Results of percutaneous double-balloon mitral commissurotomy in one medical center in Tunisia

Percutaneous balloon mitral commissurotomy was attempted in Tunisia, where rheumatic fever is still endemic, in 463 consecutive patients with severe rheumatic mitral valve stenosis. Their mean age ±SD was 33 ± 12 years (range 8 to 68), 324 patients (70%) were women, and 327 (71%) were in sinus rhythm. Valvotomy was technically successful in 454 patients (98%). The mean mitral valve gradient decreased from 20 ± 7 to 6 ± 4 mm Hg, mean left atrial pressure decreased from 27 ± 8 to 15 ± 6 mm Hg, cardiac index increased from 3.0 ± 0.7 to 3.6 ± 0.8 L/min/m2, and Gorlin mitral valve area, from 0.97 ± 0.19 to 2.2 ± 0.4 cm2 (all p < 0.001). Two-dimensional echocardiographic mitral valve area increased from 1.03 ±0.18 to 2.15 ± 0.36 cm2 (p < 0.00001). A final valve area of ≥1.5 cm2 was achieved in 98% of patients. Multivariate analysis identified a pre-mitral valve area <0.8 cm2 and an echocardiographic score (echo score) ≥12 as the strongest predictors of residual stenosis (final mitral valve area <1.5 cm2). Major procedural complications included mortality (0.4%), tamponade (0.7%), thromboembolism (2.0%), severe mitral regurgitation (4.6%), significant (pulmonary to systemic flow ratio ≥1.5) interatrial shunt (4.8%). Four hundred thirty patients were followed up between 6 and 82 months (mean 37 ± 22): 95% were in functional class I to II without reintervention, and 7 patients died (1.6%); restenosis (echocardiographic mitral valve area <1.5 cm2) occurred in 10.4% of patients. The 3-year Kaplan-Meier freedom from restenosis was 92%, and from reintervention 93%. Because fluoroscopic calcium and postprocedure mitral valve area <-1.8 cm2 were the independent predictors of restenosis, patients with calcified valves should be selected for this procedure on a case-to-case basis.