19. Kubota I, Watanabe Y, Harada M, Kaminishi T, Tsuiki K, Yasui S. Treadmill stress test using body surface mapping in coronary artery disease. The clinical significance of ST depression. Jpn Circ J 1982;46:8-15. 20. Gewirtz H, Horacek BM, Wolf HK, Rautaharju RM, Smith ER. Mechanism of persistent S-T segment elevation after anterior myocardial infarction. Am J Cardiol 1979:44:126915.
ExerciseST changesin remoteinferior infarct
21. Goris ML, Daspit SG, McLaughlin P, Kriss JP. Interpolative background subtraction. J Nucl Med 1976;17:744-7. 22. Blackburn H, Katigbak R. What electrocardiographic leads to take after exercise? AM HEART J 1964;67:184-5. 23. Kubota I, Ikeda K, Ohyama T, Yamaki M, Kawashima S, Igarashi A, Tsuiki K, Yasui S. Body surface distribution of ST segment changes after exercise in effort angina pectoris without myocardial infarction. AM HEART J 1985;110:949-55.
Percutaneous mitral valvuloplasty with a single rubber-nylon balloon (Inoue balloon): Long-term results in 71 patients The first 71 patients wtth rheumatic mitral stenosis who successfully underwent single rubber-nylon balloon (Inoue balloon) percutaneous mitral valvuloplasty (PMV) from November 1985 to August 1988 had a mean follow-up period of 27.1 + 11.8 months (range, 14 to 48 months). Functional status before PMV was New York Heart Association (NYHA) functional class IV in two, class Ill in 38, and class II in 31. Pre and post PMV and follow-up mean diastolic mitral gradient by catheter method was 17.5 + 8.9, 2.7 ? 3.5, and 3.3 k 3.4 mm Hg (p < 0.001 pre versus post PMV and pre PMV versus follow-up; and p > 0.05 post PMV versus follow-up). By Doppler method the mean diastolic gradient was 17.4 + 5.5, 8.5 f 4.7, and 9.2 + 4.1 mm Hg, respectively (p < 0.001 pre versus post PMV and pre PMV versus follow-up; and p > 0105 post PMV versus follow-up). Mitral valve area was 1.12 f 0.28, 2.04 + 0.41, and 1.92 + 0.45 cm2, respectively (p > 0.001 pre versus post PMV and pre PMV versus follow-up; and p > 0.05 post PMV versus follow-up). The phonocardiographic and vectorcardiographic studies and cardiopulmonary exercise testing showed significant improvement after PMV and at follow-up. At follow-up the NYHA functional class was I in 57 patients, class II in 13, and class Ill in one patient with severe mitral valve calcification and subvalvular fusion, in whom restenosls occurred 18 months after PMV. Thus single rubber-nylon balloon PMV can achieve very good short-term and long-term results in relieving symptomatic rheumatic mitral stenosis. Patients with severe mitral calcification and subvalvular fusion do not appear to be good candidates for PMV. (AM HEART J 1990; 120:58 1.)
Chuan Rong Chen, MD, Shi Wu Hu, MD, Ji Yan Chen, MD, Ying Ling Zhou, MD, Jia Mei, MD, and Tsung 0. Cheng, MD. Guangzhou, People’s Republic of China, and Washington, D.C.
Single rubber-nylon balloon (SRB) for mitral valvuloplasty (commissurotomy) was first used by Inoue et al.’ in 1982 as an auxiliary means of open mitral commissurotomy under direct vision. In 1984 they2 reported clinical application of transvenous mitral From the Department of Cardiology, Guangdong Provincial Cardiovascular Institute and Hospital, Guangzhou; and the Division of Cardiology, Department of Medicine, The George Washington University School of Medicine and Health Sciences. Received for publication Feb. 15, 1990; accepted April 5, 1990. Reprint requests: Tsung 0. Cheng, MD, The George Washington University Medical Center, 2150 Pennsylvania Ave. N.W., Washington, DC 2003’7 4/l/21796
commissurotomy by the transseptal catheter technique. Subsequent studies by these investigators and by other&l5 demonstrated the early results of percutaneous mitral valvuloplasty (PMV) using SRB to be satisfactory. This report describes the long-term results of PMV with SRB in our first 71 patients between November 1985 and August 1988, with a mean follow-up period of 27.1 k 11.6 months (range, 14 to 48 months). METHODS Patients. The patient population consisted of 71 subjects. There were 59 women and 12 men, aged 33.8 + 7.6 years (range 15 to 58 years). The mean duration of illness 561
Chen et al.
Fu p 0.05 post versus follow-up) (Fig. 1). By the Doppler method the mean diastolic mitral valve gradient was 17.4 k 5.5, 8.5 -t 4.7, and 9.2 t- 4.1 mm Hg pre and post PMV and at follow-up, respectively (p < 0.001 pre versus post PMV and pre PMV versus follow-up; and p > 0.05 post versus follow-up) (Fig. 1). The mitral valve area measured by two-dimensionalechocardiographywas 1.12 -t 0.26,2.04 +- 0.41, and 1.92 -t 0.45 cm2 pre and post PMV and at follow-up, respectively (p < 0.001 pre versus post PMV and pre versus follow-up; and p > 0.05 post PMV versus follow-up (Fig. 2). The phonocardiographic interval between the Q wave and the mitral component of the first heart sound was 83.7 + 14.1, 74.5 + 14.5, and 71.7 +- 15.1 msec pre and post PMV and at follow-up, respectively (p < 0.001 pre versus post PMV and pre versus follow-up; and p > 0.05 post PMV versus follow-up) (Fig. 3). The phonocardiographic interval between the aortic second sound and the opening snap increased from 72.5 +- 14.7 msec pre PMV to 90.2 2 16.1 msec post PMV, and to 90.4 _+ 16.0 msec at
Fu Fig. 2. Mitral valve area measuredby two-dimensional echocardiogramand Doppler indicating satisfactory early and long-term results.he-PMV, Before percutaneousballoon mitral valvuloplasty; Post-PMV, after percutaneous balloon mitral valvuloplasty; Fu, follow-up.
60 40 20 0 Pre-PMV
Fig. 3. Phonocardiographic interval between Q wave and mitral component of first heart sound (Q-Ml Interval) showingsignificant improvement following percutaneousmitral valvuloplasty (PMV) and at follow-up. Pre-P&iv, Before PMV; Post-PMV, after PMV; Fu, follow-up.
follow-up (p < 0.001 pre versus post PMV and pre versus follow-up; and p > 0.05 post PMV versus follow-up) (Fig. 4). The vectorcardiogram showed a marked decrease
of the voltage of the P loop: 0.24 f 0.02 mV pre PMV, 0.21 + 0.04 mV post PMV, and 0.19 +- 0.06 mV at follow-up in the frontal plane, and 0.20 -+_0.04 mV pre PMV, 0.18 t- 0.03 mV post PMV, and 0.15 -t 0.04
Chen et al.
r------‘-‘-““““‘““““““““““---------~ I p E
Fig. 5. The voltage of the P loop in both frontal and horizontal planes of orthogonal vectorcardiogram showingsignificant decreaseafter percutaneousmitral valvuloplasty (PMV) and further improvement at follow-up. Pre, Before PMV; Post, after PMV; Fu, follow-up.
mV at follow-up in the horizontal plane (JI < 0.01 pre versus post PMV, p < 0.001 pre PMV versus followup, and p < 0.05 post PMV versus follow-up) (Fig. 5). Cardiac function significantly improved post PMV
and at follow-up (Fig. 6). Before balloon dilatation, it was NYHA class IV in two patients, class III in 38, and class II in 31 patients. After dilatation it was class I in 58 patients, class II in 12, and class III in one pa-
I II III Iv w Pre-PMV
Fig. 6. Cardiac function classification indicating significant improvement following percutaneousmitral valvuloplasty (PMV) and at follow-up. NYHA , New York Heart Associationfunctional classification;PrePMV, before PMV; Post-PMV, after PMV; Fu, follow-up.
Fig. 7. Severe calcification of the anterior and posterior leaflets of the mitral valve and both commissures visualized on x-ray film. The specimenshown was removed during mitral valve replacement in a patient with mitral restenosiswho underwent balloon mitral valvuloplasty 18 months earlier.
Chen et al.
imal oxygen pulse and maximal oxygen consumption per kilogram of body weight, as well as in the anaerobic threshold (AT)16 per kilogram of body weight during the follow-up period (p < 0.001 pre PMV versus follow-up) (Table I). Mitral restenosis was found 18 months after PMV in one patient who had severe mitral calcification (Figs. 7 and 8) and subvalvular fusion (Fig. 8). Mitral valve replacement was subsequently performed in this patient. DISCUSSION
8. Same patient as in Fig. 7. Pathologic specimen showingseveremitral calcification and subvalvular fusion. A, Atria1 view. B, Ventricular view.
1. Cardiopulmonary exercise testing Pre PMV
$7 pulse,, (ml/beat) ~Ozm,/kg (ml/min/kg) VOzAT/kg (ml/min/kg) PMV, Percutaneous *p > 0.05. tp < 0.001.
tient. At follow-up,
5.9 + 1.5 6.8 + 1.6* 8.9 -+ 2.21 36.8 + 9.9 41.5 & 8.5* 49.9 ? 9.2t 14.3 t 1.6 16.4 & 4.9* 19.5 i 5.8t valvuloplasty;
it was class I in II in 13, and class I in one patient. Although the cardiopulmonary showed no significant improvement in 30 days), very good results were
exercise testing post PMV (withseen in the max-
Since its original description in 1984,’ PMV has been in wide clinical use for over 5 years. Several facts have rapidly emerged: (1) the procedure is effective and safe3-15; (2) it improves symptoms3-i5; (3) the resultant decrease in diastolic mitral gradient is significant?15; (4) the increase in mitral valve area is comparable to that observed after surgical closed mitral commissurotomyi7* l8 and may be larger than that seen with valve replacementlg; (5) single balloon technique is as efficacious as, if no better than, the double balloon technique 15,2o (6) complications such as atria1 septal defect and mitral regurgitation are clinically well tolerated and seem to diminish in magnitude with time21‘24 (7) patients with heavy valvular calcification and severe subvalvular fusion have a poor response21-22 and (8) the improvement, both subjective and objective, is maintained through 1 year of follow-up. 22p25 The current study extended this follow-up period to 14 to 48 months (mean , 27.1 -t 11.6 months). It might be of interest to note that of the initial five patients who underwent Inoue balloon dilatation of the mitral valve, three showed persistence of their dilated mitral orifice 3 to 4 years after the procedure, one successfully underwent repeat dilatation 16 months later, and one died of liver cancer.4 The clinical usefulness of PMV can only be assessed by follow-up data. Our long-term results are certainly most encouraging. Not only was the improvement well maintained up to 4 years in our patients, but the complications from PMV seem to recede with time. Thus the production of or increase in mitral regurgitation that was associated with PMV decreases in more than half of the patients at followup catheterization. 22 Three mechanisms have been postulated: (1) reversible mitral valve “stretching” by PMV; (2) fibrosis and healing of the end of the commissures, which may diminish mitral regurgitation resulting from excessive commissural splitting; and (3) improvement in transient papillary muscle dysfunction caused by balloon trauma to the papillary muscle at the time of PMV. The other compli-
cation of PMV is atria1 septal defect. Although the atrial septum has a hole made by transseptal puncture that the balloon catheter traverses, it is likely that it closes later in the majority of the patients due to a reduction of the interatrial pressure gradient achieved through successful relief of mitral stenosis. The gradual diminution of left atriomegaly following successful PMV also accounts for the continued decrease in the voltage of the P loop on the vectorcardiogram at follow-up (Fig. 5). Similarly, the continued improvement in the cardiopulmonary exercise test results at follow-up (Table I) is further evidence that gradual return of cardiopulmonary function takes place after a period of readjustment to the hemodynamic improvement. Because mitral restenosis was found to occur in 25 % 27 to 28 % 28 of patients after surgical closed mitral commissurotomy, we believe that the same problem may occur after PMV if the patient survives long enough. Should restenosis occur, it is simpler, safer, and less expensive to redilate with a percutaneously introduced balloon than it is to reoperate.2g In conclusion, our long-term follow-up results render strong support to the earlier enthusiasm that PMV is an attractive alternative to surgical mitral commissurotomy for patients with mitral stenosis.30 Not only is it equally effective, but it requires a shorter hospital stay, is associated with a low morbidity and mortality, yields a satisfactory long-term result, and may be performed on repeated occasions should stenosis recur. As a matter of fact, in experienced hands and in skilled centers, PMV should be considered the procedure of first choice for most patients with mitral stenosis13l particularly those whose mitral valve is mobile, pliable, and not heavily calcified, for those who have combined stenoses of other valves,14 and for those who develop restenosis following previous surgical commissurotomy.2g We thank Drs. Tie Zheng Ma, Tao Ye Ying, Jian Zhang Feng, Zheng Dong Huang, Jia Zhen Sun, and Zheng Xiang Luo, and Hui Qing Yang,RN for their valuable assistance and Dr. Kanji Inoue for his continued advice and cooperation.
5. 6. 7.
1. Inoue K, Nakamura T, Kitamura F, Miyamoto N. Nonoperative mitral commissurotomy by a new balloon catheter [Abstract]. Jpn Circ J 1982;46:877. 2. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984:87:394-
3. Chen CR, Chen JY, Hu SW, Mei J, Yin TY, Xiong SX, Zhang JF, Cai ZX, Huang ZD, Luo ZX. Percutaneous balloon mitral valvuloplasty. Chin J Cardiol 1986;14:321-3. 4. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N, Chen C. Transvenous mitral commissurotomy: long-term fol-
low-up and recent modification [Abstract]. Circulation 1986; 74 (suppl II):II-208. Chen C, Chen J, Huang Z, Lo Z, Cheng TO. Percutaneous transseptal balloon mitral valvuloplasty: the Chinese experience in 21 patients [Abstract]. J Am Co11 Cardiol 1987;9:83A. Chen CR, Huang ZD, Luo ZX, Zhang JF, Cai ZX. Clinical application of balloon mitral valvotomy. Chin J Thorac Cardiovast Surg 1987;3:72-4. Inoue K, Nobuyoshi M, Mitsuto K, Ishihara H, Saito S, Chen C, Li HT, Hung JS. Percutaneous transvenous mitral commissurotomy: relationships to valve condition and balloon size [Abstract]. Circulation 1986;76(suppl IV):IV-523. Chen C, Lo Z, Huang Z, Inoue K, Cheng TO. Percutaneous transseptal balloon mitral valvuloplasty: the Chinese experience in 30 patients. AM HEARTJ 1988;115:937-47. Inoue K, Nobuyoshi M, Chen C, Hung JS. Advantage of Inoue-balloon (self positioning balloon) in percutaneous transvenous mitral commissurotomy [Abstract]. Circulation 1988; 78 (suppl II):II-490. Inoue K. Percutaneous transvenous mitral commissurotomy. Lungs Heart (in Japanese) 1988;35:281-6. Chen CR, Hu SW, Chen JY, Zhou YL, Mei J, Huang ZD, Luo ZX. Evaluation of the different types of balloon catheters and methods in dilating the stenotic mitral valve. Chin J Cardiol 1989;17:18-20. Inoue K, Nobuyoshi M, Chen C, Hung JS. Advantages of Inoue-balloon (self-positioning balloon) in percutaneous transvenous mitral commissurotomy (PTMC) and aortic valvuloplasty (PTAV) [Abstract]. J Am Co11 Cardiol 1989;13:18A. Hung J-S, Lin F-C, Chiang C-W. Successful percutaneous transvenous catheter balloon mitral commissurotomy after warfarin therapy and resolution of left atrial thrombus. Am J Cardiol 1989;64:126-8. Cheng TO. Multivalve percutaneous balloon valvuloplasty. Cathet Cardiovasc Diagn 1989;16:109-12. Chen CR, Huang ZD, Lo ZX, Cheng TO. Comparison of single rubber-nylon balloon and double polyethylene balloon valvuloplasty in 94 patients with rheumatic mitral stenosis. AM HEARTJ 1990;119:102-11. Dickstein K, Barvik S, Aarsland T, Snapinn S, Karlsson J. A comparison of methodologies in detection of the anaerobic threshold. Circulation 1990;81(suppl II):II-38-46. Reyes VP, Raju BS, Raju ARG, Turi ZG, for the WSU-Nizam’s Institute Valvuloplasty Study Group. Percutaneous balloon mitral valvuloplasty vs surgery: results of a randomized clinical trial [Abstract]. Circulation 1988;78(suppl II):II-489. Reddy PS, Ziady G, Dayem K, Etriby A, Ghareeb M, Guindy R, Rifaie 0, Sayed H, Zaki T. Balloon dilatation vs closed commissurotomy in mitral stenosis [Abstract]. Circulation 1989;8O(suppl II):II-358. Rahimtoola SH. Perspective on valvular heart disease: an update. J Am Co11Cardiol 1989;14:1-23. Chen CR, Hu SW, Chen JY, Zhou YL, Mei J, Cheng TO. Single rubber-nylon balloon (Inoue balloon) percutaneous mitral valvuloplasty: long-term results [Abstract]. Circulation 1989; 8O(suppl II):II-73. Reid CL, Chandraratna AN, Kawanishi DT, Kotlewski A, Rahimtoola SH. Influence of mitral valve morphology on double-balloon catheter balloon valvuloplasty in patients with mitral stenosis. Analysis of factors predicting immediate and 3-month results. Circulation 1989;80:515-24. Palacios IF, Block PC, Wilkins GT, Weyman AE. Follow-up of patients undergoing percutaneous mitral balloon valvotomy. Analysis of factors determining restenosis. Circulation 1989;79:5;73-9. Cequier A, Bonan R, Serra A, Dyrda I, Crepeau J, Dethy M, Waters D. Left-to-right atria1 shunting after percutaneous mitral valvuloplasty. Incidence and long-term hemodynamic follow-up. Circulation 1990;81:1190-7. Pektas 0, Isik E, Coskun M, Demirkan D, Gent C, Tore HF, Uyan C, Dokumaci B. Late hemodynamic changes in percutaneous mitralvalvuloplasty. AM HEARTJ 1990;119:112-20.
Chen et al. 25. Al Zaibag M, Ribeiro PA, Al Kasab S, Halim M, Idris MT, Habbab M, Shahid M, Sawyer W. One-year follow-up after percutaneous double balloon mitral valvotomy. Am J Cardiol 1989;63:126-7. 26. Beekman RH. Percutaneous balloon valvuloplasty: long-term studies are needed. J Am Co11 Cardiol 1987;9:732-3. 27. Belcher JR. Restenosis of the mitral valve. Ann R Co11 Surg Engl 1979;61:258-64. 28. Heger JJ, Wann LS, Weyman AE, Dillon JC, Feigenbaum H. Long-term changes in mitral valve area after successful mitral commissurotomy. Circulation 1979;59:443-8.
September 1990 Heart Journal
29. Serra A, Bonan R, Cequier A, Dyrda I, Crepeau J, Waters D. Mitral restenosis after surgical commissurotomy. Is percutaneous mitral valvuloplasty an alternative to reoperation? [Abstract]. Circulation 1989;8O(suppl II):II-72. 30. Roberts WC. Good-bye to thoracotomy for cardiac valvulotomy. Am J Cardiol 1987;59:198-202. 31. Kirklin JW, Hickey MSJ, Blackstone EH, Dean LS. Outcome after closed and open surgical mitral commissurotomy: implications for balloon valvuloplasty [Abstract]. Circulation 1989;8O(suppl II):II-359.
Balloon valvuloplasty for mitral restenosis previous surgery: A comparative study
We studied 203 patients with mitral stenosis treated by transarterial valvuloplasty. Forty two (group A) had undergone closed (n = 30) or open n = 12) surgical commissurotomy 15 2 5 years before. The remaining 161 had not undergone previous surgery (group 6). There were no significant differences between both groups in terms of age, sex, functional class, left atrial size, two-dimensional anatomic features of the valve, incidence of mild basal mitral regurgitation, or ejection fraction. A comparative analysis of both groups showed no significant differences in terms of changes in the mean gradient, mitral valve area, and incidence of severe postvalvuloplasty mitral regurgitation (9.5% versus 5.5%). Echo-Doppler follow-up studies (11 ;t 7 months) showed persistent gradlent relief in either group. We conclude that the immediate and short-term results of balloon valvuloplasty in patients who had undergone previous surgery are similar to those observed in patients who had not had commissurotomy. (AM HEART J 1990; 120:568.)
Alfonso Medina, MD, Jose Suarez De Lezo, MD, Enrique Manuel Pan, MD, Miguel Romero, MD, Francisco Melian, Manuel Sancho, MD, Armando Bethencourt, MD, Ricardo Francisco Jimenez, MD, Jose Segura, MD, Ignacio Coello, Antonio Drumond, MD. Las Palmas and Cbrdoba, Spain
Mitral restenosis has been described as an uncommon cause of recurrent symptoms following mitral commissurotomy. ‘1 2 However, restenosis or an unsuccessful permanent result after surgical commissurotomy can develop in 5 % to 18 % of patients over a period of 10 years. Although new surgery can be performed, the risks and the need for mitral valve slightly over the first replacement increase From the Hospital de1Pino, Las Palmas; and Hospital Reina Sofia, C6rdoba. Received for publication Sept. 11, 1989; accepted April 15, 1990. Reprint requests:Dr. Alfonso Medina, Unidad de Cardiologia, Hospital de1 Pino, Angel Guimerh 91, Las Palmas, Spain. 4/l/21992
Hernandez, MD, MD, Vivancos, MD, MD, and
operation.2p 3 On the other hand, balloon mitral valvuloplasty has proved to be an alternative to surgery in patients with mitral stenosis.4-7 Although experience is still limited, the application of balloon valvuloplasty for the treatment of patients with mitral restenosis after previous surgery has initially been described as successful.8 The present article shows our findings in a comparative study on the effects of balloon valvuloplasty in patients with mitral restenosis compared with the effects in patient with unoperated mitral stenosis.
METHODS From May 1986 to January 1989 we studied 203 patients with mitral stenosis treated by transarterial balloon valvu-