Poor outcome following percutaneous balloon mitral valvotomy in patients with atrial fibrillation

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1 J Crdiovsc Thorc Res, 2016, 8(3), doi: /jcvtr TUOMS Publishing Group Originl Article Poor outcome following percutneous blloon mitrl vlvotomy in ptients with tril fibrilltion Nser Aslnbdi, Smd Ghffri, Nser Khezerlouy Aghdm *, Msoumeh Ahmdzde, Bbk Kzemi, Bbk Nsiri, Ahmd Seprhm, Bhrm Sohrbi, Mohmdrez Tbn, Arsh Aslnbdi Crdiovsculr Reserch Center, Tbriz University of Medicl Sciences, Tbriz, Irn Article info Article History: Received: 5 June 2016 Accepted: 28 September 2016 epublished: 30 September 2016 Keywords: Mitrl Stenosis Blloon Mitrl Vlvotomy Atril Fibrilltion Abstrct Introduction: Atril fibrilltion (AF) is the most common rrhythmi in ptients with mitrl stenosis (MS) nd it my increse complictions nd decreses success rtes of percutneous blloon mitrl vlvotomy (PBMV). This study imed to investigte the short nd long term results of PBMV in ptients with AF compred to sinus rhythm (SR). Methods: In this cross sectionl study, 1000 ptients with MS who hd undergone PBMV between 1999 nd 2013 were enrolled including 585 nd 415 ptients with AF nd SR respectively. Ptients were followed for men of 7.27 ± 3.16 yers. Clinicl, echocrdiogrphic nd hemodynmic dt were collected. Procedure success, in-hospitl nd long-term outcome were evluted. Results: Ptients with AF were older nd hd greter symptoms, mitrl regurgittion, mitrl echocrdiogrphic score, nd mitrl pressure grdient before PBMV. PBMV success rte were significntly lower in AF group (P < 0.001). In-hospitl complictions, including severe mitrl regurgittion, emergency mitrl vlve surgery, peripherl embolism nd long-term complictions, including mortlity, re-vlvotomy, mitrl replcement surgery nd peripherl embolism/stroke were significntly higher in ptients with AF. Conclusion: AF leds to worse in-hospitl nd long-term outcome nd lower PBMV success rte. Repeted ssessment nd erly decision to PBMV in ptients with MS to reduce AF nd AF relted compliction seems necessry. Plese cite this rticle s: Aslnbdi N, Ghffri S, Khezerlouy Aghdm N, Ahmdzde M, Kzemi B, Nsiri B, Sohrbi B, Seprhm A, Tbn M, Aslnbdi A. Poor outcome following percutneous blloon mitrl vlvotomy in ptients with tril fibrilltion. J Crdiovsc Thorc Res 2016;8(3): doi: /jcvtr Introduction Mitrl stenosis (MS) is still public helth problem in developing countries. 1,2 Percutneous blloon mitrl vlvotomy (PBMV) is performed s preferred lterntive to surgery for most ptients with hemodynmiclly significnt MS. 3-9 Atril fibrilltion (AF) is the most common rrhythmi tht occurs in 40%-75% of symptomtic ptients with MS. 10,11 Severl studies hve shown tht AF ffects short nd long term outcomes nd the mortlity risk of PBMV nd in most cses it hs been ssocited with decresed success rte of PBMV nd worse clinicl outcome So considering tht the previous studies hve been conducted on smller number of ptients, this study imed t investigting the immedite success rtes of PBMV, short nd long term results, nd mortlity risk in ptients with MS nd AF compred to sinus rhythm (SR) in lrge dt bse. Mterils nd Methods Between 1999 nd 2013, bout 1800 ptients underwent PBMV t our tertiry hert center. Out Of these, 1000 consecutive ptients who hd complete informtion requirements on their files were enrolled in this cross sectionl study. All ptients were divided into two groups bsed on initil crdic rhythm (SR vs. AF). In ech group, demogrphic vribles such s ge, gender nd clinicl vribles, including the severity of dyspne ccording to New York Hert Assocition functionl clss (NYHA-FC), echocrdiogrphic vribles including MS echocrdiogrphic score, nd the mitrl vlve re (MVA) before nd fter PBMV nd hemodynmic vribles such s men left tril pressure (LAP), men trnsmitrl pressure grdient (mtmpg) nd pulmonry rtery systolic pressure (spap) levels were checked nd the results were compred between the two groups. In-hospitl complictions in- *Corresponding uthor: Nser Khezerlouy Aghdmi, Emil: nkhezerlou90@gmil.com 2016 The Author(s). This is n open ccess rticle distributed under the terms of the Cretive Commons Attribution License ( org/licenses/by/4.0), which permits unrestricted use, distribution, nd reproduction in ny medium, provided the originl work is properly cited.

2 Outcome of percutneous blloon mitrl vlvotomy cluding emergent mitrl vlve replcement (MVR), developing severe mitrl regurgittion (MR 3+), tmponde, deth, nd peripherl embolism, s well s dverse events t long-term follow-up such s deth, peripherl embolism/stroke, nd need for re-pbmv or MVR were checked nd compred in the two groups. Demogrphic clinicl nd procedurl vribles were collected retrospectively using review of medicl records nd telephone contct. Our technique in performing PBMV (Inoue technique) hs been reported previously. 19,20 PBMV success ws defined s finl MVA>1.5 cm 2 without resulting >2+ ngiogrphic MR. 21 In ll ptients trnsthorcic echocrdiogrphy ws done t lest one week prior to the procedure nd trnsesophgel echocrdiogrphy ws performed on the morning of the procedure nd echocrdiogrphic score of the mitrl pprtus, bseline MVA, left ventriculr ejection frction (LVEF) nd presence of MR were determined. Mitrl vlvulr nd sub-vlvulr morphology ws grded ccording to the Wilkins s scoring system which ssigns higher scores to vlues with more severe disese. 22 MVA ws clculted by plnimetry or, in the bsence of significnt mitrl regurgittion, from pressure hlf-time. 23 Semi-quntittive estimtion of mitrl regurgittion ws mde with color flow mpping in prsternl long xis nd picl four-chmber views. mtmpg nd spap were estimted using continuous-wve Doppler echocrdiogrphy. LAP nd mtmpg were mesured during ctheteriztion. All PBMV procedures were done without heprin. 24 Sttisticl nlysis Ctegoricl vribles, expressed s percentges, were compred by Fisher or χ 2 exct tests. Continues dt, shown s men ± SD, were compred by Mnn-Whitney U test nd independent smple t test. Multivrite regression nlysis ws performed to determine the independent vribles for predicting dverse events nd subgroup nlysis. P vlues <0.05 were considered to indicte sttisticl significnce. Dt recording nd nlysis were performed using SPSS version 17.0 softwre (SPSS Inc., Chicgo, IL). Results Bseline chrcteristics Out of 1000 ptients who were enrolled in the study, 239 were mle (23.9%) nd 761 were femle (76.1%), ged yers (men ge ± yers). Five hundred eighty-five ptients hd SR nd the rest 415 were in AF. Tble 1 shows the bse findings in both groups. The AF group ws older, ws more in dyspne NYHA-FC (III-IV), hd greter MR before PBMV, higher mitrl vlve echo scores, nd higher mtmpg compred to the SR group. spap, MVA, nd LAP were similr in both groups. Tble 2 shows the findings of two groups fter PBMV. There were more cses of severe MR (MR 3 + ) nd dyspne NY- HA-FC (III-IV), higher LAP, higher mtmpg nd smller MVA in the AF group compred to the SR group. spap ws similr in both groups. Three ptients with AF converted to SR fter PBMV. Procedure success PBMV ws successful in 554 (94.7%) of SR ptients nd 281 (67.7%) of AF ptients (P < 0.001). After PBMV, mt- MPG were significntly lower nd MVA were significntly higher in SR group. In subgroups nlysis we evluted the reltionship between demogrphic nd bseline chrcteristic with incidence of complictions in both groups. In the AF group (Tble 3), older ge, severe dyspne NY- HA-FC (III-IV) before PBMV, MR before nd fter PBMV nd higher LAP before PBMV hd significnt reltionship with the incidence of complictions during follow-up. Multivrite regression nlysis showed tht NYHA-FC before PBMV could independently predict complictions during follow-up (odds rtio [OR]: 1.66, 95% CI: ; P = 0.04). Also in the SR group (Tble 4), MR before nd fter PBMV, the success rte of the procedure, the mi- Tble 1. Bseline chrcteristic in both groups SR (n=585) AF (n=415) P vlue Age, yers ± ± <0.001 Femle 454 (77.6%) 307 (74%) 0.18 Vlve score 8.37 ± ± 0.96 <0.001 NYHA-FC III-IV 198 (33.8%) 180 (43.4%) No MR 156 (26.7%) 63 (15.2%) <0.001 MR (44.1%) 137 (33%) <0.001 MR (29.2) 215 (51.8%) <0.001 spap, mm Hg ± ± MVA, cm ± ± LAP, mm Hg ± ± mtmvg, mm Hg ± ± Abbrevitions: AF, tril fibrilltion; LAP, left tril pressure; MR, mitrl regurgittion; mtmvg, men trnsmitrl vlve grdient; MVA, mitrl vlve re; NYHA-FC, New York Hert Assocition functionl clss; spap, systolic pulmonry rtery pressure; SR, sinus rhythm; Vlues were shown s men ± SD. P vlue is significnt. Tble 2. Post-PBMV results nd in-hospitl outcome SR (n=585) AF (n=415) P vlue spap, mmhg 36.25± ± MVA, cm ± ± LAP, mmhg 17.19± ±5.23 <0.001 mtmvg, mm Hg 4.62± ±2.69 <0.001 All complictions 20 (3.4%) 45 (10.8%) <0.001 MVR 10 (1.7%) 23 (5.5%) Severe MR ( 3+) 0 4 (1%) 0.02 Tmponde 0 1 (0.2%) 0.41 Peripherl emboli 10 (1.7%) 17 (4.1%) 0.02 Abbrevitions: AF, tril fibrilltion; LAP, left tril pressure; MR, mitrl regurgittion; mtmvg, men trnsmitrl vlve grdient; MVA, mitrl vlve re; MVR, mitrl vlve replcement; spap,systolic pulmonry rtery pressure; SR, sinus rhythm; Vlues were shown s men±sd. P vlue is significnt. J Crdiovsc Thorc Res, 2016, 8(3),

3 Aslnbdi et l Tble 3. Comprison of bseline nd echocrdiogrphic findings between complicted nd uncomplicted ptients in the SR group Complicted (n=84) Uncomplicted (n=501) P vlue Age, yers 47.79± ± Femle 687 (81%) 386 (77%) 0.42 NYHA-FC I-II before PBMV 57 (67.9%) 330 (65.9%) NYHA-FC III-IV before PBMV 27 (32.1%) 171 (34.1%) 0.7 NYHA-FC I-II fter PBMV 72 (85.7%) 453 (90.4%) NYHA-FC III-IV fter PBMV 12 (14.3%) 48 (9.6%) 0.18 MR before PBMV 82 (97.6%) 347 (69.3%) Absent MR before PBMV 2 (2.4%) 154 (30.7%) <0.001 MR fter PBMV 82 (97.6%) 268 (53.5%) Absent MR fter PBMV 2 (2.4%) 233 (46.5%) <0.001 PBMV success 69 (82.1%) 485 (96.8%) <0.001 Vlve score 8.11± ± spap before PBMV, mmhg 45.79± ± spap fter PBMV, mmhg 35.8± ± MVA before PBMV, cm 2 0.9± ± MVA fter PBMV, cm ± ±0.22 <0.001 LAP before PBMV, mmhg 29.11± ± LAP fter PBMV, mmhg 17.26± ± mtmpg before PBMV, mm Hg 12.02± ± mtmpg fter PBMV, mm Hg 4.51± ± Abbrevitions: LAP, left tril pressure; MR, mitrl regurgittion; mtmvg, men trnsmitrl vlve grdient; MVA, mitrl vlve re; NYHA-FC, New York Hert Assocition functionl clss; PBMV, percutneous blloon mitrl vlvotomy; spap, systolic pulmonry rtery pressure; SR, sinus rhythm; Vlues were shown s men±sd. P vlue is significnt. trl vlve echocrdiogrphic score nd MVA before nd fter PBMV were significntly ssocited with dverse events rte. Multivrite regression nlysis showed tht the low MVA fter PBMV, could independently predict occurrence of lte complictions in this group (OR: 4.42, 95% CI: ; P = 0.04). In-hospitl (short-term) outcome Tble 2 shows the in-hospitl results in two groups. In totl, 45 ptients of AF group (10.8%) nd 20 ptients of SR group (3.4%) hd in-hospitl complictions (P < 0.001). MVR surgery ws required in 23 (5.5%) of AF ptients nd in 10 (1.7%) of the SR group (P < 0.001). Severe MR occurred in 4 (1%) ptients in the AF group nd in none of the SR group (P = 0.02). Tmponde occurred in 1 (0.2%) ptient in the AF group nd in none of the SR group (P = 0.41). Peripherl embolic events occurred in 17 (4.1%) ptients in the AF group nd in 10 (1.7%) of SR ptients (P = 0.02). Long-term outcome Tble 5 show long-term follow-up results of ptients in both groups. Ptients were followed for men of 7.27±3.16 yers ( minimum of 2 yers nd mximum of 14 yers). Adverse events (including MVR, re-pbmv, stroke, peripherl embolism nd deth) were seen in 148 (35.7%) ptients in the AF group nd in 93 (15.9%) ptients in the SR group (P < 0.001). MVR ws required in 31 (7.5%) ptients in the AF group nd 19 (3.2%) ptients in the SR group (P < 0.003). re-pbmv ws performed in 77 (18.6%) ptients in the AF group nd in 46 (7.9%) ptients in the SR group (P < 0.001). Stroke occurred in 17 (4.1%) ptients with AF nd in 11 ptients (1.9%) with SR (P = 0.03). Peripherl embolic events occurred in 12 ptients (2.9%) in the AF nd in 8 (1.4%) ptients in the SR group (P = 0.03). Twenty-two (5.3%) ptients in the AF nd 7 (1.2%) in the SR group died during long term follow up (P < 0.001). Discussion The min findings of our study were tht ptients with AF who underwent PBMV hd significntly lesser immedite success rtes, higher mortlity rte (Figure 1), higher mtmpg, lower MVA, higher short term nd long term compliction rtes in comprison to ptients with SR. Additionlly, MS ptients with AF before PBMV were significntly older, hd higher mitrl echocrdiogrphic Wilkins scores, NYHA-FC, greter MR nd mtmpgs compred to ptients with SR. These findings re in line with previous clinicl, echocrdiogrphic nd hemodynmic findings of AF ptients who were cndidtes for PBMV which showed significnt ssocition between AF nd older ge, higher NYHA-FC, nd higher mitrl vlve scores in MS ptients ,14,15 Similr to other studies, we lso found tht the results of PBMV in AF ptients re poor compred to SR with incresed short nd long term dverse events Leon et l showed tht ptients with AF hd higher TMPG nd smller MVA before PBMV nd higher men LAP fter PBMV. 12 Fwzy et l found tht ptients with AF hd smller MVA nd more re-stenosis fter PBMV. 17 Once more, Nir et l demonstrted tht AF ptients hd smller MVA fter PBMV compred to SR ptients with higher rte of complictions during follow-up. 18 The ssocition of AF with 128 J Crdiovsc Thorc Res, 2016, 8(3),

4 Outcome of percutneous blloon mitrl vlvotomy Tble 4. Comprison of bseline nd echocrdiogrphic findings between complicted nd uncomplicted ptients in the AF group Complicted (n=139) Uncomplicted (n=280) P vlue Age, yers 57.38± ±11.80 <0.001 Femle 101 (72.7%) 206 (74.6%) 0.66 NYHA-FC I-II before PBMV 91 (65.5%) 144 (52.2%) NYHA-FC III-IV before PBMV 48(34.5%) 132 (47.8%) NYHA-FC I-II fter PBMV 115(82.7%) 237 (85.9%) NYHA-FC III-IV fter PBMV 24 (17.3%) 39 (14.1%) MR before PBMV 134 (96.4%) 218 (79%) Absent MR before PBMV 5 (3.6%) 58 (21%) MR fter PBMV 129 (92.8%) 189 (68.5%) Absent MR fter PBMV 10 (7.2%) 87 (31.5%) PBMV success 93 (66.9%) 188 (68.1%) 0.8 Vlve score 8.77± ± spap before PBMV, mmhg 47.6± ± <0.001 <0.001 spap fter PBMV, mmhg 34.79± ± MVA before PBMV, cm ± ± MVA fter PBMV, cm ± ± LAP before PBMV, mmhg 29.69± ± LAP fter PBMV, mmhg 18.86± ± mtmpg before PBMV, mmhg 12.31± ± 0.85 mtmpg fter PBMV, mmhg 5.23± ± Abbrevitions: AF, tril fibrilltion; LAP, left tril pressure; MR, mitrl regurgittion; mtmvg, men trnsmitrl vlve grdient; MVA, mitrl vlve re; NYHA-FC, New York Hert Assocition functionl clss; PBMV, percutneous blloon mitrl vlvotomy; spap, systolic pulmonry rtery pressure; Vlues were shown s men±sd. P vlue is significnt older ge, higher NYHA-FC, higher mitrl vlve Wilkins score indictes tht AF is presenttion of long term rheumtic MS with more severe morphologicl nd structurl chnges which could estimte less desirble response to tretment nd more incidence of dverse events. The success rte of the PBMV procedure hd different results in the previous studies. In the study by Mtouk et l, the success rte of the PBMV in AF vs. SR ptients ws st- Figure 1. Kpln-Meier survivl curve shows survivl time in ptients with AF nd SR. tisticlly similr (89.7% vs. 92.3%, respectively; P = NS). 15 On the other hnd, Nir et l. hd similr results to our study, indicting higher success rte of PBMV in SR ptients (93.6% vs. 84.2%; P = 0.032). 18 Different PBMV success rte in this study my relted to the fct tht our hospitl is tertiry referrl center with the lrgest number of ptients undergoing PBMV (N = 1800) tht hs ever been reported. Our study hd the gretest percentge of AF ptients (41.5%) compred to previous studies (the next study being the one by Nir et l with 11.6% AF ptients). The higher percentge of AF ptients in our center does not necessrily represent higher prevlence but more likely is cused by referrl bis since more complicted MS ptients including ptients with AF re referred to our tertiry centers. We lso found tht some of the demogrphic nd some bseline chrcteristics vribles (high dyspne NY- HA-FC before PBMV in AF ptients nd lower MVA fter PBMV in SR ptients) cn independently predict higher compliction rtes. Use of these vribles in clinicl decision mking my reduce the rte of complictions nd improve the prognosis in these subsets of ptients. Conclusion Ptients with MS who hve AF re significntly older, hve higher mitrl vlve scores, NYHA-FC, nd greter MR nd mtmpgs compred to ptients with MS nd SR. Ad- J Crdiovsc Thorc Res, 2016, 8(3),

5 Aslnbdi et l Tble 5. Long term outcome in both groups SR AF P vlue (n=585) (n=415) All complictions 93 (15.9%) 148 (35.7%) <0.001 MVR 19 (3.2%) 31 (7.5%) re-pbmv 46 (7.9%) 77 (18.6%) <0.001 CVA 11 (1.9%) 17 (4.1%) 0.03 Peripherl emboli 8(1.4%) 12 (2.9%) 0.09 Mortlity 7 (1.2%) 22 (5.3%) <0.001 Abbrevitions: AF, tril fibrilltion; CVA, cerebrovsculr ccident; MVR, mitrl vlve replcement; NYHA-FC, New York Hert Assocition functionl clss; re-pbmv, repet percutneous blloon mitrl vlvotomy; SR, sinus rhythm; Vlues were shown s men±sd. P vlue is significnt. ditionlly, fter PBMV they hve lesser immedite success rtes, higher short term nd long term compliction rtes, nd higher mortlity during follow up. It seems tht erlier decision to PBMV could be justified to lesser AF nd other complictions relted to durtion of MS. Screening in endemic res my hve role to erlier dignosis nd intervening to decrese AF nd other dverse events which is relted to chronicity of MS. Higher dyspne NY- HA-FC before PBMV in AF ptients nd lower MVA fter PBMV in SR ptients cn independently predict higher dverse events. Our findings support erlier intervention in ptients with hemodynmiclly significnt MS to decrese AF nd AF relted complictions. PBMV is n cceptble low risk procedure in ptients with AF despite of reltively lower success rte in comprison to ptients with SR. Study limittions About 800 ptients who underwent PBMV t this center were excluded from the study due to lck of complete informtion requirements on their files for the study or follow-up informtion. Follow up durtion nd intervls were not identicl in ll ptients. It is possible tht ptients with miniml symptom hve not completed their follow up regulrly. Also detiled informtion bout the cuse of deth during follow up ws not vilble. Ethicl Approvl The study protocol ws pproved by the ethics committee of Tbriz University of Medicl Sciences. Competing interests Authors declre no conflict of interest in this study. Acknowledgments The uthors deeply pprecite ll the stff of the Cth eteriztion Lbortory of Shhid Mdni hert center for their grcious ssistnce during this reserch. References 1. Kumr RK, Tndon R. Rheumtic fever & rheumtic hert disese: the lst 50 yers. Indin J Med Res 2013;137(4): Shw TR, Sutri N, Prendergst B. Clinicl nd hemodynmic profiles of young, middle ged, nd elderly ptients with mitrl stenosis undergoing mitrl blloon vlvotomy. Hert 2003;89: doi: / hert Fwzy ME. Mitrl blloon vlvuloplsty. J Sudi Hert Assoc 2010;22(3): doi: /j.jsh Inoue K, Owki T, Nkmur F, Kitmur F, Miymoto N. Clinicl ppliction of trnsvenous mitrl commissurotomy by new blloon ctheter. Thorc Crdiovsc Surg 1984;87(3): Prendergst BD, Shw TR, Iung B, Vhnin A, Northridge DB. Contemporry criteri for the selection of ptients for percutneous blloon mitrl vlvuloplsty. Hert 2002;87: doi: /hert Fwzy ME, Stefdouros MA, Hegzy H, Sher FE, Chudhry MA, Fdley FA. Long term clinicl nd echocrdiogrphic results of mitrl blloon vlvotomy in children nd dolescents. Hert 2005;91: doi: /hrt Sutri N, Elder AT, Shw TR. Long term outcome of percutneous mitrl blloon vlvotomy in ptients ged 70 nd over. Hert 2000;83: doi: /hert Iung B, Grbrz E, Michud P, Helou S, Frh B, Berdh P, et l. Lte results of percutneous mitrl commissurotomy in series of 1024 ptients. Anlysis of lte clinicl deteriortion: frequency, ntomic findings, nd predictive fctors. Circultion 1999;99: doi: /01. CIR Kng DH, Prk SW, Song JK, Kim HS, Hong MK, Kim JJ, et l. Longterm clinicl nd echocrdiogrphic outcome of percutneous mitrl vlvuloplsty: rndomized comprison of Inoue nd double-blloon techniques. J Am Coll Crdiol 2000;35(1): doi: /S (99) Pourfkri L, Ghffri S, Bncroft GR, Tjlil A, Nder ND. Fctors ssocited with tril fibrilltion in rheumtic mitrl stenosis. Asin Crdiovsc Thorc Ann 2015;23(1): doi: / Vor A, Krnd D, Goyl V, Nik A, Gupt A, Lokhndwl Y, et l. Control of rte versus rhythm in rheumtic tril fibrilltion: rndomized study. Indin Hert J 2004;56(2): Leon MN, Hrrell LC, Simos HF, Mhdi NA, Pthn A, Lopez-Cuellr J, et l. Mitrl blloon vlvotomy for ptients with mitrl stenosis in tril fibrilltion: immedite nd long-term results. J Am Coll Crdiol 1999;34(4): doi: /S (99) Trk EA, Blitz LR, Herrmnn HC. Hemodynmic effects nd long-term outcome of percutneous blloon vlvuloplsty in ptients with mitrl stenosis nd tril fibrilltion. Clin Crdiol 2000;23(9): doi: / clc Lngerveld J, Hemel NM, Ernst SM, Plokker HW, Kelder JC, Jrsm W. The predictive vlue of chronic tril fibrilltion for the short- nd long-term outcome fter percutneous mitrl blloon vlvotomy. J Hert Vlve Dis 2001;10(4): Mtouk F, Betbout F, Ben-Frht M, Addd F, Gmr H, Ben-Hmd K, et l. Blloon mitrl commissurotomy for ptients with mitrl stenosis in tril fibrilltion: ten-yer clinicl nd echocrdiogrphic cturil results. J Hert Vlve Dis 2005;14(6): Kim HK, Kim YJ, Shin JI, Hwng SJ, Jo SH, Prk JS, et l. Echocrdiogrphic nd hemodynmic findings in 130 J Crdiovsc Thorc Res, 2016, 8(3),

6 Outcome of percutneous blloon mitrl vlvotomy ptients with mitrl stenosis undergoing percutneous mitrl commissurotomy compring those with chronic tril fibrilltion versus those with norml sinus rhythm. Am J Crdiol 2007;100(7): doi: /j. mjcrd Fwzy ME, Shoukri M, Osmn A, El Amroui S, Shh S, Nowyhed O, et l. Impct of tril fibrilltion on immedite nd long-term results of mitrl blloon vlvuloplsty in 531 consecutive ptients. J Hert Vlve Dis 2008;17(2): Nir KK, Pilli HS, Thjudeen A,, Krishnmoorthy KM, Sivsubrmonin S, Nmboodiri N, et l. Immedite nd long-term results following blloon mitrl vlvotomy in ptients with tril fibrilltion. Clin Crdiol 2012;35(12):35-9. doi: /clc Aslnbdi N, Golmohmmdi A, Sohrbi B, Kzemi B. Repet percutneous blloon mitrl vlvotomy vs. mitrl vlve replcement in ptients with restenosis fter previous blloon mitrl vlvotomy nd unfvorble vlve chrcteristics. Clin Crdiol 2011;34(6): doi: /clc Aslnbdi N, Toufn M, Slehi R, Alizdehsl A, Ghffri S, Sohrbi B, et l. Mitrl regurgittion fter percutneous blloon mitrl vlvotomy in ptients with rheumtic mitrl stenosis: single-center study. J Teh Univ Hert Ctr 2014;9(3): Bernrd L, Eric G, Pierre M, Steeven H, Bruno F, Ptrici B, et l.lte Results of Percutneous Mitrl Commissurotomy in Series of 1024 Ptients. Circultion 1999;99(25): doi: /01.CIR Wilkins GT, Weymn AE, Abscl VM, Block PC, Plcios IF. Percutneous blloon dilttion of the mitrl vlve: n nlysis of echocrdiogrphic vribles relted to outcome nd the mechnism of dilttion. Br Hert J 1988;60: doi: /hrt Plcios IF. Wht is the gold stndrd to mesure mitrl vlve re postmitrl blloon vlvuloplsty? Cthet Crdiovsc Dign 1994;33(4): doi: /ccd Ghffri S, Sohrbi B, Aslnbdi N, Mogdm AR, Sepehrvnd N, Pourfkri L, et l. Percutneous trnsvenous mitrl commissurotomy: with or without heprin? A rndomised double blind study. Krdiol Pol 2011; 69(5): J Crdiovsc Thorc Res, 2016, 8(3),