This preprint is under consideration at Journal of Cardiothoracic Surgery. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
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Research article
Clinical and Echocardiographic Trends in Percutaneous Balloon Mitral Valvuloplasty
Ofir Koren
Emek Medical Center
Corresponding Author
ORCiD: https://orcid.org/0000-0002-8666-8276
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background
Percutaneous balloon mitral valvuloplasty (PBMV) is the current standard of care for selected patients with rheumatic mitral stenosis. We examined trends in patient demographics, Wilkins score and additional echocardiographic characteristics, success rates, and complications over a 30-year period.
Methods
We conducted a retrospective observational descriptive study. The study population consists of patients hospitalized in intensive cardiac care (ICCU) due to significant symptomatic MS, from January 1990 to May 2019.
Results
417 patients who underwent PBMV were eligible. Age did not change significantly over time. Male patients who were smoking and had multiple comorbidities such as hypertension, dyslipidemia, ischemic heart disease, and chronic kidney disease became more prevalence (p=0.02, p=0.02, p=0.001, p=0.01, p=0.02, and p=0.001 respectively). Wilkins score and all its components increased over time, which was higher in females (p=0.01), and was not correlated with age (p=0.95). Severe leaflets immobility (Grade 4) predicted complications (p=0.03, respectively). Wilkins over 9 successfully predicted the occurrence of complications, conversely, no efficient cutoff was found in the following decades. Wilkins score managed to predict a technically successful procedure (p=0.02), but not complications (p=0.12). Lastly, complication rates did not significantly change over the years.
Conclusion
Our research covers three decades of experience in PBMV and shows several trends: We see more male patients, who have multiple comorbidities. The Wilkins score increased over the years and was predictive of successful operations as opposed to complications who were predicted mainly by the leaflet mobility index.
Keywords
Mitral Valve Stenosis, Rheumatic Heart Disease, Balloon Valvuloplasty, Echocardiography, Cardiac Catherization
Figure 1
Figure 2
Figure 3
Changes and trends in patient characteristics and in valve morphology over time may be an integral part of the declining trend in the incidence of disease that has occurred in all developed countries throughout the world. Over time we see more male patients, with age not significantly changing. These patients present with a higher incidence of comorbidities over time, namely, smoking, hypertension, dyslipidemia, chronic kidney disease, and ischemic heart disease. In addition, more complex and less favorable valve morphology with increasing Wilkins score and its components. The aforementioned could be attributed to PBMV procedures becoming more difficult with time. In our estimation, those trends could derive from the sex change over time, and due to the unique morphological patterns of MS progression, such as pronounced leaflet calcification, which changes the onset of symptoms and consequently the preconditions for a successful procedure. These can explain, in part, why the rate of rate of successful operations decreased significantly in the third decade relatively to the first decade.
We believe that our growing experience and a more meticulous selection of patients have led us to a stable, nonincreasing excess mortality or morbidity. We presume that the absence of any increase in complication rates is also explained by the development of the PBMV technique over the years —that is, from the use of the balloon-over-the-wire technique to the Inoue-balloon-catheter system, which enables easier maneuvering, gradual balloon expansion, and the absence of a stiff guide wire, leading to a higher incidence of left ventricle rupture.
4.1 Limitations Of Study
This study included prospective data collection and a retrospective analysis of research that began more than 20 years ago. The data analysis was based on the results of echocardiographic tests carried out in our institute and inserted into the hospital's computer system. Due to technical limitations, we have limited ability to reevaluate these measurements. Patient medical data regarding hospitalizations and visits to medical centers in our region were loaded on a 'Clalit' database several years after the initiation of the first PBMV procedures. It is possible that certain data of PBMV surgery performed at another medical center or MVR surgery that were not coordinated with our center, were missing. We estimated an uncertainty rate of missing data of no more than three percent. This rate, in our analysis, does not change the results and conclusions of the study.
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This preprint is under consideration at Journal of Cardiothoracic Surgery. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
Clinical and Echocardiographic Trends in Percutaneous Balloon Mitral Valvuloplasty
Ofir Koren
Emek Medical Center
Corresponding Author
ORCiD: https://orcid.org/0000-0002-8666-8276
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Under Review
Version 1
Posted 21 Dec, 2020
No community comments so far
First submitted
On 13 Dec, 2020
Editor assigned
On 13 Dec, 2020
Submission checks complete
On 13 Dec, 2020
Editor invited
On 13 Dec, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background
Percutaneous balloon mitral valvuloplasty (PBMV) is the current standard of care for selected patients with rheumatic mitral stenosis. We examined trends in patient demographics, Wilkins score and additional echocardiographic characteristics, success rates, and complications over a 30-year period.
Methods
We conducted a retrospective observational descriptive study. The study population consists of patients hospitalized in intensive cardiac care (ICCU) due to significant symptomatic MS, from January 1990 to May 2019.
Results
417 patients who underwent PBMV were eligible. Age did not change significantly over time. Male patients who were smoking and had multiple comorbidities such as hypertension, dyslipidemia, ischemic heart disease, and chronic kidney disease became more prevalence (p=0.02, p=0.02, p=0.001, p=0.01, p=0.02, and p=0.001 respectively). Wilkins score and all its components increased over time, which was higher in females (p=0.01), and was not correlated with age (p=0.95). Severe leaflets immobility (Grade 4) predicted complications (p=0.03, respectively). Wilkins over 9 successfully predicted the occurrence of complications, conversely, no efficient cutoff was found in the following decades. Wilkins score managed to predict a technically successful procedure (p=0.02), but not complications (p=0.12). Lastly, complication rates did not significantly change over the years.
Conclusion
Our research covers three decades of experience in PBMV and shows several trends: We see more male patients, who have multiple comorbidities. The Wilkins score increased over the years and was predictive of successful operations as opposed to complications who were predicted mainly by the leaflet mobility index.
Figure 1
Figure 2
Figure 3
Changes and trends in patient characteristics and in valve morphology over time may be an integral part of the declining trend in the incidence of disease that has occurred in all developed countries throughout the world. Over time we see more male patients, with age not significantly changing. These patients present with a higher incidence of comorbidities over time, namely, smoking, hypertension, dyslipidemia, chronic kidney disease, and ischemic heart disease. In addition, more complex and less favorable valve morphology with increasing Wilkins score and its components. The aforementioned could be attributed to PBMV procedures becoming more difficult with time. In our estimation, those trends could derive from the sex change over time, and due to the unique morphological patterns of MS progression, such as pronounced leaflet calcification, which changes the onset of symptoms and consequently the preconditions for a successful procedure. These can explain, in part, why the rate of rate of successful operations decreased significantly in the third decade relatively to the first decade.
We believe that our growing experience and a more meticulous selection of patients have led us to a stable, nonincreasing excess mortality or morbidity. We presume that the absence of any increase in complication rates is also explained by the development of the PBMV technique over the years —that is, from the use of the balloon-over-the-wire technique to the Inoue-balloon-catheter system, which enables easier maneuvering, gradual balloon expansion, and the absence of a stiff guide wire, leading to a higher incidence of left ventricle rupture.
4.1 Limitations Of Study
This study included prospective data collection and a retrospective analysis of research that began more than 20 years ago. The data analysis was based on the results of echocardiographic tests carried out in our institute and inserted into the hospital's computer system. Due to technical limitations, we have limited ability to reevaluate these measurements. Patient medical data regarding hospitalizations and visits to medical centers in our region were loaded on a 'Clalit' database several years after the initiation of the first PBMV procedures. It is possible that certain data of PBMV surgery performed at another medical center or MVR surgery that were not coordinated with our center, were missing. We estimated an uncertainty rate of missing data of no more than three percent. This rate, in our analysis, does not change the results and conclusions of the study.