Journal Of Indian College Of Cardiology

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 11  |  Issue : 2  |  Page : 66--69

Outcome of rheumatic heart disease and percutaneous balloon mitral valvotomy: A tertiary care center experience


Shilpa Deshmukh Kadam 
 Department of Cardiology, MGM Hospital, Navi Mumbai, Maharashtra, India

Correspondence Address:
Dr. Shilpa Deshmukh Kadam
1002, 10th Floor, Awing, Lords, Above Croma Shop, Sector 15, CBD Belapur, Navi Mumbai - 400 614, Maharashtra
India

Abstract

Background: Rheumatic heart disease (RHD) is still a leading cause of valvular heart disease in India. Balloon mitral valvotomy (BMV) is simple and safe procedure to improve the quality of life in patients with severe mitral stenosis. Aim: (1) To evaluate outcome of RHD patients in tertiary care hospital in developing country like India in twenty first century. (2) To evaluate safety and efficacy of BMV. Materials and Methods: We performed retrospective analysis of 500 patients with RHD undergoing echocardiography in a tertiary care hospital in Maharashtra, India. 15% (74 patients) of them underwent balloon mitral valvuloplasty between June 2012 and November 2019 and 37.6% (188 patients) were treated with valve replacements. Results: Successful BMV was performed in 72 patients. The rate of complication was 2.7%. No mortality was noted. One hundred and eighty-eight patients underwent Valve replacements. Conclusions: Balloon mitral valvuloplasty is a technically difficult procedure and demands considerable expertise in transseptal catheterization. Percutaneous balloon mitral valvotomy is a safe and effective treatment for symptomatic severe Mitral stenosis in experienced centers.



How to cite this article:
Kadam SD. Outcome of rheumatic heart disease and percutaneous balloon mitral valvotomy: A tertiary care center experience.J Indian coll cardiol 2021;11:66-69


How to cite this URL:
Kadam SD. Outcome of rheumatic heart disease and percutaneous balloon mitral valvotomy: A tertiary care center experience. J Indian coll cardiol [serial online] 2021 [cited 2021 Oct 22 ];11:66-69
Available from: https://www.joicc.org/text.asp?2021/11/2/66/315269


Full Text



 Introduction



Rheumatic heart disease (RHD) is a chronic manifestation of rheumatic carditis, which occurs in 60%–90% of cases of rheumatic fever (RF). RF is late sequela to Group A hemolytic streptococcal infection of the throat. Although all of the cardiac valves may be involved by this rheumatic process, the mitral valve is involved most prominently.[1]

India is home to 40% of all people living with RHD. Of the estimated 33 million people with RHD, 13.2 million live in India. Likewise, in the year 2015, of the 347,000 deaths due to RHD worldwide, nearly 120,000 (over a third) are estimated to have occurred in India. During the 25-year period from 1990 to 2015, the age-standardized mortality due to RHD worldwide fell from 9.2 to 4.8/100 000 population, a reduction of nearly 48%. However, the reduction for India is a mere 18% (from 15.5 to 12.7/100,000 population).[2]

 Methods



We have studied 500 patients with RHD undergoing echocardiography in the department of Cardiology in Tertiary Care Centre in Maharashtra, India. Out of them, 74 patients (14.8%) with severe rheumatic mitral stenosis with favorable valve anatomy who underwent balloon mitral valvotomy (BMV) between June 2012 and November 2019 were evaluated retrospectively. Inclusion criteria for BMV were an isolated severe symptomatic Mitral stenosis, Wilkins score < 8, mitral regurgitation (MR) less than Grade II, no clot in the left atrium on transesophageal echocardiography (TEE). Success of the procedure was defined by doubling of the mitral valve area and halving of the mitral valve gradient. In two patients, BMV was abandoned as clot was noted in left atrium on TEE, just before the procedure. Therefore, BMV was performed in 72 patients.

 Results



Patient's ages ranged from 14 years to 54 years. 16.6% (12 patients) were <20 years of age. 37.5% (27 patients) were males and 62.5% (44 patients) were females. Ejection fraction was noted to be < 60% in five patients (6.9%). Atrial fibrillation was noted in 18% of patients.

Results of BMV were as shown in [Table 1].{Table 1}

Trivial to Grade I aortic regurgitation was noted in 18 patients (25%). Trivial to Grade II Tricuspid regurgitation was noted in 25 patients (34.7%). Before the procedure, trivial MR was noted in 26 patients (36.1%). Grade I MR was noted in nine patients (12.5%). Postprocedure Grade I MR was noted in 22 patients (30.5%). Pulmonary artery hypertension (PAH) was noted in 24 patients (33.3%). Grade of PAH dropped significantly post-BMV. Furthermore, patients with dyspnea NYHA Class III and IV improved to Class I and II post-BMV.

In three patients, (4.1%) Redo BMV was successfully done after an average of 10 years. Three patients with severe mitral stenosis were referred to cardiology department in the antenatal period in second trimester. One patient, who was symptomatic on medical management, underwent successful BMV at 26 weeks of gestation. Two asymptomatic patients with severe mitral stenosis were advised medical management and followed up regularly till the last trimester and during labor. Both underwent uneventful normal labor.

Post-BMV, one patient developed severe MR and had to undergo mitral valve replacement (MVR). One patient developed pericardial perforation while performing septal puncture and was managed successfully with pericardial tapping and auto transfusion. Therefore, the rate of complication was 2.7% in our study. There was no mortality.

Out of 500 patients, 37.6% (188 patients) underwent successful valve replacements over a period of 6 years. Patients with unfavorable valve anatomy for BMV and significant aortic or Tricuspid valve disease were subjected to valve replacements. MVR was done in 110 patients (58%). Aortic valve replacement was done in 47 patients (25%). Double valve replacement (DVR) was done in 31 patients (16.4%) 5.3% (10 patients) were brought to the hospital with stuck valve over a period of 5 years' postsurgery. Causes of stuck valve were found to be inadequate access to health-care facilities in small towns and villages, inadequate INR monitoring and anticoagulant consumption. Half of them were thrombolysed and managed successfully.

 Discussion



The RF/RHD continues to be an important cause of disease burden in India, affecting the population in their prime and productive phase of the life.[3] India is a young country having 53% of the population younger than 25 years according to the census by government of India in 2001.

History of Rheumatism in India dates back to 1835, when Malcomson observed that rheumatism was prevalent among sepoys[4] and in 1870 Moore[5] reported numerous cases of rheumatism in Rajasthan. The first clinical evidence of RF came from Punjab by Wig in 1935[6] and on rheumatism in childhood and adolescence by Kutumbiah in 1940.[7],[8]

The prevalence of RHD in India from recent school surveys is 0.5/1000 children in the age group of 5–15 years.[3] ICMR's multicentric “Jai Vigyan Mission Mode Project on RF/RHD” was undertaken from 2000 to 2010 to estimate the prevalence of RF/RHD in 176904 school children in the age group of 5–14 years. The prevalence of RHD in this multicentric school study ranged from 0.13 to 1.5/1000 in school children in the age group of 5–9 years and 0.13–1.1/1000 in the age group of 10–14 years.[9]

Before the advent of BMV, most patients with symptomatic MS were treated with surgical mitral commissurotomy, either open or closed. Closed mitral commissurotomy was first described by Harken and Bailey in the late 1940s.[1] Subsequently, after the development of cardiopulmonary bypass; the open surgical commissurotomy replaced the closed technique in most countries in the late 1960s and early 1970s. In 1982, Kanji Inoue, a Japanese cardiac surgeon, first developed the idea that a degenerated mitral valve could be inflated using a balloon made of strong yet pliant natural rubber.[1],[10]

Commissural fusion is now recognized as the principal pathology underlying mitral stenosis, and commissural splitting underlies successful interventional treatment.[1],[11]

Balloon mitral valvotomy (BMV) has emerged as the treatment of choice for hemodynamically significant mitral stenosis (MS).[1],[12]

The binary end point of immediate procedural success is most often a final valve area of 1.50 cm2 without moderate or severe MR. After BMV, mitral valve area approximately doubles in most successful cases.[12] It has been shown that the most important predictor of post procedural MVA is the anatomy of the valve.[12],[13] Lock et al. in India, first reported the use of such a cylindrical balloon for mitral valvuloplasty.[14]

Minor increase in MR is common (20%–46%), severe MR is rare.[13] Procedure mortality is <1% in most centers.[13] Fawzy et al.[1],[15],[16] reported an event-free survival rate of 79% at 10 years and 43% at 15 years in relatively younger patients (mean age 31 ± 11 years) and were significantly higher for patients with optimal valve anatomy (88% at 10 years, 66% at 15 years). They found that favorable valve anatomy, age, and post procedural mitral valve area were predictors of event-free survival.[17] Older age; smaller valve area, previous commissurotomy, or baseline MR should be considered as potential predictors for poor immediate outcome with a similar predictive strength as valve calcification.[12] Lung et al. reported an event-free survival (survival with freedom from repeat PMBV, MVR, cardiac death, high NYHA class) rate of 61% at 10 years in 1000 patients (mean age 49–14 years) with successful Percutaneous balloon mitral valvotomy (PBMV).[18] The incidence of restenosis was 40% at 7 years' follow-up.[19]

Balloon valvotomy offers distinct advantages to surgical commissurotomy and these include avoidance of thoracotomy and general anesthesia. The discomfort is minimized and hospital stay is markedly reduced. In our society, balloon therapy has a special place in unmarried females where operative scar is considered a social handicap.[13],[20] Balloon valvotomy is also preferable in patients with restenosis with favorable anatomy, and in patients with high surgical risk due to severe pulmonary hypertension or associated diseases.[13]

Contraindications to PBMV are persistent left atrial thrombus, more than moderate MR, massive or bicommissural calcification, severe concomitant aortic valve disease, severe organic tricuspid stenosis, or severe functional regurgitation with enlarged annulus, severe concomitant coronary artery disease requiring bypass surgery.[1]

The natural history of mitral stenosis varies across geographical areas. In North America, for example, it is most commonly an indolent and slowly progressive disease, with a latency period as long as 20–40 years between the initial infection and the onset of clinical symptoms. In developing countries, on the other hand, mitral stenosis progresses much more rapidly, perhaps because of more severe or repeated streptococcal infections, genetic influences, or economic conditions, and may lead to symptoms in the late teens and early twenties.[21] Twelve patients in our study were <20 years of age. Two of our DVR patients were under 18 years of age.

Rheumatic mitral stenosis constitutes a major cause of acquired heart disease complicating pregnancy in India.[22] Women with MS often become symptomatic during pregnancy because of significant increases in plasma volume (≈50%) and heart rate (≈20%–30%).[23] Medical therapy should be targeted toward decreasing heart rate, which will increase left ventricular filling time and thereby decrease left atrial pressure. BMV has been performed successfully in women who fail medical therapy and is recommended over open commissurotomy.[24]

Transjugular BMV may be performed in patients with anomalies of inferior vena cava, dextrocardia, huge or aneurysmal LA, or unfavorable interatrial septal anatomy or secondarily to causes like kyphoscoliosis.[25]

The WHO and the World Heart Federation have called for a 25% relative reduction in mortality due to noncommunicable diseases including RHD by the year 2025. Emphasis on treating established valve disease is needed to reduce RHD related mortality.[26],[27]

Because RF/RHD affects the young population, the potential and productivity of the country are affected adversely. Thus, it is imperative that country must invest in prevention and control of RF/RHD. The most effective intervention for the prevention of RF/RHD could be creating enabling environment through policy intervention to promote sanitation, hygiene, better living conditions, nutrition, and access to affordable and quality health-care equitably.[3]

 Conclusion



RHD is still an important health problem in developing countries like India. BMV is a safe and effective treatment in patients with favorable valve anatomy in experienced centers, especially in adolescent females with severe symptomatic mitral stenosis for two reasons. One, women in reproductive age group do not have to be on warfarin anticoagulation post BMV and can safely complete their family within the tenure of 8–10 years, post-BMV. Second, they can avoid the stigma of the huge scar on the chest by undergoing BMV verses MVR or open mitral commissurotomy. Pregnant patients with severe mitral stenosis with symptoms well controlled can be managed with optimum medical management.

Early detection of Valvular heart disease with echocardiography and timely intervention can reduce the morbidity and mortality significantly.

Acknowledgment

Dr. V D Chavan sir for his mentorship

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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