late (12 months) follow up of clinical and Doppler echocardiographic results between percutaneous mitral balloon valvuloplasty and open commissurotomy in a prospective and randomized trial. METHODS: Eighty eight symptomatic patients with severe mitral stenosis and favorable anatomy were randomized in a prospective trial comparing the two procedures. All patients were submitted to clinical and Doppler echocardiographic evaluation before the procedures and immediate and twelve months thereafter. RESULTS: Mean mitral gradient (mmHg) decreased from 12.2±5.8 to 5.80±2.7 (p<0.001) in commissurotomy group (CG) and from 11.7±6.1 to 5.0±2.4 (p<0.001) in the balloon valvuloplasty group (VG). Mitral valve area (cm²) increased from 0.98±0.21 to 2.52±0.46 in CG and from 1.05±0.25 to 2.18±0.40 in VG (p<0.001). In both groups there was a slight decrease in mitral valve area at 12 month follow-up. There was no death in either group. One patient in the VG had moderate mitral regurgitation and underwent surgery. At the 12 month follow-up, all patients in CG and 97.7% of patients in VG were in New York Heart Association functional class I or II. CONCLUSION: Both procedures were safe and showed similar immediate improvement in mitral gradient and functional class. Mitral valve area had a greater increase immediately after commissurotomy, however there was a significantly greater reduction in the CG after 12 months of follow-up, when compared to balloon valvuloplasty. In both groups, mitral gradient remained reduced and most patients did not change functional class during the follow-up.

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