Donate Help Contact The AHA Sign In Home
American Heart Association
Circulation
Search: search_blue_button Advanced Search
« Previous Article | Table of Contents | Next Article »
Circulation. 1997;95:382-389

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Orrange, S. E.
Right arrow Articles by Rahimtoola, S. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Orrange, S. E.
Right arrow Articles by Rahimtoola, S. H.

(Circulation. 1997;95:382-389.)
© 1997 American Heart Association, Inc.

Articles

Actuarial Outcome After Catheter Balloon Commissurotomy in Patients With Mitral Stenosis

Sharon E. Orrange, MHS; David T. Kawanishi, MD; Becky M. Lopez, RN; Susan M. Curry, RDCS; Shahbudin H. Rahimtoola, MB, FRCP, MACP

the Griffith Center, Division of Cardiology, Department of Medicine, University of Southern California and LAC+USC Medical Center (Los Angeles).

Correspondence to Shahbudin H. Rahimtoola, MD, Distinguished Professor, University of Southern California, Division of Cardiology, 2025 Zonal Ave, Los Angeles, CA 90033.


*    Abstract
up arrowTop
 *Abstract
down arrowIntroduction
 down arrowMethods
 down arrowResults
 down arrowDiscussion
 down arrowAddendum
 down arrowReferences
 
Background The goal of the present study was to determine the intermediate-term survival and the independent predictors of survival and event-free survival for patients who undergo catheter balloon commissurotomy (CBC).

Methods and Results CBC for the treatment of mitral stenosis was performed in 132 patients from 1986 through 1994. The use of CBC increased the mitral valve area (MVA) from 1.0±0.3 to 1.9±0.6 cm2 (P<.001). There were six early deaths (4.5%) up to 1 month after CBC ("hospital" deaths). In the past 4.5 years, there have been no hospital deaths. Four late deaths occurred after elective mitral valve replacement (MVR). Actuarial 7-year survival was 95±1%; when mortality after MVR is included, 7-year survival was 83±6%. Actuarial 1-, 3-, 5-, and 7-year event-free survival (survival without MVR or repeat CBC) was 80±4%, 77±4%, 65±6%, and 65±6%. On multivariate analysis, the only two independent predictors (both after CBC) of 7-year event-free survival were MVA of >=1.5 versus <1.5 cm2 (75±7% versus 32±12%) and mean pulmonary artery wedge pressure of <=18 versus >18 mm Hg (84±6% versus 38±11%) (P<.001 for both). Patients with MVA of >=1.5 cm2 (n=96) could be further subdivided into high- and low-risk subgroups for 7-year event-free survival by two post-CBC variables: mean pulmonary artery wedge pressure of <=18 versus >18 mm Hg (90±6% versus 48±14%) (P=.0002) and cardiac index of >=2.5 versus <2.5 L·min-1·m-2 (82±8% versus 61±13%) (P=.004). Patients with post-CBC MVA of <1.5 cm2 (n=24) had no additional predictors of event-free survival. Of patients who did not undergo MVR or repeat CBC, 8% were in New York Heart Association functional class III and 92% were in class I or early class II at the last follow-up.

Conclusions The rates for intermediate-term survival and event-free survival after CBC are very encouraging. Most patients without events were asymptomatic or minimally symptomatic. Thus, in selected patients with mitral stenosis who require an interventional procedure, CBC is the procedure of choice at centers with physicians who have experience and skill in performing this procedure.


Key Words: mitral valve • stenosis • valvuloplasty


*    Introduction
up arrowTop
 up arrowAbstract
 *Introduction
down arrowMethods
 down arrowResults
 down arrowDiscussion
 down arrowAddendum
 down arrowReferences
 
The use of CBC for MS in adults was reported by Inoue et al in 19841 and for children and adolescents by Lock et al in 1985.2 Al Zaibag et al3 reported the use of the double-balloon technique in 1986; subsequently, the Inoue balloon became available for percutaneous use.4 The encouraging very early experience5 in small numbers of patients was confirmed in subsequent studies. CBC has been documented to result in an immediate reduction in LAP and PAP and increases in CO and MVA.6 7 8 These beneficial effects persisted at follow-up both at rest and on exercise, and the patients were symptomatically improved.9 Subsequently, randomized trials have documented that the early results of CBC were similar to those obtained with closed or open surgical valvotomy.10 11 12 13 The early results and complications of CBC have been reviewed extensively, and follow-up data are available.14 15 16 17 18 19 20 21 22 The goals of the present study were to determine the intermediate-term survival and event-free survival (<=7 years) and to identify predictors of intermediate-term survival and event-free survival.


*    Methods
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 *Methods
down arrowResults
 down arrowDiscussion
 down arrowAddendum
 down arrowReferences
 
Study Population
Between February 1986 and June 1994, CBC was attempted in 132 patients with MS at LAC+USC Medical Center. These 132 patients included all patients in whom CBC was attempted. The protocol was approved by our institutional review board, and written informed consent was obtained from all patients. The study group included 104 women and 28 men (mean±SD age, 44±14 years; median age, 43.5 years). All except 2 patients were symptomatic: 99 patients (77%) were in NYHA functional class III or IV (Table 1Down).


View this table:
[in this window]
[in a new window]
  		Table 1. Baseline Clinical Characteristics and Mitral Valve Score of 132 Patients in Whom Catheter Balloon Commissurotomy Was Attempted

Mitral CBC Procedure
Percutaneous mitral CBC was performed as previously described; the double-balloon technique8 was used in 83 patients, and the Inoue balloon4 was used in 49 patients in the later part of our experience. All patients had previously undergone clinical, echocardiographic/Doppler ultrasound evaluation and complete diagnostic cardiac catheterization and angiography to determine whether the patients needed interventional therapy for their MS.8 9 Complete right- and left-heart catheterization with determination of intracardiac and intravascular pressures, arterial and venous blood oxygen saturations by oximetry, and CO were performed immediately before and after CBC. CO was calculated according to the Fick principle with measured body oxygen consumption and, in most patients, also with thermodilution. Blood oxygen saturations were also determined after CBC to detect interatrial left-to-right shunts. The MVA was calculated both immediately before and after CBC according to the Gorlin formula23 using the CO determined with the Fick principle. Follow-up cardiac catheterization/angiography was performed in 68 patients between 3 and 6 months after CBC, in most as part of a research protocol.

Echocardiographic/Doppler Ultrasound Evaluation
M-mode and two-dimensional echocardiography and Doppler ultrasound were performed usually <=24 hours before CBC and initially both immediately and 24 hours after CBC.9 24 Additional studies were performed at 3 to 6 months in many patients, at 12 months after CBC, and annually thereafter. Transesophageal echocardiography was also performed before CBC in many patients in the past few years, mainly to exclude the presence of LA thrombus and also, in some patients, to obtain a better view of the mitral valve. The presence of MR was defined as a high-velocity jet that occurred in systole and extended from the mitral valve into the left atrium. Evaluations were made from the apical four-chamber view. The Doppler sample volume was moved throughout the entire left atrium to identify the maximal extent of the regurgitant jet. The regurgitant jet was graded as 1+ to 4+. The morphological features of the mitral valve were categorized as was previously described (USC scoring system).24 Each echocardiogram was evaluated with respect to valvular mobility and thickening, calcification, and subvalvular thickening. A score was assigned for each feature on a scale ranging from 0 to 2; leaflet motion and thickness were the only two echocardiographic features of the mitral valve morphology that were shown to be predictive of the immediate post-CBC MVA.24 To provide consistency in the echocardiographic readings, all echocardiograms were evaluated by one of the authors (Dr Kawanishi), who also rereviewed all of the early echocardiograms.

Follow-up Studies
Early follow-up was performed for clinical care at 2 to 4 or 4 to 6 weeks or as frequently as was clinically indicated. Subsequent clinical follow-up data were obtained at 3 to 6 months and at 12 months after CBC and at 1-year intervals thereafter as part of the research protocol; data were obtained more frequently for clinical care purposes if indicated. Predefined end points of follow-up and of events were death, MVR, or repeat CBC. All patients were seen in the Griffith Teaching/Research Center. Exercise treadmill tests (Bruce protocol)25 were performed in many patients before CBC as well as at 3 months and 1, 2, 3, and 4 years after CBC. Telephone interviews were conducted when visits to the Griffith Center were logistically impossible.

Statistical Analysis
Data are reported as mean±SD. A value of P<=.05 was considered to indicate statistical significance. Continuous data (eg, exercise treadmill times) were compared with the use of paired-sample t test. Kaplan-Meier estimates were used to determine total survival and event-free survival (defined as the absence of repeat CBC, MVR, or death).26 27 The first event (repeat CBC, MVR, or death) was considered to be an end point, and the patient was censored. However, for clinical interest, survival data that include deaths after MVR are also presented. Survival analysis was based on all 132 patients in whom the procedure was attempted.

Twenty-seven (16 baseline and 11 postprocedural) demographic, hemodynamic, and echocardiographic variables were evaluated by Cox proportional hazards regression to identify predictors of event-free survival.28 29 30 The 16 baseline variables were age, degree of MR, LVEDP (mm Hg), mean PAP (mm Hg), mean PAWP (mm Hg), LV ejection fraction, exercise treadmill time (seconds), MVA, indexed MVA, body surface area, MVG (mm Hg), mean LAP (mm Hg), sex, CO, CI according to the Fick principle, and the mitral valve echocardiographic score. The 11 post-CBC variables were MVA, indexed MVA, mean LAP, degree of MR, LVEDP, MVG, mean PAP, mean PAWP, CO, CI according to the Fick principle, and LV ejection fraction. Variables that were significant as continuous variables were selected for categorical analysis, and cutoff points were determined to define subgroups for comparison with the log rank statistic. For each categorical variable, Cox proportional hazard ratios were calculated, with the subgroup with the most favorable characteristic as the reference category. The hazard ratios from the Cox analysis were used as estimates of relative hazard.28 Kaplan-Meier probability of survival was calculated for each independent predictor at 1, 2, 3, 4, 5, 6, and 7 years.

To identify independent predictors of event-free survival, multiple stepwise (forward conditional) Cox regression analysis was performed with significant variables from the continuous univariate analysis. A model was constructed containing only baseline (postprocedural) variables. A second model was constructed that contained postprocedural variables, and both models were tested for two- and three-way interactions. The validity of the proportionality assumption was verified graphically.28 The two significant multivariate postprocedural predictors were entered into Kaplan-Meier survival analysis to determine event-free survival according to subgroup at 1, 2, 3, 4, 5, 6, and 7 years.


*    Results
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 *Results
down arrowDiscussion
 down arrowAddendum
 down arrowReferences
 
Immediate
Baseline clinical and echocardiographic characteristics of the study population are summarized in Table 1Up. CBC was completed successfully in 126 of the 132 patients (95%) in whom it was attempted. There were 6 (4.5%) "hospital deaths" (<=1 month after procedure). The causes of death were acute pulmonary edema/cardiogenic shock (1 functional class IV patient), LV perforation (2 patients), cardiac arrest during induction of anesthesia for MVR for acute 4+ MR (1 patient), cardiac arrest during attempted emergency CBC after resuscitation from a cardiac arrest (1 patient who was previously in functional class IV), and death after arrival in emergency department in a comatose state at 30 days after successful CBC, secondary to a cerebrovascular accident (possibly embolus or hemorrhage) (1 patient). In the past 4.5 years of the study during which CBC was performed in 69 of 132 patients (52%), the success rate was 100%, and there have been no hospital deaths.

CBC resulted in increases in the MVA (from 1.0±0.3 to 1.9±0.6 cm2), CO (from 4.1±1.2 to 4.6±1.3 L/min), and LVEDP (from 11.4±5 to 13.4±7 mm Hg) and decreases in the MVG (from 14.3±5.6 to 5.7±2.8 mm Hg), mean PAP (from 39.6±13.7 to 31.5±11 mm Hg), mean PAWP (from 26.4±8.1 to 17.5±5.6 mm Hg), and mean LAP (from 25.3±7 to 17.1±6 mm Hg) (P<.001 for all comparisons). LV ejection fraction showed no significant change (from 0.58±0.11 to 0.59±0.10).

In the 99 patients in whom MR was assessed by angiography immediately before and after CBC, the degree of MR was unchanged in 49 patients, increased by 1 grade in 17 patients, increased by 2 grades in 13, increased by >=3 grades in 7, and decreased in 13 patients (Table 2Down). After CBC, grade 3 or 4 MR was present in 6 of the 99 patients.


View this table:
[in this window]
[in a new window]
  		Table 2. MR Grade by LV Angiography Before and Immediately After CBC

Follow-up
Follow-up data for an average period of 29±29 months (range, 0 to 100 months) were available for all patients in whom CBC was attempted. Patients followed for 0 months were either "hospital" deaths or patients who left the country after the procedure. Among the 126 patients in whom the procedure was successfully completed, 25 (20%) had persistence or recurrence of symptoms that necessitated repeat CBC in 6 (4.5%) at an average time of 17±23 months (median, 9 months) after CBC and MVR in 19 (15%) at an average time of 18±25 months (median, 7 months) after CBC. After exclusion of patients who either had an event and were censored or were not available for follow-up at the last observation date, 73 patients remained available after 1 year for further observation, 58 remained at the end of 2 years, 44 remained at the end of 3 years, 34 remained at the end of 4 years, 25 remained at the end of 5 years, and 15 and 9 patients remained at the end of 6 and 7 years, respectively.

Of the 132 patients, there were 6 hospital deaths, and 3 patients were confirmed to have left the country; the follow-up period of the remaining patients was for 32.4±29.2 months (median, 24 months). Twenty-five patients reached a study end point (repeat CBC or MVR); follow-up for clinical care is available in these patients. Of the remaining 98 patients who have not reached a study end point, 77 (79%) had current follow-up at the time of data analysis; follow-up time of these patients was 41.7±27 months (median, 37 months), and in the 21 patients who were lost to follow-up, the follow-up time was 21.6±27 months (median, 7 months) before being lost to follow-up.

MVR or repeat CBC was performed in 25 patients (20%); all of these patients were in NYHA functional class III or IV. MVR was performed in 19 patients (15%). The indications for MVR were a persistence or recurrence of symptoms associated with an unsatisfactory result of CBC. Of the 19 patients, after CBC, 5 patients had MR grade 3 or 4, 7 had an immediate post-CBC MVA of <1.5 cm2, and 7 patients had an immediate post-CBC MVA of >=1.5 cm2 (of these 7, 6 had a mean PAWP of >18 mm Hg, and the post-CBC mean PAWP was not recorded in 1). Repeat CBC was performed in 6 patients (5%). The indications for repeat CBC were the same as for MVR; however, the valve was considered suitable for repeat CBC because of a low echocardiographic score and the absence of grade 3 or 4 MR. The repeat CBC was successful in each instance.

The actuarially determined overall survival rate at 7 years was 95±1% (Fig 1Down). When mortality after MVR (four deaths) was included, survival at 2 and 7 years was 93±2% and 83±6%, respectively (see Statistical Analysis). The probability of event-free survival (survival without MVR or repeat CBC) was 80±4% at 1 year, 77±4% at 3 years, and 65±6 at 7 years (Fig 1Down).



View larger version (14K):
[in this window]
[in a new window]
  		Figure 1. Actuarial curves showing the probability of survival and event-free survival (survival without MVR or repeat CBC) after CBC for MS. The post-MVR mortality is not included (see text). The number of patients available for survival analysis at the end of each year of follow-up was 73, 58, 44, 34, 25, 15, and 9, respectively.

There were no strokes and no systemic emboli except for the one hospital death at 30 days; patients who were in atrial fibrillation were treated with long-term anticoagulants.

At 3 months after CBC, 59% of patients were in functional class I, 30% were in class II, 10% were in class III, and 1 patient was in class IV. The percentage of patients in functional class III and IV at 1, 5, and 7 years of follow-up was 6%, 22%, and 0%, respectively. All functional class III and IV patients were offered MVR or repeat CBC; thus, those in functional class III and IV varied from year to year. Some patients who were offered MVR refused the procedure. At last follow-up, of 77 patients (above), 6 (7.8%) were in functional class III, and the remaining patients were in functional class I and II.

The treadmill time (seconds) for patients in functional class I or II before CBC was 435±179 (n=22) versus 330±151 (n=78) for those in functional class III or IV (P=.007) (Table 3Down). At 3 months after CBC, treadmill time for patients in functional class I or II was 501±190 (n=61) compared with 236±149 (n=7) for patients in functional class III or IV (P<.001). The treadmill times of the patients at 1, 2, 3, and 4 years after CBC are shown in Table 3Down. Patients who were in NYHA functional class I or II had significantly longer exercise treadmill times at 3-month and 1- and 2-year follow-up than those in functional class III or IV (Table 3Down).


View this table:
[in this window]
[in a new window]
  		Table 3. CBC for MS Exercise Treadmill Time by NYHA Functional Class

Predictors Of Event-Free Survival
The continuous univariate Cox analysis identified four baseline and eight postprocedural clinical, hemodynamic, and echocardiographic variables as potential predictors of long-term event-free survival after CBC.

Baseline Predictors
Direct univariate baseline predictors included LVEDP, age, degree of MR, and mean PAP (P<.05 for all four). Twelve other baseline variables were LV ejection fraction, exercise treadmill times, MVA, indexed MVA, body surface area, MVG, mitral valve echocardiographic score, mean PAWP, mean LAP, sex, CO, and CI by the Fick principle were not significant predictors of long-term outcome. In the stepwise multivariate Cox analysis of baseline variables, there were no independent predictors of longer event-free survival.

Immediate Post-CBC Predictors
Continuous univariate postprocedural predictors included MVA, indexed MVA, mean LAP, degree of MR, LVEDP, MVG, mean PAP, and mean PAWP. CO, CI, and LV ejection fraction were not significant postprocedural predictors of long-term outcome. For these significant univariate predictors, clinically reasonable categories were identified and compared by the log-rank statistic.

As categorical variables, one baseline and seven postprocedural variables were significant univariate predictors of long-term outcome. The predicted rates of event-free survival for subgroups defined according to these variables were estimated at yearly intervals (Table 4Down).


View this table:
[in this window]
[in a new window]
  		Table 4. Categorical Predictors of Event-Free Survival After CBC According to the Univariate Analysis

Multivariate Analyses
In contrast to the baseline variables, when hemodynamic variables measured immediately after the procedure were included in the stepwise multivariate analysis, the post-CBC MVA (P=.003) and post-CBC mean PAWP (P=.001) emerged as the only statistically significant predictors of long-term outcome. None of the baseline variables in the predictive model were significant factors in the determination of long-term outcome. Actuarial event-free survival after CBC was 75±7% at 7 years in 96 patients with MVA of >=1.5 cm2 versus 32±12% in 24 patients with MVA of <1.5 cm2 (P<.001) (Fig 2Down).



View larger version (15K):
[in this window]
[in a new window]
  		Figure 2. Actuarial curves showing the probability of event-free survival after CBC for MS according to the immediate post-CBC MVA of >=1.5 cm2 versus <1.5 cm2.

Patients with MVA of >=1.5 cm2 (n=96) could be further divided into high- and low-risk subgroups for 7-year event-free survival by three post-CBC variables. In patients with MVA of >=1.5 cm2 and mean PAWP of <=18 mm Hg, the actuarial 7-year survival was 90±6% versus 48±14% in those with MVA of >=1.5 cm2 and mean PAWP >18 mm Hg (P=.0002) (Fig 3Down). In patients with post-CBC MVA of >=1.5 cm2 and CI of >=2.5 L·min-1·m-2, the actuarial 7-year event-free survival was 82±8% versus 61±13% in those with a CI value of <2.5 L·min-1·m-2 (P=.004) (Fig 4Down). Patients with MVA of >=1.5 cm2 and mean PAP of <30 mm Hg had an actuarial 7-year event-free survival rate of 89±6% versus 61±12% in those with mean PAP of >=30 mm Hg (P=.09). Patients whose post-CBC MVA was <1.5 cm2 (n=24) had no additional predictors of event-free survival.



View larger version (16K):
[in this window]
[in a new window]
  		Figure 3. Actuarial curves showing the probability of event-free survival after CBC for MS according to the immediate post-CBC MVA of >=1.5 cm2 and mean PAWP of <=18 versus >18 mm Hg.



View larger version (15K):
[in this window]
[in a new window]
  		Figure 4. Actuarial curves showing the probability of event-free survival after CBC for MS according to the immediate post-CBC MVA of >=1.5 cm2 and CI of >=2.5 versus 2.5 L·min-1·m-2.


*    Discussion
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 up arrowResults
 *Discussion
down arrowAddendum
 down arrowReferences
 
Our study demonstrates that CBC for MS was successfully completed in 95% of patients in whom it was attempted. The actuarial 7-year survival was 95±1%; the event-free survival was 65±6%. Independent predictors of event-free survival on multivariate analysis were MVA of >=1.5 cm2 and mean PAWP of <=18 mm Hg immediately after the CBC; the best subgroup of patients were those who had an MVA value of >=1.5 cm2 and a mean PAWP of <=18 mm Hg. Most of the patients were functionally improved initially; this improvement was largely maintained on further follow-up and was documented by an increase in exercise treadmill times.

The overall success rate was 95%, which is similar to that reported by others.31 32 The "hospital" (30-day) mortality rate was 4.5%. Both of these were at least partly related to a "learning phase" with regard to selection of suitable patients for the procedure and reduction in complications, such as perforation of the left ventricle. In the past 4.5 years of the study during which CBC was performed in 69 patients (52%), the success rate has been 100% and there have been no hospital deaths. The early death rate is similar to that observed by other investigators (from 1% to 9%) and in the multicenter NHLBI Registry (3%)19 31 32 33 (also see below). Of the six hospital deaths in our study, one was due to an out-of-hospital cerebrovascular accident (possibly embolus or hemorrhage) 30 days after CBC, and one occurred in a patient who was in extremis before the CBC. The hospital mortality for closed surgical commissurotomy in the early era of surgery ranged from <1% to 19%34 35 36 and later dropped to 3.4% and 3.7%.37 38 39 40 Subsequently, the operative mortality of closed/open surgical commissurotomy in the late 1960s to mid-1984 ranged from 0% to 2.3%.41 42 43 44 45 46 47 48 49 50 Patients entered into randomized trials of CBC versus surgery after the "learning phase" of CBC was at least partly completed, the hospital mortality of CBC and of surgical commissurotomy were not significantly different.10 11 12 13

We previously documented that at 3 months after CBC, patients maintain the increase in MVA as well as the reductions in mean PAWP and mean PAP, not only at rest but also at an increased level of exercise.9 In a preliminary report, we showed that these hemodynamic improvements were still present at 3 years after CBC.51 The lower mean PAWP (indirect LAP) at exercise is the major hemodynamic reason9 for the observed improvement in symptomatic state (NYHA functional class), which was documented objectively by an improvement in exercise treadmill times9 (Table 3Up).

The overall actuarial 7-year survival rate was 95±1%. This does not include the four late deaths, all of which were hospital deaths that occurred after MVR, which was performed at an average follow-up time of 18±25 months (median, 7 months). These are not included in the overall survival rate because MVR was an end point of the study; including these deaths, the 7-year survival was 83±6%. In the NHLBI Registry, the patients were also censored at the time of subsequent mitral valve surgery or repeat CBC.52

MVR or repeat CBC was performed in 25 patients (20%; MVR in 19 [15%] and repeat CBC in 6 [5%]). These findings are similar to those reported by others; Cohen et al31 reported that 18% of patients underwent subsequent MVR or repeat CBC, and Palacios et al53 reported that 21% of their patients underwent MVR at 4 years of follow-up.

We previously documented that the use of an objective quantitative echocardiographic scoring system (USC scoring system) of 0 to 4 was the best predictor of the MVA immediately after CBC.24 Similar observations have been made about a subjective semiquantitative echocardiographic (MGH) scoring system19 54 ; the r value for a change in MVA after CBC using the latter system was -0.40 in the MGH study55 and -0.15 in the NHLBI Registry.32 Using the USC scoring system, 46% and 51% of patients with a pre-CBC score of 0 and 1 to 2, respectively, achieved a post-CBC MVA of >=2.0 cm2. Furthermore, 78% and 84% of patients with a score of 0 or 1 to 2, respectively, achieved an MVA of >=1.5 cm2, but only 3 of 10 patients (30%) with a score of 3 or 4 achieved an MVA of >=1.5 cm2.

The event-free actuarial 7-year survival was 65±6%; however, in various subgroups, it ranged from 90% to 13% (Figs 2 through 4UpUpUp). By univariate analysis, there were several predictors of event-free survival. However, by multivariate analysis, only two post-CBC variables (MVA of >=1.5 cm2 and mean PAWP of <=18 mm Hg) were statistically significant independent predictors of an event-free 7-year survival. Patients with a post-CBC MVA of >=1.5 cm2 and a mean PAWP of <=18 mm Hg had the best 7-year event-free survival of 90±6% (Fig 3Up). In our study, 96 of all patients (73%) achieved an MVA of >=1.5 cm2, and 59 patients (45%) fit into the category for the best 7-year result (post-CBC MVA of >=1.5 cm2 and mean PAWP of <=18 mm Hg). Of interest, patient 29 in our series was age 21 years and in functional class III before CBC and had a mitral valve score of 1, an MVA of 0.70 cm2, and mean PAWP of 32 mm Hg. After CBC, she had an MVA of 2.1 cm2 and a mean PAWP of 14 mm Hg. At 7 years after CBC, she has had 4 uneventful pregnancies and is minimally symptomatic with full unrestricted activity taking care of her family and the house.

Of patients with pre-CBC score of 0 and 1 or 2, 54% and 51% of patients had a post-CBC MVA of >=1.5 cm2 and mean PAWP of <18 mm Hg, and only 1 patient (10%) with a score of 3 or 4 fit into this best category. The pre-CBC echocardiographic score was not a statistically significant independent predictor of 7-year event-free survival; this is probably because the pre-CBC echocardiographic score is the best predictor of the immediate post-CBC MVA.19 20 24 32 Most patients (>80%) with an echocardiographic score of 0, 1, or 2 achieved an MVA of >=1.5 cm2 immediately after CBC. It is reasonable that the MVA and the hemodynamics present after CBC should represent an excellent and/or best predictor of the subsequent outcome.

Other studies have reported 4- and 5-year results after CBC. Cohen and coworkers31 reported follow-up data on 145 patients for a period averaging 36±20 months. The number of patients available for observation at the end of each time period was not given. The actuarial 5-year survival was 76%, and actuarial event-free survival was 51%, which is lower than that seen in the present study. Palacios et al53 reported on 320 patients who survived the procedure; the follow-up time averaged 20±12 months. On follow-up, after the patients who died or were censored at time of either MVR or development of NYHA functional class III or IV, the number of patients remaining for observation at the end of 1, 2, 3, and 4 years were 218, 106, 36, and 12, respectively. At 4 years, the actuarial survival was 90±4%; the actuarial event-free survival was 66%, with a 95% confidence interval of 57% to 75%. In the preliminary report from the NHLBI Registry,52 at a mean follow-up of 3.2 years, at 4 years the actuarial survival was 84% and the actuarial event-free survival was 60%. The number of patients available for observation at the end of 4 years was 141. Multivariate predictors of mortality included NYHA class IV, higher echocardiographic score, higher postprocedural PA systolic pressure, and higher LVEDP (P<=.01).

It is important to keep in mind that patient-related factors influence the results and outcome of a procedure and the incidence of these factors may be different in the various studies.56 For example, the ages of patients in various US studies were 59±15 years31 and 55±5 years19 ; in the NHLBI Registry, patient age was 54±15 years for women and 55±14 years for men.32 In our study, the patient age was 44±14 years, and the median age was 43.5 years. In a study from France, the age was 43±16 years.20 The ages of the patients in the four randomized trials from Asia and South Africa averaged 19, 27, 30, and 30 years.10 11 12 13 The review of Carroll and Feldman16 documented that the mean ages of patients reported from China, Saudi Arabia, India, Korea, and South Africa were in the 20- to 39-year age group16 ; the study from Japan reported patient age as 53±11 years. However, age may not be as important a factor as morphology of the valve; in other words, the patient with a morphologically suitable valve for CBC may get a good result from CBC regardless of the age of the patient. In two of the US studies, 34%31 and 14%19 were in NYHA functional class IV; NYHA functional class IV was present in 13% in the NHLBI Registry and 9% in our study. Most studies do not present "hospital" (ie, 30-day) mortality, as is recommended for surgical studies. In the NHLBI Registry, 64 of the patients (9%) were excluded because of unknown vital status at 30 days.33 The hospital (30-day) mortality in the remaining patients, therefore, was 25 of 674 (3.7%); in year 1 of the registry, it was 5%, and in year 2, it was 2%.32 In our study, the 30-day mortality was 4.5%. However, our study was initiated almost 2 years before the NHLBI Registry; in our study, in the last 4.5 years of the study (when 52% of the patients were studied), there was no 30-day mortality.

The long-term (<=25 years) results of closed surgical commissurotomy are good and are particularly excellent in patients who had characteristics that would make them the best candidates for CBC.57 The long-term results of open versus closed surgical commissurotomy are similar.58 The short-term results from randomized trials of CBC versus closed or open surgical commissurotomy are not significantly different10 11 12 13 ; nonrandomized studies yielded similar conclusions.59 Our data show that the 7-year results of CBC are good and are excellent in selected subgroups of patients. These findings of favorable intermediate-term results strengthen the previous conclusions14 17 53 58 59 60 61 that CBC should be the procedure of first choice in selected patients in centers with experience and skill in performing this procedure.


*    Addendum
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 up arrowResults
 up arrowDiscussion
 *Addendum
down arrowReferences
 
Since submission of our manuscript, Jung and coworkers (J Am Coll Cardiol. 1996;27:407-414) reported on 528 patients who underwent CBC from 1986 to 1992. Forty patients underwent a repeat mitral valve procedure (35 had surgery and 5 had repeat CBC), and 22 were in NYHA class III or IV but did not undergo a reoperation. At 5 years, survival was 93±4%, survival without repeat procedure was 84±6%, and survival without repeat procedure and in class I or II was 76±6% (38 patients at risk).


*    Selected Abbreviations and Acronyms
 
CBC = catheter balloon commissurotomy
CI = cardiac index
CO = cardiac output
LA = left atrial
LAP = left atrial pressure
LV = left ventricular
LVEDP = left ventricular end-diastolic pressure
MR = mitral regurgitation
MS = mitral stenosis
MVA = mitral valve area
MVG = mitral valve gradient
MVR = mitral valve replacement
NHLBI = National Heart, Lung, and Blood Institute
NYHA = New York Heart Association
PAP = pulmonary artery pressure
PAWP = pulmonary artery wedge pressure


*    Footnotes
 
Presented in part at the 44th Annual Scientific Sessions of the American College of Cardiology, New Orleans, La, March 20, 1995.

Received January 10, 1996; revision received August 19, 1996; accepted September 1, 1996.


*    References
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 up arrowResults
 up arrowDiscussion
 up arrowAddendum
 *References
 

  1. 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;87:394-402.[Abstract]
  2. Lock JE, Khalilullah M, Shrivastava S, Bahl V, Keane JF. Percutaneous catheter commissurotomy in rheumatic mitral stenosis. N Engl J Med. 1985;313:1515-1518.[Abstract]
  3. Al Zaibag M, Ribeiro PA, Al Kasab S, Al Fagih MR. Percutaneous double-balloon mitral valvotomy for rheumatic mitral valve stenosis. Lancet. 1986;1:757-761.[Medline] [Order article via Infotrieve]
  4. Nobuyoshi M, Hamashaki N, Kimura T, Nosaka H, Yokoi H, Yasumoto H, Horiuchi H, Shindo T, Mori T, Miyamoto AT, Inoue K. Indications, complications, and short-term clinical outcome of percutaneous transvenous mitral commissurotomy. Circulation. 1989;80:782-792.[Abstract/Free Full Text]
  5. Rahimtoola SH. Catheter balloon valvuloplasty of aortic and mitral stenosis in adults: 1987. Circulation. 1987;75:895-901. Editorial.[Abstract/Free Full Text]
  6. Palacios IF, Block PC, Brandi S, Blanco P, Casal H, Pulido JI, Munoz S, D'Empair G, Ortega MA, Jacobs M, Vlahakes G. Percutaneous balloon valvotomy for patients with severe mitral stenosis. Circulation. 1987;75:778-784.[Abstract/Free Full Text]
  7. McKay RG, Lock JE, Safian RD, Come PC, Diver DJ, Baim DS, Berman AD, Warren SE, Mandell VE, Royal HD, Grossman W. Balloon dilation of mitral stenosis in adult patients: postmortem and percutaneous mitral valvuloplasty studies. J Am Coll Cardiol. 1987;9:723-731.[Abstract]
  8. McKay CR, Kawanishi DT, Rahimtoola SH. Catheter balloon valvuloplasty of the mitral valve in adults using a double-balloon technique. JAMA. 1987;257:1753-1761.[Abstract]
  9. McKay CR, Kawanishi DT, Kotlewski A, Parise K, Odom-Maryon T, Gonzalez A, Reid CL, Rahimtoola SH. Improvement in exercise capacity and exercise hemodynamics 3 months after double balloon catheter balloon valvuloplasty in the treatment of patients with symptomatic mitral stenosis. Circulation. 1988;77:1013-1021.[Abstract/Free Full Text]
  10. Patel JJ, Shama D, Mitha AS, Blyth D, Hassen F, LeRoux BT, Chetty S. Balloon valvuloplasty versus closed commissurotomy for pliable mitral stenosis: a prospective hemodynamic study. J Am Coll Cardiol. 1991;18:1318-1322.[Abstract]
  11. Arora R, Nair M, Kalra GS, Nigam N, Khalilullah M. Immediate and long-term results of balloon and surgical closed mitral valvotomy: a randomized comparative study. Am Heart J. 1993;125:1091-1094.[Medline] [Order article via Infotrieve]
  12. Turi ZG, Reyes VP, Raju S, Raju R, Kumar DN, Rajagopal P, Sathyanarayana PV, Rao P, Srinath K, Peters P, Conners B, Fromm B, Farkas P, Wynne J. Percutaneous balloon versus surgical closed commissurotomy for mitral stenosis: a prospective randomized trial. Circulation. 1991;83:1179-1185.[Abstract/Free Full Text]
  13. Reyes VP, Raju S, Wynne J, Stephen LW, Raju R, Fromm BS, Rajagopal P, Mehta P, Singh S, Rao P, Satvanarayana PV, Turi ZG. Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med. 1994;331:961-967.[Abstract/Free Full Text]
  14. Rahimtoola SH. Perspective on valvular heart disease: an update. J Am Coll Cardiol. 1989;14:1-23.[Medline] [Order article via Infotrieve]
  15. Kulick DL, Reid CL, Kawanishi DT, Rahimtoola SH. Catheter balloon commissurotomy in adults, Part II: mitral and other stenoses. Curr Probl Cardiol. 1990;15:399-470.
  16. Carroll JD, Feldman T. Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis. JAMA. 1993;270:1731-1736.[Abstract]
  17. Kawanishi DT, Rahimtoola SH. Catheter balloon commissurotomy for mitral stenosis: complications and results. J Am Coll Cardiol. 1992;19:192-195. Editorial.[Medline] [Order article via Infotrieve]
  18. Lau KW, Ding ZP, Hung JS. Percutaneous balloon mitral commissurotomy: an update. J Invas Cardiol. 1994;6:145-152.[Medline] [Order article via Infotrieve]
  19. Palacios IF, Block PC, Wilkins GT, Weyman AE. Follow-up of patients undergoing percutaneous mitral balloon valvotomy: analysis of factors determining restenosis. Circulation. 1989;79:573-579.[Abstract/Free Full Text]
  20. Vahanian A, Michel PL, Cormier B, Vitoux B, Michel X, Slama M, Sarano E, Trabelsi S, Ismail MB, Acar J. Results of percutaneous mitral commissurotomy in 200 patients. Am J Cardiol. 1989;63:847-852.[Medline] [Order article via Infotrieve]
  21. Cheng CR, Cheng TO, Chen JY, Zhou YL, Mei J, Ma TJ. Long-term results of percutaneous mitral valvuloplasty with the Inoue balloon catheter. Am J Cardiol. 1992;70:1445-1448.[Medline] [Order article via Infotrieve]
  22. Feldman T. Hemodynamic results, clinical outcome, and complications of Inoue balloon valvotomy. Cathet Cardiovasc Diagn. 1994;suppl 2:2-7.
  23. Cohen MV, Gorlin R. Modified orifice equation for the calculation of mitral valve area. Am Heart J. 1972;84:839-840.[Medline] [Order article via Infotrieve]
  24. Reid CL, Chandraratna PAN, 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;80:515-524.[Abstract/Free Full Text]
  25. Bruce RA, Hornsten TR. Exercise stress testing in the evaluation of patients with ischemic heart disease. Prog Cardiovasc Dis. 1969;11:371-390.[Medline] [Order article via Infotrieve]
  26. Grunkemeier GL, Starr A. Actuarial analysis of surgical results: rationale and method. Ann Thorac Surg. 1977;24:404-408.[Abstract]
  27. Lee E, Desu M. A computer program for comparing K samples with right sensored data. Comput Methods Programs Biomed. 1972;2:315-321.
  28. Katz MH, Hauck WW. Proportional hazards (Cox) regression. J Gen Intern Med. 1993;8:702-710.[Medline] [Order article via Infotrieve]
  29. Norusis MJ. SPSS for Windows Advanced Statistics Release 6.0. Chicago, Ill: SPSS; 1993:275-312.
  30. Walter SD, Feinstein AR, Wells CK. A comparison of multivariable mathematical methods for predicting survival-II. Statistical selection of prognostic variables. J Clin Epidemiol. 1990;4:349-359.
  31. Cohen DJ, Kuntz RE, Gordon SPF, Piana RN, Safian RD, McKay RG, Baim DS, Grossman W, Diver DJ. Predictors of long-term outcome after percutaneous mitral valvuloplasty. N Engl J Med. 1991;327:1329-1335.[Abstract]
  32. The National Heart, Lung, and Blood Institute Valvuloplasty Registry Participants. Multicenter experience with balloon mitral commissurotomy: NHLBI Balloon Valvuloplasty Registry Report on immediate and 30-day follow-up results. Circulation. 1992;85:448-461.[Abstract/Free Full Text]
  33. The National Heart, Lung, and Blood Institute. Complications and mortality of percutaneous balloon mitral commissurotomy: a report from the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry. Circulation. 1992;86:2014-2024.
  34. Ellis LB, Singh JB, Morales DD, Harken DE. Fifteen to twenty-year study of one thousand patients undergoing closed mitral valvuloplasty. Circulation. 1973;48:357-364.[Abstract/Free Full Text]
  35. Nathaniels EK, Moncure AC, Scannell JG. A fifteen-year follow-up study of closed mitral valvuloplasty. Ann Thorac Surg. 1970;10:27-36.[Medline] [Order article via Infotrieve]
  36. Rutledge R, McIntosh CL, Morrow AG, Picken CA, Siwek LG, Zwischenberger, Schier JJ. Mitral valve replacement after closed mitral commissurotomy. Circulation. 1982;66(suppl I):I-162-I-166.
  37. John S, Bashi VV, Jairaj PS, Muralidharan S, Ravikumar E, Rajarajeswari T, Krishnaswami S, Sukumar IP, Sundar Rao PSS. Closed mitral valvotomy: early results and long-term follow-up of 3,724 consecutive patients. Circulation. 1983;68:891-896.[Abstract/Free Full Text]
  38. Hoeksema TD, Wallace RB, Kirklin JW. Closed mitral commissurotomy: recent results in 291 cases. Am J Cardiol. 1966;17:825-828.
  39. Grantham RN, Daggett WM, Cosimi AB, Buckley MJ, Mundth ED, McEnany MT, Scannell JG, Austen WG. Transventricular mitral valvulotomy: analysis of factors influencing operative and late results. Circulation. 1974;49-50(suppl II):II-200-II-212.
  40. Mullin MJ, Engelman RM, Isom W, Boyd AD, Glassman E, Spencer FC. Experience with open mitral commissurotomy in 100 consecutive patients. Surgery. 1974;76:974-982.[Medline] [Order article via Infotrieve]
  41. Housman LB, Bonchek L, Lambert L, Grunkemeier G, Starr A. Prognosis of patients after open mitral commissurotomy. J Thorac Cardiovasc Surg. 1977;73:742-745.[Abstract]
  42. Aaron BL, Lowes RR. Advantages of open mitral commissurotomy using a triple-orifice technique. Ann Thorac Surg. 1975;19:654-658.[Abstract]
  43. Smith WM, Nevtze JM, Barratt-Boyes BG, Lowe JB. Open mitral valvotomy: effect of preoperative factors on result. J Thorac Cardiovasc Surg. 1981;82:738-751.[Abstract]
  44. Montoya A, Mulet J, Pifarre R, Moran JM, Sullivan HJ. The advantages of open mitral commissurotomy for mitral stenosis. Chest. 1979;75:131-135.[Abstract/Free Full Text]
  45. Vega JL, Fleitas M, Martinez R, Gallo JI, Gutierrez JA, Colman T, Duran CMG. Open mitral commissurotomy. Ann Thorac Surg. 1981;31:266-270.[Abstract]
  46. Halseth WL, Elliott DP, Walker EL, Smith EA, Eiseman B. Open mitral commissurotomy: a modern reappraisal. J Thorac Cardiovasc Surg. 1980;80:842-848.[Abstract]
  47. Gross RI, Cunningham JN, Snively S, Catinella FP, Nathan IM, Adams PX, Spencer FC. Long-term results of open radical mitral commissurotomy: ten year follow-up study of 202 patients. Am J Cardiol. 1981;47:821-825.[Medline] [Order article via Infotrieve]
  48. Laschinger JC, Cunningham JN, Baumann FG, Isom OW, Catinella FP, Mendelson A, Adams PX, Spencer FC. Early open radical commissurotomy: surgical treatment of choice for mitral stenosis. Ann Thorac Surg. 1982;34:287-298.[Abstract]
  49. Nakano S, Kawashima Y, Hirose H, Matsuda H, Shirakura R, Sato S, Taniguchi K, Kawamoto T, Sakaki S, Ohyama C. Reconsiderations of indications for open mitral commissurotomy based on pathologic features of the stenosed mitral valve. J Thorac Cardiovasc Surg. 1987;94:336-342.[Abstract]
  50. Cohn LH, Allred EN, Cohn LA, Disease VJ, Shemin RJ. Long-term results of open mitral valve reconstruction for mitral stenosis. Am J Cardiol. 1985;55:731-734.[Medline] [Order article via Infotrieve]
  51. Kawanishi DT, Lopez B, Orrange S, Curry S, Rahimtoola S. Late cardiac catheterization results of catheter balloon commissurotomy for mitral stenosis at rest and exercise. J Am Coll Cardiol. 1995;25:403A. Abstract.
  52. Dean LS, Mickel M, Bonan R, Palacios IF, Rahimtoola SH, Davis K, Kennedy JW. Long-term follow-up of patients undergoing percutaneous balloon mitral commissurotomy: a report from the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry. Circulation. 1994;90:I-65. Abstract.
  53. Palacios IF, Tuzcu ME, Weyman AE, Newell JB, Block PC. Clinical follow-up of patients undergoing percutaneous mitral balloon valvotomy. Circulation. 1995;91:671-676.[Abstract/Free Full Text]
  54. Wilkins GT, Weyman AE, Abscal BM, Block PC, Palacios IF. Percutaneous mitral valvotomy: an analysis of echocardiographic variables related to outcome in a mechanism of dilation. Br Heart J. 1988;60:299-308.[Abstract/Free Full Text]
  55. Abascal VM, Wilkins GT, O'Shea JP, Choong CY, Palacios IF, Thomas JD, Rosas E, Newell JB, Block PC, Weyman AE. Prediction of successful outcome in 130 patients undergoing percutaneous balloon mitral valvotomy. Circulation. 1990;82:448-456.[Abstract/Free Full Text]
  56. Rahimtoola SH. Lessons learned about the determinants of the results of valve surgery. Circulation. 1988;78:1503-1507. Editorial.[Free Full Text]
  57. Rihal CS, Schaff HV, Frye RL, Bailey KR, Hammes LN, Holmes DR Jr. Long-term follow-up of patients undergoing closed transventricular mitral commissurotomy: a useful surrogate for percutaneous balloon mitral valvuloplasty? J Am Coll Cardiol. 1992;20:781-786.[Abstract]
  58. Hickey MS, Blackstone EH, Kirklin JW, Dean LS. Outcome probabilities and life history after surgical mitral commissurotomy: implications for balloon commissurotomy. J Am Coll Cardiol. 1991;17:29-42.[Abstract]
  59. Dean LS. Percutaneous transvenous mitral commissurotomy: a comparison to the closed and open surgical techniques. Cathet Cardiovasc Diag. 1994;suppl 2:76-81.
  60. Rahimtoola SH. Perspective on valvular heart disease: update II. In: Knoebel S, Dack S, eds. An Era in Cardiovascular Medicine. New York, NY: Elsevier; 1991:45-70.
  61. Kirklin JW. Percutaneous balloon versus surgical closed commissurotomy for mitral stenosis. Circulation. 1991;83:1450-1451. Editorial.[Free Full Text]



This article has been cited by other articles:


Home page
 CirculationHome page
2006 WRITING COMMITTEE MEMBERS, R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, et al.
2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
Circulation, October 7, 2008; 118(15): e523 - e661.
[Full Text] [PDF]

Home page
 CirculationHome page
M.-J. Kim, J.-K. Song, J.-M. Song, D.-H. Kang, Y.-H. Kim, C. W. Lee, M.-K. Hong, J.-J. Kim, S.-W. Park, and S.-J. Park
Long-Term Outcomes of Significant Mitral Regurgitation After Percutaneous Mitral Valvuloplasty
Circulation, December 19, 2006; 114(25): 2815 - 2822.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
A. D. Zimmet, A. A. Almeida, R. W. Harper, J. J. Smolich, J. Goldstein, G. C. Shardey, and J. A. Smith
Predictors of surgery after percutaneous mitral valvuloplasty.
Ann. Thorac. Surg., September 1, 2006; 82(3): 828 - 833.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al.
ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons
J. Am. Coll. Cardiol., August 1, 2006; 48(3): e1 - e148.
[Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al.
ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons
J. Am. Coll. Cardiol., August 1, 2006; 48(3): 598 - 675.
[Full Text] [PDF]

Home page
 Eur Heart JHome page
B. Iung, A. Nicoud-Houel, O. Fondard, H. Akoudad, T. Haghighat, E. Brochet, E. Garbarz, B. Cormier, G. Baron, P. Luxereau, et al.
Temporal trends in percutaneous mitral commissurotomy over a 15-year period
Eur. Heart J., April 2, 2004; 25(8): 701 - 707.
[Abstract] [Full Text] [PDF]

Home page
 Eur Heart JHome page
H Gamra, F Betbout, K Ben Hamda, F Addad, F Maatouk, Z Dridi, S Hammami, M Abdellaoui, H Boughanmi, T Hendiri, et al.
Balloon mitral commissurotomy in juvenile rheumatic mitral stenosis: a ten-year clinical and echocardiographic actuarial results
Eur. Heart J., July 2, 2003; 24(14): 1349 - 1356.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
S. H. Rahimtoola, A. Durairaj, A. Mehra, and I. Nuno
Current Evaluation and Management of Patients With Mitral Stenosis
Circulation, September 3, 2002; 106(10): 1183 - 1188.
[Full Text] [PDF]

Home page
 Eur Heart JHome page
B. Iung, C. Gohlke-Barwolf, P. Tornos, C. Tribouilloy, R. Hall, E. Butchart, and A. Vahanian
Recommendations on the management of the asymptomatic patient with valvular heart disease
Eur. Heart J., August 2, 2002; 23(16): 1253 - 1266.
[PDF]