Balloon valvotomy for pregnant patients with severe pliable mitral stenosis using the lnoue technique with total abdominal and pelvic shielding Balloon valvotomy by means of the moue technique was attempted in seven pregnant (5 to 9 months) patients with severe mitral stenosis; the mean age of the patients was 32 + 8 years, and all had a two-dimensional echocardiographic mitral valve score of ~8. Indications for lnoue balloon valvotomy included severe symptomatic mitral stenosis with a Doppler mitral valve area 51 cm* and heart failure refractory to medical therapy, or absolute contraindications for the use of D-blockade; lnoue valvotomy was also indicated for patients who lived a long distance from the hospital. lnoue balloon valvotomy was performed with no angiography and total pelvic and abdominal shielding; the balloon catheter was introduced into the right atrium without the aid of fluoroscopy, which was used for the transseptal puncture. Stepwise two-dimensional echocardiographic Doppler mitral valve dilatation was done. After lnoue balloon valvotomy the mean Doppler mitral valve area increased from 0.8 + 0.1 to 2.0 * 0.3 cm* (p < 0.01) and by two-dimensional echocardiography from 0.8 -t 0.2 to 1.9 + 0.3 cm* (p < O.Ol), with no significant Doppler residual stenosis (defined as mitral valve area ~1.5 cm*). The mean total fluoroscopy time was 18 + 7 minutes. The degree of mitral regurgitation increased in two patients from grade 1+/4+ to grade 2+/4+ and from grade 0+/4+ to grade 2+/4+, respectively. There was no mortality or significant morbidity. Pregnancy was uneventful in all patients, and all were delivered of normal babies without complications. After delivery the mean Doppler mitral valve area was 1.9 f 0.3 cm* with no mitral valve restenosis. We conclude that lnoue balloon valvotomy with total pelvic and abdominal shielding and echocardiography may be a valid therapeutic alternative for pregnant patients with severe symptomatic pliable mitral stenosis. (AM HEART J 1992;124:1558.)

Paulo A. Ribeiro, MD, PhD, Mohamed Eid Fawzy, FRCP, Mahmoud Awad, MD, Bruce Dunn, MD, and Carlos G. Duran, MD, PhD Riyadh, Saudi Arabia

Severe mitral valve stenosis in pregnant patients results in increased fetal and maternal morbidity and mortality.’ Acute pulmonary edema in patients with severe mitral stenosis is the leading cause of maternal death. Surgical mitral valvotomy may be indicated in pregnant patients with severe symptomatic mitral valve stenosis.2‘5 Emergency surgical mitral valvotomy may be lifesaving in patients with intractable pulmonary edema.6 Mitral balloon valvotomy is an established therapeutic alternative to the surgical treatment of severe mitral valve stenosis.7-11The use of this technique in pregnant patients with mitral

From

the King

Received

Faisal

Specialist

Hospital

for publication

Dec.

23, 1991;

and accepted

Reprint requests: Pm10 A. Rib&o, MD, Medical Center~Cardiovascular Laboratory, St., Loma Linda, CA 92354. 411141304

1558

Research

Centre.

June

8, 1992.

Centre.

PhD, Loma Linda University Room 2426, 11234 Anderson

stenosis has been hampered by the risk of radiation exposure to the fetus. Palacious et a1.12and Safian et a1.13described two pregnant patients who underwent successful double-balloon mitral valvotomy with abdominal and pelvic shielding. We describe the use of the Inoue balloon valvotomy technique with total abdominal and pelvic shielding and echocardiography in seven symptomatic pregnant patients with severe mitral stenosis. The immediate results after balloon valvotomy and the mitral valve area after delivery were studied. METHODS

We attempted balloon valvotomy by meansof the Inoue technique in seven pregnant patients with severe symptomatic mitral valve stenosis,who were chosenfrom a consecutiveseriesof 105patients. The meanageof the patients was32 f 8 years, and they were between 5 and 9 months’ pregnant (Table I). Indications for Inoue balloon valvotomy included severe symptomatic mitral valve stenosis

Volume Number

124 6

Mitral

balloon

ualvotomy

during

1559

pregnancy

I. Clinical characteristics and echocardiographic and Doppler results of Inoue balloon valvotomy in seven symptomatic pregnant patients with severemitral stenosis

Table

Age (yr)

Pregnancy (4

NYHA class

3

28 41 38

4 6 8

4 .5

20 30

8 5

6 7

28 40

4 5

III IV IV III III/IV III III

Patient

1 2

32&86+2 ZDE, Two-dimensional echocardiography; pressure before valvotomy; ME, mitral

*p