PERCUTANEOUS TRANSMITRAL COMMISSUROTOMY (PTMC)

PROCEDURAL SUCCESS AND IMMEDIATE RESULTS, A TERTIARY CARE HOSPITAL EXPERIENCE FROM DEVELOPING COUNTRY

Abstract

Background: Mitral stenosis is one of the grave consequences of rheumatic heart disease.
Balloon valvuloplasty for stenosed mitral and pulmonary valves has been practiced with good results in the
world. Since Inoue et al. introduced balloon valvuloplasty in 1982, percutaneous transmitral commissurotomy
(PTMC) has become the treatment of choice for mitral stenosis replacing surgical commissurotomy and
mitral valve replacement in many cases. Objective: The aim of this study was to audit the procedural
success, in hospital outcome in patients undergoing percutaneous trans-mitral balloon commissurotomy
(PTMC) in our set up. Study Design: Observational cross sectional study. Place and Duration: The study
was conducted at Faisalabad Institute of Cardiology Faisalabad from March 2011 to December 2013.
Materials and Methods: Total one hundred and twenty four patients underwent percutaneous transmitral
commissurotomy from March 2011 to December 2013. Any patient of age ≥ 10 years with mitral stenosis
who fulfills the inclusion and exclusion criteria for PTMC was enrolled in this study. A full history particularly,
age, sex, occupation, address, symptoms regarding their referral for medical checkup was noted. Detailed
clinical examination especially relevant cardiovascular examination of all the patients was done. ECG of
every patient was done. Baseline routine investigations including blood complete with ESR, electrolytes,
CRP, LFT, RFT was done in each case. A baseline echocardiography was performed in all patients. Mitral
valve area was calculated by planimetry and by pressure half time method. Severity of mitral stenosis was
graded as: very sever stenosis (valve area <1cm2), severe (valve area 1- 1.5 cm 2) moderate (valve area
1.5- 2 cm2) and mild (valve area > 2.0 cm2). To exclude any clot in LA and LA appendage Transesophageal
echocardiography (TEE) was performed. In Cath Lab pre and post PTMC invasive hemodynamics including
LA, RA, RV, left ventricular end-diastolic pressure (LVEDP), and transmitral pressure gradient (PG) was
calculated. Those patients who have echo contrast on echocardiography were given 5000 IU heparin
IV after septal puncture. Antibiotic prophylaxis was initiated in all patients thereafter. The procedure was
performed under local anesthesia, if needed moderate sedation was given with midazolam. The procedure
was ended when either at least one commissure was splitted, adequate increase in mitral valve area or
increase in degree of MR or decrease in mean LA pressure to ½ of pre PTMC value or decrease in mitral
valve gradient was observed. After 24-48 hours patient was discharged and before discharge transthorasic
echo was done to measure all the parameters as pre PTMC along with any echo finding of pericardial
effusion. Results: Total 124 patients were studied, 92(74.2%) were female and 32(25.8%) were male
showing a female predominance. The mean age was 27.29±9.3. Most of the patients 58(46.8%) were in
age group 21-30 years. 87(70.16%) patients were in atrial fibrillation and 37(29.83%) had sinus rhythm. The
procedure was successful in 118(95.16%) patients. 2(1.6%) patients need urgent MVR due to severe MR
and 1 (0.8%) died during procedure. Most of the patients 85(68.55%) were in NYHA class III. After PTMC,
ASD was present in 13(10.5%) patients. After PTMC moderate MR was seen in 2(1.6%) and severe MR was
observed in 4(2.173%) patients. Most of the patients 115(92.7%) before PTMC were in severe pulmonary
hypertension and after PTMC most of the patients 91(73.4%) were in mild pulmonary hypertension. Pre
PTMC mean MVA (cm2) was 0.684± 0.1226 and post PTMC it was 1.533± 0.281 cm2. Mean MVPG pre
PTMC was 26.178±5.94 mmHg and post PTMC it was 7.62±5.007 mmHg with significant p value 0.0001.
Mean LA pressure before procedure was 29.68±8.137 mmHg and post PTMC it was 12.28±6.99 and p
value was 0.0001. 10 patients had special problems, 3 had previous H/O PTMC, 3 were pregnant lady, one
has kyphoscoliosis, one had large IAS aneurysm, one had H/O CVA and one patient was suffering from
renal cell carcinoma. Conclusions: The outcome of this study suggests that PTMC is a safe procedure in
experienced hand with good success rate and optimal results even in patients with special problems like
pregnancy, previous CVA and redo cases.