417 patients (334 Females; aged 23–88) underwent PBMV over the 30-year study period. The overall average patient age was 56.2 ± 11.0 years. Analysis by year revealed no significant trend in age (p = 0.09) (Table 1). There was a significant increase in the rates of male patients, smoking, dyslipidemia, and chronic kidney disease, this remained true after adjusting for age (p = 0.02, p = 0.001, p = 0.02 and p = 0.001, respectively). In addition, after adjusting for age - there was also an increasing trend in hypertension and ischemic heart disease (p = 0.02 and p = 0.01)
Linear regression analysis of the mean Wilkins score revealed that the Wilkins score increased on average by 1.379 per decades, and 0.151 per year, and median Wilkins increased on average by 1.295 per decade, and 0.145 per year (Fig. 2). The Jonckheere-terpstra test showed a significant trend for all Wilkins variables (calcification of leaflets, Calcification of subvalvular apparatus, mobility, and thickening) (Table 2). Wilkins score was not associated with age (r = 0.003, p = 0.95), but it was significantly higher in male patients (p < 0.01), with mean Wilkins 9.27 as opposed to 8.77 in females.
Table 2
Wilkins score and components over decades (N = 417).
|
|
Decades
|
|
|
Pairwise Bonferroni Corrected p
|
|
1990–1999 (1)
(N = 166)
|
2000–2009 (2)
(N = 181)
|
2010–2019 (3)
(N = 70)
|
Jonckheere
-Terpstra
P-value
|
1 vs 2
|
1 vs 3
|
2 vs 3
|
Wilkins total
|
7.7 ± 1.3
(8; 4–12)
|
9.4 ± 1.3
(9; 5–12)
|
10.3 ± 1.1
(10; 7–13)
|
.0011
|
.001
|
.001
|
.001
|
< 8
8
|
71 (42.8)
95 (57.2)
|
10 (5.5)
171 (94.5)
|
1 (1.4)
69 (98.6)
|
.001
|
.001
|
.001
|
.001
|
< 9
≥ 9
|
124 (74.7)
42 (25.3)
|
43 (23.8)
138 (76.2)
|
4 (5.7)
66 (94.3)
|
.001
|
.001
|
.001
|
.001
|
< 10
≥ 10
|
154 (92.8)
12(7.2)
|
100 (55.4)
81(44.6)
|
14(20.0)
56 (80.0)
|
.001
|
.001
|
.001
|
.001
|
< 11
≥ 11
|
162 (97.6)
4 (2.4)
|
145 (80.1)
36 (19.9)
|
39 (55.7)
31 (44.3)
|
.001
|
.001
|
.001
|
.001
|
Calcification of leaflets
|
1.92 ± 0.80
(2; 1–4)
|
2.26 ± 0.84
(3; 1–4)
|
2.80 ± 0.75
(3; 1–4)
|
.001
|
.001
|
.001
|
.001
|
Calcification of subvalvular apparatus
|
2.05 ± 0.72
(2; 1–4)
|
2.27 ± 0.85
(2; 1–4)
|
2.60 ± 0.73
(3; 1–4)
|
.001
|
.02
|
.001
|
.009
|
Mobility
|
1.90 ± 0.77
(2; 1–4)
|
2.25 ± 0.64
(2; 1–4)
|
2.43 ± 0.71
(2; 1–4)
|
.001
|
.001
|
.001
|
.051
|
Thickening
|
1.84 ± 0.81
(2; 1–4)
|
2.60 ± 0.60
(3; 1–4)
|
2.49 ± 0.61
(2; 1–4)
|
.001
|
.001
|
.001
|
.32
|
1Linear regression |
*Data is mean ± SD (Median; range) |
Out of the 417 patients, 200 (48.0%) had complications, 184 (44.4%) mitral regurgitations, 9 (2.2%) tamponades, 6 (1.4%) ASD, 1 (0.2%) stroke, and 7 (1.7%) required urgent surgery. The rate of complications did not change over decades. Age, hypertension, LVEF, and grade 4 Mobility predicted the occurrence of complications. After correcting for age, hypertension and LVEF were no longer predictive (p = 0.07 and p = 0.11) (Table 3).
Table 3
Patient characteristics and complications.
|
|
|
|
Age adjusted
|
Patient characteristics
|
Complications
(N = 200)
|
No complications (N = 217)
|
P-value
|
OR
|
P-value
|
OR
|
Age (Mean ± SD years)
(Median; range)
|
57.5 ± 10.2
(57; 29–84)
|
55.0 ± 11.7
(55; 23–88)
|
.02
|
1.02
|
-
|
---
|
Sex
Female
Male
|
166 (49.7)
33 (40.2)
|
168 (50.3)
49 (59.8)
|
.12
|
1.47
1.00
|
.09
|
1.54
1.00
|
Obesity (BMI > 30)
|
91 (45.7)
|
88 (40.7)
|
.31
|
1.23
|
.48
|
1.15
|
Smoking
|
70 (35.2)
|
83 (39.2)
|
.40
|
0.84
|
.32
|
0.82
|
Hypertension
|
100 (50.8)
|
85 (39.5)
|
.02
|
1.58
|
.07
|
1.46
|
Dyslipidemia
|
95 (48.5)
|
94 (43.9)
|
.36
|
1.20
|
.56
|
1.12
|
Diabetes mellitus
|
55 (28.1)
|
54 (25.2)
|
.52
|
1.16
|
.82
|
1.05
|
Chronic kidney failure
|
35 (17.9)
|
37 (17.5)
|
.92
|
1.03
|
.95
|
0.98
|
Ischemic heart disease
|
56 (28.9)
|
66 (30.7)
|
.69
|
0.92
|
.20
|
0.74
|
CABG
|
8 (4.1)
|
15 (7.0)
|
.21
|
0.57
|
.20
|
0.56
|
Atrial fibrillation
|
101 (50.5)
|
110 (50.9)
|
.93
|
0.98
|
.49
|
0.87
|
Stroke
|
28 (14.3)
|
29 (13.6)
|
.83
|
1.06
|
.95
|
1.02
|
Endocarditis
|
4 (2.1)
|
6 (2.9)
|
.61
|
0.72
|
.60
|
0.71
|
Decade
|
|
|
.83
|
|
.09
|
|
1990–1999
|
73 (44.2)
|
92 (55.8)
|
|
1.00
|
|
1.00
|
2000–2009
|
98 (53.8)
|
84 (46.2)
|
.07
|
1.47
|
.06
|
1.51
|
2010–2019
|
29 (41.1)
|
41 (58.9)
|
.69
|
0.89
|
.75
|
0.91
|
Wilkins total
|
9.0 ± 1.5
(9; 5–12)
|
8.8 ± 1.7
(9; 4–13)
|
.12
|
1.10
|
.14
|
1.10
|
Category
< 8
≥ 8
|
Rate
35 (42.7)
37 (42.0)
|
47 (57.3)
51 (58.0)
|
.37
.31
|
1.00
1.29
|
.29
|
1.00
1.02
|
≥ 9
|
53 (54.1)
|
45 (45.9)
|
.08
|
1.42
|
10
|
1.40
|
10
11+
|
41 (52.6)
34 (47.9)
|
37 (47.4)
37 (52.1)
|
.54
.34
|
1.13
1.25
|
.52
.34
|
1.14
1.25
|
Calcification of leaflets
1
2
3
4
|
41 (47.7)
89 (47.1)
56 (51.9)
14 (41.2)
|
45 (52.3)
100 (52.9)
52 (48.1)
20 (58.8)
|
.72
---
.92
.62
.49
|
1.00
0.98
1.16
0.75
|
.76
---
.89
.66
.50
|
1.00
0.97
1.14
0.76
|
Calcification of subvalvular apparatus
1
2
3
4
|
33 (45.8)
93 (47.0)
63 (51.2)
11 (45.8)
|
39 (54.2)
105 (53.0
60 (48.8)
13 (54.2)
|
.80
---
.84
.40
> .99
|
1.00
1.06
1.28
1.00
|
.79
---
.72
.34
.86
|
1.00
1.11
1.33
1.09
|
Mobility
1
2
3
4
|
28 (39.4)
117 (50.6)
44 (44.4)
11 (73.3)
|
43 (60.6)
114 (49.4)
56 (55.6)
4 (26.7)
|
.06
---
.14
.62
.03
|
1.00
1.50
1.17
4.03
|
.11
---
.18
.79
.04
|
1.00
1.46
1.09
3.83
|
Thickening
1
2
3
4
|
27 (39.7)
85 (47.0)
81 (53.6)
7 (41.2)
|
41 (60.3)
96 (53.0)
70 (46.4)
10 (58.8)
|
.28
---
.31
.07
.95
|
1.00
1.34
1.71
1.04
|
0.30
---
.29
.07
.78
|
1.00
1.37
1.73
1.16
|
ECHO characteristics
|
|
|
|
|
|
|
LVEF
|
58.0 ± 4.7
(60; 45–83)
|
58.9 ± 4.2
(60; 40–72)
|
.03
|
|
0.11
|
0.96
|
Other characteristics
|
|
|
NS
|
|
|
|
LVEF; left ventricular ejection fraction |
Table 4
Patient characteristics and technically successful operations.
|
|
|
|
Age adjusted
|
Patient characteristics
|
Successful
(N = 389)
|
Not successful (N = 27)
|
P-value
|
OR
|
P-value
|
OR
|
Age (Mean ± SD years)
(Median; range)
|
56.4 ± 11.0
(56; 23–88)
|
52.8 ± 10.0
(52; 36–76)
|
.10
|
1.03
|
--
|
---
|
Sex
Female
Male
|
313 (94.0)
75 (91.5)
|
20 (6.0)
7 (8.5)
|
.40
|
1.46
1.00
|
.38
|
|
Obesity (BMI > 30)
Yes
No
|
166 (93.3)
221 (93.6)
|
12 (6.7)
15 (6.4)
|
.88
|
0.94
1.00
|
.70
|
|
Smoking
|
144 (94.1)
|
9 (5.9)
|
.77
|
1.13
|
.85
|
|
Hypertension
Yes
No
|
168 (90.8)
221 (95.6)
|
17 (7.2)
10 (4.4)
|
.052
|
0.46
1.00
|
.02
|
0.38
1.00
|
Dyslipidemia
|
177 (93.7)
|
12 (6.3)
|
.85
|
1.08
|
.93
|
|
Diabetes mellitus
|
100 (92.6)
|
8 (7.4)
|
.60
|
0.80
|
.41
|
|
Chronic kidney failure
|
67 (93.1)
|
5 (6.9)
|
.91
|
0.94
|
.85
|
|
Ischemic heart disease
|
111 (91.0)
|
11 (9.0)
|
.20
|
0.60
|
.05
|
|
CABG
|
21 (91.3)
|
2 (8.7)
|
.69
|
0.74
|
.69
|
|
Atrial fibrillation
|
194 (91.9)
|
17 (8.1)
|
.19
|
0.59
|
.10
|
|
Stroke
|
52 (92.9)
|
4 (7.1)
|
.86
|
0.91
|
.79
|
|
Endocarditis
|
9 (90.0)
|
1 (10.0)
|
.67
|
0.64
|
.67
|
|
Decade
|
|
|
.01
|
|
.02
|
|
1990–1999
|
159 (97.0)
|
5 (3.0)
|
|
1.00
|
|
1.00
|
2000–2009
|
170 (93.4)
|
12 (6.6)
|
.32
|
0.45
|
.18
|
0.48
|
2010–2019
|
60 (85.7)
|
10 (14.3)
|
.007
|
0.19
|
.005
|
0.20
|
Wilkins total
|
8.8 ± 1.5
(9; 5–13)
|
10.0 ± 2.4
(9; 4–12)
|
.001
|
0.60
|
.001
|
0.61
|
Category
< 8
≥ 8
|
Rate
76 (93.8)
313 (93.4)
|
5 (6.2)
22 (6.6)
|
.90
|
1.00
0.94
|
.89
|
1.00
0.93
|
< 9
≥ 9
|
163 (96.4)
226 (91.5)
|
6 (3.6)
21 (8.5)
|
.04
|
1.00
0.40
|
.05
|
1.00
0.39
|
< 10
≥ 10
|
257(96.3)
132 (88.6)
|
10 (3.7)
17 (11.4)
|
.002
|
1.00
0.30
|
.004
|
1.00
0.30
|
Calcification of leaflets
1
2
3
4
|
82 (95.3)
176 (93.6)
102 (94.4)
29 (85.3)
|
4 (4.7)
12 (6.4)
6 (5.6)
5 (14.7)
|
.25
--
.57
.79
.08
|
1.00
0.72
0.83
0.28
|
.28
--
.54
.75
.08
|
1.00
0.70
0.81
0.29
|
Calcification of subvalvular apparatus
1
2
3
4
|
68 (95.8)
189 (95.5)
117 (95.1)
15 (62.5)
|
3 (4.2)
9 (4.5)
6 (4.9)
9 (37.5)
|
.001
--
.90
.82
.001
|
1.00
0.93
0.86
0.07
|
.001
--
.96
.85
.001
|
1.00
0.97
0.87
0.08
|
Mobility
1
2
3
4
|
68 (95.8)
216 (93.9)
92 (92.0)
13 (86.7)
|
3 (4.2)
14 (6.1)
8 (8.0)
2 (13.3)
|
.55
--
.59
.34
.20
|
1.00
0.68
0.51
0.29
|
.48
--
.52
.26
.17
|
1.00
0.66
0.47
0.27
|
Thickening
1
2
3
4
|
65 (95.6)
168 (93.3)
142 (94.0)
14 (82.4)
|
3 (4.4)
12 (6.7)
9 (6.0)
3 (17.6)
|
.30
--
.51
.66
.08
|
1.00
0.65
0.73
0.22
|
.40
--
.53
.65
.11
|
1.00
0.66
0.74
0.25
|
ECHO characteristics
|
|
|
|
|
|
|
LVEF
|
58.5 ± 4.5
(60; 50–60)
|
58.2 ± 3.7
(60; 50–60)
|
.79
|
1.01
|
.71
|
1.02
|
Pressure gradients over MV
|
14.73 ± 6.24
(14; 3–60)
|
12.74 ± 7.29
(12; 5–36)
|
.02
|
1.06
|
.06
|
1.09
|
MVA
|
1.59 ± 0.25
(1.6; 0.7–2.5)
|
1.38 ± 0.05
(1.4; 1.3–1.5)
|
.001
|
115.5
|
.001
|
109.4
|
LVEF; left ventricular ejection fraction, MVA; Mitral valve area |
In the first decade, Wilkins score with a cutoff of 9 (< 9/>=9) was a significant predictor of complications, even after adjusting for age (χ2 = 5.31, p = 0.02). There were no significant cutoffs in the second or third decade. Decade ROC analysis curve revealed no significant Wilkins cutoff points. However, Wilkins score did seem to predict a technically successful procedure (p = 0.02).
Hypertension decreased the odds of a technically successful operation after adjusting for age (p = 0.02). Wilkins 9 plus or 10 plus also predicted a technically successful operation (p = 0.04 and p = 0.002, respectively). This remained true after adjusting for age (p = 0.05 and p = 0.004, respectively). In addition, the third decade had significantly lower technically successful operations compared to the first decade. (Fig. 3). Multivariate logistic regression analysis revealed that after adjusting for age, decade (p = 0.02) and hypertension (p = 0.02) were significant predictors of a technically successful operation while Wilkins 9 or higher, or 10 or higher were not significant (p = 0.74, and p = 0.22 respectively).