The medical records of 995 patients after PMV were reviewed. Thirty-four patients had acute major complications, four patients developed tamponade and 30 patients underwent surgical mitral valve replacement due to valve rupture and severe mitral regurgitation. Among the 30 patients requiring surgery, six had a Wilkins score of 8 or less (group I) and 24 had a Wilkins score of 9 or10 (group II). Also, two out of 30 patients had bicommissural calcification and 4 out of 30 patients had unicommissural calcification.
We included 961 patients and reviewed their records. The mean age of the patients was 46.6 ± 12.2 years, and 81.7% of the patients (n=785) were females. Three-hundred and fifty-three patients (36.7%) had a Wilkins score of 8 or less and were included in group I, 559 patients (58.1%) had a Wilkins score of 9 or 10 and were assigned to group II, and 49 other patients (5.0%) with a score greater than 10 were classified as group III. Baseline characteristics and echocardiographic measurements of patients based on Wilkins score are summarized in table 1. MVA and indexed MVA were both significantly lower in groups II and III (Respectively P<0.01 and P=0.01), and LA diameter was significantly greater in groups II and III (P<0.01). Also, MVMG was significantly higher in groups II and III (P<0.01).
Table 1. Baseline Characteristics and Echocardiographic Parameters of the Study
P-value
|
Group III (N=49)
|
Group II (N=559)
|
Group I (N=353)
|
Total (N=961)
|
Variable
|
0.2
|
49.2 ±12.7
|
47.0 ± 12.2
|
45.3 ± 12.2
|
48.4 ± 12.2
|
Age (year)
|
0.4
|
37 (75.5)
|
454 (81.2)
|
294 (83.3)
|
785 (81.7)
|
Female Gender
|
0.8
|
2 (4.1)
|
27 (4.8)
|
18 (5.1)
|
47 (4.9)
|
Diabetes mellitus
|
0.7
|
4 (8.2)
|
61(10.9)
|
37 (10.2)
|
102 (10.6)
|
Hypertension
|
0.8
|
0 (0)
|
8 (1.4)
|
4 (0.7)
|
12 (1.2)
|
Previous CVA
|
|
|
|
|
|
Echocardiographic Parameters
|
<0.01
|
0.8 ± 0.2
|
0.9 ± 0.4
|
0.9 ± 0.2
|
0.9 ± 0.3
|
MVA (cm2)
|
0.01
|
0.4 ± 0.1
|
0.4 ± 0.2
|
0.4 ± 0.2
|
0.4 ± 0.2
|
Indexed MVA (cm2/m2)
|
<0.01
|
13.3 ± 2
|
13 ± 3.2
|
11.7 ± 2.5
|
11.9 ± 2.1
|
Mitral valve mean gradient (mmHg)
|
0.5
|
50.6 ± 3.9
|
51.7 ± 4.2
|
51.3 ± 4.5
|
51.5 ± 4.4
|
LVEF (%)
|
0.1
|
32 ± 6.1
|
31.8 ± 6
|
32.7 ± 6.4
|
32.3 ± 6.1
|
LVESD (mm)
|
0.05
|
46 ± 5.9
|
44.9 ± 5.2
|
45.8 ± 5
|
45.6 ± 5.5
|
LVEDD (mm)
|
<0.01
|
51.2 ± 9.1
|
50.1 ± 9.8
|
45.6 ± 8.5
|
47.4 ± 8.3
|
LA diameter (mm)
|
0.06
|
57.5 ± 8.2
|
54.8 ± 10.8
|
53.4 ± 9.5
|
53.9 ± 10
|
SPAP (mmHg)
|
CVA: Cerebrovascular accident; MVA: Mitral valve area; LVEF: Left ventricular ejection fraction; LVESD: Left ventricular end-systolic diameter; LVEDD: left ventricular end-diastolic diameter; LA: Left atrium; SPAP: Systolic pulmonary artery pressure
In the echocardiographic evaluation 6 months after the PMV, MVA and indexed MVA both increased significantly in all 3 Wilkins groups (p<0.0001), SPAP and MVMG markedly decreased in all groups (P<0.01 for all values).
In the mid-term follow up, the mean MVA and indexed MVA were significantly higher in all three Wilkins groups compared to baseline measurements (P<0.001). Also, SPAP and MVMG markedly decreased in all groups (P<0.001).
Six patients in group I (1.6%), 34 patients (6.08%) in group II, and three patients (6.12%) in group III showed restenosis in mid-term follow-up echocardiography. The rate of restenosis was significantly higher in groups II and III than in group I (P<0.01). None of the patients had more than moderate mitral regurgitation before PMV, but in mid-term follow-up 29 patients in group I (8.03%), 64 patients in group II (11.44%), and 5 patients (10.20%) in group III showed more than moderate mitral regurgitation who needed a surgical mitral valve replacement. This difference between the three groups was not statistically significant (P=0.09). Comparison of restenosis and mitral regurgitation rates in mid-term follow-up between 2 groups is shown in figure 1.
Commissural calcification
Based on the absence or presence of commissural calcification, we compared echocardiographic and clinical outcomes. One-hundred and ninety patients (19.77%) had commissural calcification, with 136 of them (71.57%) having calcification in anterolateral commissure, and 34 having posteromedial commissural calcification (17.89%) and 20 patients (10.52%) had bicommissural calcification. MVA and indexed MVA were significantly lower in patients with commissural calcification (P<0.01). MVMG was significantly higher in patients with commissural calcification (P<0.01). However, there was no significant difference in Wilkins score in presence or absence of commissural calcification (P=0.16) (table 2).
Table 2. Echocardiographic Parameters based on Commissural Calcification
Echocardiographic Parameters
|
Present commissural calcification
(190 patients)
|
No commissural calcification
(771 patients)
|
P-value
|
MVA
|
0.91 ± 0.17
|
0.92 ± 0.22
|
<0.01
|
Indexed MVA
|
0.57 ± 0.16
|
0.64 ± 0.18
|
<0.01
|
MVMG
|
12.92 ± 2.49
|
11.82 ± 2.17
|
<0.01
|
SPAP
|
54.78 ± 8.63
|
54.15 ± 7.93
|
0.3
|
Wilkins score
|
8.40 ± 0.67
|
8.48 ± 0.68
|
0.1
|
MVA: Mitral valve area; MVMG: Mitral valve mean gradient; SPAP: Systolic pulmonary artery pressure.
In short-term follow-up after successful PMV, MVA and indexed MVA increased significantly in all patients, and MVMG and SPAP decreased significantly in both groups based on the absence or presence of commissural calcification. (P<0.01 for all parameters). Similarly, in mid-term follow-up, MVA and indexed MVA increased significantly compared to before PMV in all patients (with or without commissural calcification). These findings are summarized in table 6.
Restenosis occurred in seven patients without commissural calcification (0.90%). In patients with commissural calcification, 10 patients (9 patients with unicommissural calcification and 1 patients with bicommissural calcification) showed restenosis in mid-term follow-up (5.26%), which was significantly higher in comparison with patients without commissural calcification(p<0.01) (Figure 2).
The occurrence of mitral valve surgery due to mitral regurgitation (moderate or more) was 52 in patients without commissural calcification (6.74%) and 23 (12.10%) in patients with commissural calcification (all of them had unicommissural calcification) that this difference was statistically significant (P=0.03). Mid-term clinical outcomes based on the absence or presence of commissural calcification are shown in figure2.