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1 Disclosures ESC Paris 2011 Claire Bouleti, MD Research Grant from Servier
2 Long-term impact of repeat Percutaneous Mitral Commissurotomy on the need for surgery in mitral stenosis. Insight from a series of 912 patients with a 20-year follow-up. Bouleti C, Iung B, Himbert D, Messika-Zeitoun D, Brochet E, Garbarz E, Cormier B,Vahanian A. Bichat Hospital, AP-HP, Paris, France
3 Background After good immediate results, long-term efficacy of percutaneous mitral commissurotomy (PMC) is hampered by mitral restenosis. Surgery is the most frequent treatment of mitral restenosis; however, PMC can be repeated in selected patients. To assess the impact of repeat PMC on the possibility of deferring mitral sugery, we compared survival without reintervention to survival without surgery alone.
4 Variables Study Population 912 patients with good immediate results of PMC (valve area 1.5 cm² with mitral regurgitation 2/4) from 1024 consecutive patients ( ) Mean ± SD or n(%) Age, yr. 48 ± 13 Female sex 755 (83) NYHA functional class I-II III IV 223 (25) 657 (72) 32 (3) Atrial fibrillation 352 (39) Previous commissurotomy 135 (15) Valve area (echocardiography), cm 2 1.1±0.2 Mean gradient (Doppler), mmhg 10 ± 5 Mitral regurgitation (67) 290 (32) 10 (1)
5 Valve anatomy Cormier s classification (Arch Mal Coeur 1989;82:185-91) Group 1 : Pliable valves and mild impairment of subvalvular apparatus (chordae 10 mm) Group 2 : Pliable valves and severe impairment of subvalvular apparatus (chordae <10 mm) Group 3 : Valve calcification confirmed by fluoroscopy
6 Procedure Antegrade transvenous approach - Single-balloon : 17 patients (2%) - Double-balloon : 338 patients (37%) - Inoue balloon : 557 patients (61%), systematically after October 1990.
7 cm² mmhg Immediate results Valve function Valve area Mean gradient Before PMC Mean Gradient After PMC
8 Follow-up FU was complete in 814 patients (89%) Median FU: 144 months [interquartile range, 54 to 189] Clinical endpoints : - death - re-intervention. surgery. re-pmc Composite endpoints Survival without re-intervention (surgery or re-pmc) Survival without surgery alone
9 Twenty-year results 20-Year Results Events Overall (n=912) n= < 50 years (n=504) n= Deaths 136 Cardiovascular-related 79 Noncardiovascular 57 Procedure on mitral valve 351 Repeat PMC 85 Conservative surgery 19 Isolated MVR 189 MVR + other procedure
10 Twenty-year results 20-Year Results Events Overall (n=912) n= < 50 years (n=504) n= Deaths 136 Cardiovascular-related 79 Noncardiovascular 57 Procedure on mitral valve 351 Repeat PMC 85 Conservative surgery 19 Isolated MVR 189 MVR + other procedure
11 20-Year Results Overall survival ±2% 75±2% Survival (%) Patients aged < 50 yrs (n=504) All patients (n=912) No. No. at at Risk Risk Years
12 20-Year Results Survival without re-intervention or surgery (whole cohort) Event-free survival (%) Survival without mitral surgery Survival without intervention on the mitral valve 46±2% 38±2% No. No. at at Risk Years
13 20-Year Results Survival without re-intervention or surgery (whole cohort) Event-free survival (%) Survival without mitral surgery Survival without intervention on the mitral valve 46±2% 38±2% No. at Risk Years
14 20-Year Results Survival without re-intervention or surgery (pts <50 years) Event-free survival (%) Survival without mitral surgery Survival without intervention on the mitral valve 57±3% 45±3% No. at Risk Years
15 Variables Re-PMC (n=85) Mean±SD or n(%) Mitral surgery (n=266) Mean±SD or n(%) Age, yr. 40±10 49 ± 11 <0.001 Female sex 74 (87) 214 (80) 0.17 NYHA functional class 0.22 I-II III-IV Re-Interventions 23 (27) 62 (73) 55 (21) 211 (79) Atrial fibrillation 23 (27) 108 (41) Previous commissurotomy 23 (27) 44 (17) 0.03 Valve area (echocardiography), cm 2 1.1± ± Mean gradient (Doppler), mmhg 11±4 11 ± p Echocardiographic group < (24) 53 (62) 12 (14) 29 (11) 133 (50) 104 (39)
16 Variables Re-PMC (n=85) Mean±SD or n(%) Mitral surgery (n=266) Mean±SD or n(%) Age, yr. 40±10 49 ± 11 <0.001 Female sex 74 (87) 214 (80) 0.17 NYHA functional class 0.22 I-II III-IV Re-Interventions 23 (27) 62 (73) 55 (21) 211 (79) Atrial fibrillation 23 (27) 108 (41) Previous commissurotomy 23 (27) 44 (17) 0.03 Valve area (echocardiography), cm 2 1.1± ± Mean gradient (Doppler), mmhg 11±4 11 ± p Echocardiographic group < (24) 53 (62) 12 (14) 29 (11) 133 (50) 104 (39)
17 Variables Re-PMC (n=85) Mean±SD or n(%) Mitral surgery (n=266) Mean±SD or n(%) Age, yr. 40±10 49 ± 11 <0.001 Female sex 74 (87) 214 (80) 0.17 NYHA functional class 0.22 I-II III-IV Re-Interventions 23 (27) 62 (73) 55 (21) 211 (79) Atrial fibrillation 23 (27) 108 (41) Previous commissurotomy 23 (27) 44 (17) 0.03 Valve area (echocardiography), cm 2 1.1± ± Mean gradient (Doppler), mmhg 11±4 11 ± p Echocardiographic group < (24) 53 (62) 12 (14) 29 (11) 133 (50) 104 (39)
18 Variables Re-PMC (n=85) Mean±SD or n(%) Mitral surgery (n=266) Mean±SD or n(%) Age, yr. 40±10 49 ± 11 <0.001 Female sex 74 (87) 214 (80) 0.17 NYHA functional class 0.22 I-II III-IV Re-Interventions 23 (27) 62 (73) 55 (21) 211 (79) Atrial fibrillation 23 (27) 108 (41) Previous commissurotomy 23 (27) 44 (17) 0.03 Valve area (echocardiography), cm 2 1.1± ± Mean gradient (Doppler), mmhg 11±4 11 ± p Echocardiographic group < (24) 53 (62) 12 (14) 29 (11) 133 (50) 104 (39)
19 Re-PMC criteria No usual contra-indications to PMC and Patients in NYHA class 2 Restenosis with refusion of both commissures Refusion of both commissures Commissural opening
20 cm² mmhg Results of the 85 Re-PMC Immediate results: - 80 pts (94%) had good immediate results - 5 pts had poor immediate results: IM 3/4 in 3 pts (4%) and valve area<1.5 in 2 pts (2%) Valve function after good immediate results Before PMC 0 Mean Gradient After PMC Follow-up: 29 pts (34%) underwent subsequent re-intervention: - 4 pts third PMC after a mean of 75 months - 25 pts mitral valve replacement after a mean of 52 months
21 Conclusion After successful PMC: Re-intervention is frequently needed during long term follow-up. Repeat PMC can be performed in 1 out of 4 patients needing re-intervention, enabling surgery to be further postponed. In patients aged < 50 at their first PMC, 35% benefited from a repeat PMC so that 57% of them remained free from mitral surgery at 20 years.
22
23
24 Natural evolution of MS
25 MS Survival (Lancet 2009)
26 Inoue Stepwise technique
27 Scoring systems Wilkins score Leaflet mobility Leaflet thickening Valve calcification Involvement of the subvalvular apparatus Cormier s classification: more general assessment of valve anatomy + length of chordae Correspondance between Cormier s and Wilkins scores: 8,0 +/- 0,8 (7 to 9) for group 1 9,9 +/- 1,3 (8 to 12) for group 2 12,5 +/- 1,3 (10 to 15) for group 3
28 Scoring system Fatkin s score Commissure score (TEE) (Sutaria and al) None of the scores available has been shown to be superior to any of the others, and we can only recommend the use of the score with which one is most familiar and at ease.
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