Proceedings of the Fourth Scientific Meeting of the World Society for Pediatric and Congenital Heart Surgery
Catheter Interventions for Mitral Stenosis in Children: Results and Perspectives
World Journal for Pediatric and Congenital Heart Surgery 2015, Vol. 6(2) 250-256 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135114568785 pch.sagepub.com
Anita Saxena, MD, DM, FACC, FAMS1
Abstract Stenosis of the mitral valve most often occurs as a result of chronic rheumatic heart disease, causing thickening and fibrosis of the mitral valve apparatus. Rheumatic heart disease continues to be a major public health problem in several developing countries and mitral stenosis is also common in these regions. According to the reports from India and Africa, the disease tends to follow a rapidly progressive course in children. The treatment of choice is balloon dilatation of the mitral valve. Echocardiography is indispensable for this procedure. Before planning the procedure, it is essential to assess the suitability of balloon dilatation. Echocardiography performed during the procedure helps to decide whether the size of the balloon needs to be increased in case of inadequate relief of stenosis. Most published series have reported an immediate success rate of over 90% with balloon dilatation in children and young adults. With an increase in mitral valve area and improvement in functional class, the left atrial pressure and the transmitral gradients fall. These gratifying results are also reported from very young children of less than 12 years of age. It is recommended to start with a smaller balloon size and increase its size in a stepwise fashion to minimize complications. The complications, seen in about 1% to 2% of cases, include development of significant mitral regurgitation and hemopericardium, secondary to cardiac chamber perforation. The long-term results indicate slightly higher restenosis rates in children than in adults. Most children with restenosis can undergo successful repeat dilatation. Keywords heart valve, interventional catheterization, mitral valve disease, echocardiography Submitted August 27, 2014; Accepted December 17, 2014 Presented at the 4th Scientific Meeting of World Society for Pediatric and Congenital Heart Surgery, Sao Paulo, Brazil; July 17-20, 2014.
Introduction Mitral stenosis (MS) refers to restricted opening of the mitral valve orifice and occurs as a result of abnormally thickened mitral valve leaflets. In vast majority of instances, the underlying etiology is chronic rheumatic heart disease (RHD). Rarely MS is secondary to congenital abnormality of the mitral valve. Generally, the whole of mitral valve apparatus including leaflets, chordate tendinae, and papillary muscles are involved, irrespective of the underlying etiology. This article will discuss indications, technique, and results of catheter interventions for MS, developing secondary to RHD. Rheumatic heart disease continues to be a major public health problem in several developing countries, and MS secondary to RHD is also commonly seen in these regions. Rheumatic fever results in carditis in more than 60% of cases, affecting the cardiac valves (mitral valve being most commonly affected), which over a variable period of time causes stenosis and/or regurgitation of the valve. Mitral stenosis results from leaflet thickening, commissural fusion, chordal fusion, and/or shortening, all secondary to chronic rheumatic process. The usual age at presentation is beyond 20 years or so, that is, in the adult age. However,
in some of the developing countries severe MS at a younger age is not uncommon. In these regions, MS tends to progress very rapidly, following a malignant course. Young children and adolescents present with advanced symptoms. Worldwide 75% to 80% of patients with RHD are children and young adults.
Mitral Stenosis in Children In several developing countries including Africa and India, severe MS develops at a very young age.1-4 It is generally believed that 25% of patients with MS are 1.5 cm2 or 1 cm2/m2, (c) absence of significant mitral regurgitation, and (d) absence of any complication. All these criteria must be satisfied.
Immediate Results Immediate success is obtained in more than 90% of cases, seen as immediate fall in left atrial pressure, reduction in transmitral gradients, fall in pulmonary pressures, increase in MVA, and improvement in functional class. Children who are
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World Journal for Pediatric and Congenital Heart Surgery 6(2)
Figure 3. Fluoroscopy images during mitral valve balloon dilatation with the Inoue balloon showing initial inflation of distal balloon (A), partial inflation across mitral valve (B), and fully inflated balloon across mitral valve (C). Table 1. Published Series on Mitral Valve Balloon Dilatation in Patients Younger Than 20 Years of Age. Author, year
Country
No.
Age in years (mean)
MVA Pre-BMV, cm2
MVA Post-BMV, cm2
Success, %
Joseph et al, 1997
India
107
10-18 (14.5 þ 2.3)
0.73 + 0.18
1.7 + 0.53
98
Zaki et al, 1999
Egypt
46
7-19 (15.5 þ 3.2)
Brazil Nairobi
40 45
10-18 (15.5 +2.2) 9-20 (14 þ 2.6)
1.54 + 0.23 (indexed) 2.03 + 0.50 1.9 þ 0.2
98
Mattos et al, 1999 Yonga and Bonhoeffer, 2003 Gamra et al, 2003
0.65 + 0.14 (indexed) 0.86 + 0.21 0.6 + 0.2
MVR-1, temponade-1, Mod MR-5 MVR-1, CVA-1
91.7 100
MVR-3, temponade-1 MR-0
Tunisia
110
Catheter Interventions for Mitral Stenosis in Children: Results and Perspectives
World Journal for Pediatric and Congenital Heart Surgery 2015, Vol. 6(2) 250-256 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135114568785 pch.sagepub.com
Anita Saxena, MD, DM, FACC, FAMS1
Abstract Stenosis of the mitral valve most often occurs as a result of chronic rheumatic heart disease, causing thickening and fibrosis of the mitral valve apparatus. Rheumatic heart disease continues to be a major public health problem in several developing countries and mitral stenosis is also common in these regions. According to the reports from India and Africa, the disease tends to follow a rapidly progressive course in children. The treatment of choice is balloon dilatation of the mitral valve. Echocardiography is indispensable for this procedure. Before planning the procedure, it is essential to assess the suitability of balloon dilatation. Echocardiography performed during the procedure helps to decide whether the size of the balloon needs to be increased in case of inadequate relief of stenosis. Most published series have reported an immediate success rate of over 90% with balloon dilatation in children and young adults. With an increase in mitral valve area and improvement in functional class, the left atrial pressure and the transmitral gradients fall. These gratifying results are also reported from very young children of less than 12 years of age. It is recommended to start with a smaller balloon size and increase its size in a stepwise fashion to minimize complications. The complications, seen in about 1% to 2% of cases, include development of significant mitral regurgitation and hemopericardium, secondary to cardiac chamber perforation. The long-term results indicate slightly higher restenosis rates in children than in adults. Most children with restenosis can undergo successful repeat dilatation. Keywords heart valve, interventional catheterization, mitral valve disease, echocardiography Submitted August 27, 2014; Accepted December 17, 2014 Presented at the 4th Scientific Meeting of World Society for Pediatric and Congenital Heart Surgery, Sao Paulo, Brazil; July 17-20, 2014.
Introduction Mitral stenosis (MS) refers to restricted opening of the mitral valve orifice and occurs as a result of abnormally thickened mitral valve leaflets. In vast majority of instances, the underlying etiology is chronic rheumatic heart disease (RHD). Rarely MS is secondary to congenital abnormality of the mitral valve. Generally, the whole of mitral valve apparatus including leaflets, chordate tendinae, and papillary muscles are involved, irrespective of the underlying etiology. This article will discuss indications, technique, and results of catheter interventions for MS, developing secondary to RHD. Rheumatic heart disease continues to be a major public health problem in several developing countries, and MS secondary to RHD is also commonly seen in these regions. Rheumatic fever results in carditis in more than 60% of cases, affecting the cardiac valves (mitral valve being most commonly affected), which over a variable period of time causes stenosis and/or regurgitation of the valve. Mitral stenosis results from leaflet thickening, commissural fusion, chordal fusion, and/or shortening, all secondary to chronic rheumatic process. The usual age at presentation is beyond 20 years or so, that is, in the adult age. However,
in some of the developing countries severe MS at a younger age is not uncommon. In these regions, MS tends to progress very rapidly, following a malignant course. Young children and adolescents present with advanced symptoms. Worldwide 75% to 80% of patients with RHD are children and young adults.
Mitral Stenosis in Children In several developing countries including Africa and India, severe MS develops at a very young age.1-4 It is generally believed that 25% of patients with MS are 1.5 cm2 or 1 cm2/m2, (c) absence of significant mitral regurgitation, and (d) absence of any complication. All these criteria must be satisfied.
Immediate Results Immediate success is obtained in more than 90% of cases, seen as immediate fall in left atrial pressure, reduction in transmitral gradients, fall in pulmonary pressures, increase in MVA, and improvement in functional class. Children who are
Downloaded from pch.sagepub.com at EMORY UNIV on April 20, 2015
254
World Journal for Pediatric and Congenital Heart Surgery 6(2)
Figure 3. Fluoroscopy images during mitral valve balloon dilatation with the Inoue balloon showing initial inflation of distal balloon (A), partial inflation across mitral valve (B), and fully inflated balloon across mitral valve (C). Table 1. Published Series on Mitral Valve Balloon Dilatation in Patients Younger Than 20 Years of Age. Author, year
Country
No.
Age in years (mean)
MVA Pre-BMV, cm2
MVA Post-BMV, cm2
Success, %
Joseph et al, 1997
India
107
10-18 (14.5 þ 2.3)
0.73 + 0.18
1.7 + 0.53
98
Zaki et al, 1999
Egypt
46
7-19 (15.5 þ 3.2)
Brazil Nairobi
40 45
10-18 (15.5 +2.2) 9-20 (14 þ 2.6)
1.54 + 0.23 (indexed) 2.03 + 0.50 1.9 þ 0.2
98
Mattos et al, 1999 Yonga and Bonhoeffer, 2003 Gamra et al, 2003
0.65 + 0.14 (indexed) 0.86 + 0.21 0.6 + 0.2
MVR-1, temponade-1, Mod MR-5 MVR-1, CVA-1
91.7 100
MVR-3, temponade-1 MR-0
Tunisia
110
