Comparative study of percutaneous transvenous mitral commissurotomy using ACCURA balloon in juvenile vs adult rheumatic mitral stenosis

Abstract

Objective: Mitral stenosis (MS) is rarely seen in children and adolescents but is not uncommon in developing countries where rheumatic fever is still endemic. Rheumatic MS in India commonly affects children and young adults less than 20 years old (juvenile mitral stenosis). Although percutaneous transvenous mitral commissurotomy (PTMC) using the ACCURA balloon catheter has been shown to be safe and effective technique in large series of adult patients, reports of this technique in children are scarce. In our study, we aim to evaluate the immediate and early follow-up results of PTMC in 50 patients of rheumatic MS age ≤ 20 years and compare the same with those of the patients aged > 20 years. Methods: Fifty consecutive patients aged ≤ 20 years with symptomatic rheumatic MS who met the inclusion criteria and whose valves are suitable for PTMC formed the cases, another 50 consecutive patients aged > 20 years with similar characteristics formed the control group. PTMC was done for both the groups as per the standard protocol and hemodynamic and echocardiography parameters were noted. Appropriate statistical tests were used to compare these data. Results: The juvenile group had more often severe MS than adult patients at baseline [mitral valve area (MVA) 0.77(0.16) cm2 vs. 0.86(0.15) cm2, p<0.0069]. Atrial fibrillation was rare in juvenile patients (2%). Following PTMC, when absolute MVA was compared between the two groups, there was no significant difference, but when the post-PTMC MVA was indexed to body surface area, the juvenile group had statistically significant increase in indexed MVA as compared to adults [1.28 (0.30) cm2/m2 vs. 1.06 (0.26) cm2/m2, p<0.0001]. The same significant gain in indexed MVA was maintained at 6 months follow-up in juvenile patients as compared to adults (p<0.001). Juvenile patients also had significantly higher baseline invasive hemodynamic parameters like mean mitral valve gradient [23.44 (8.14) mm of Hg vs. 19.02(5.79) mm of Hg, p<0.002], mean PAP [50.92 (19.16) mm of Hg vs. 40.94 (11.82) mm of Hg, p<0.002] and mean pulmonary vascular resistance index [8.99 (7.29) U/m2 vs. 5.61 (4.30) U/m2, p<0.006] when compared to adult patients. Invasively measured mean left atrial pressure and mean pulmonary capillary wedge pressure were also high in juvenile patients than in adult patient but not statistically significant. Conclusion: Juvenile patients had severe mitral valve disease with severe pulmonary arterial hypertension at presentation, both echocardiographically and hemodynamically than adult patients. Juvenile patients had significantly better immediate echocardiographic and hemodynamic benefits following PTMC than adult patients, and this was observed even at 6 months following the procedure. PTMC is safe and effective in juvenile rheumatic MS. It provides better immediate results in juvenile patients than in adults.

Keywords

• mitral stenosis
• adult
• juvenile
• percutaneous transvenous mitral commissurotomy
• mitral valve area