HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Praveen Kerala Varma Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Varma, P. K. Articles by Neema, P. K. Search for Related Content PubMed Articles by Varma, P. K. Articles by Neema, P. K. Related Collections Valve disease Related Article

J Thorac Cardiovasc Surg 2006;131:927-928
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor

^a Division of Cardio-thoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, India 695 011
^b Division of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, India 695 011

We thank Choudhary and his colleagues for their interest in our article. ¹ Experience in our center and also reported by others ² shows that the majority of patients with severe subvalvular disease achieve a satisfactory outcome with percutaneous transmitral commissurotomy (PTMC). Hence we believe that we have to look beyond the role of undiagnosed subvalvular disease as the sole mechanism in producing mitral regurgitation (MR) after PTMC. This allows us to further clarify our hypothesis.

In 14 cases of MR that we analyzed, only 10 involved severe subvalvular disease. However, all had severe commissural fusion. In PTMC, commissural splitting is the mechanism for relieving mitral stenosis. Normally, commissures split at the point of least resistance to balloon pressure. However, in the presence of such rigid commissures, areas with lesser resistance can "give way." The posterior leaflet is often rolled up and thickened, whereas a more pliable anterior leaflet becomes vulnerable. In the series described by Choudhary and colleagues, a split could be not be achieved in most cases because of severe commissural fusion. Tearing of the anterior leaflet (16/25) was the commonest cause of MR necessitation surgery in their study and in most other large series. ^1,3 These data further support our findings that severity of commissural disease may be the most important determinant of production of MR after PTMC.

Failure to assess adequately the commissural disease might be the reason why many scoring systems for assessment of valves for PTMC have poor predictive value regarding the outcome and complications. ⁴ However, echocardiographic assessment of commissural morphology has excellent correlation with outcome. ^4,5 These researchers ⁴ observed that there was more frequent need for oversizing the balloon in patients with single or no commissural splitting. Furthermore, in patients in whom commissural splitting could not be achieved (n = 4), there was a tear of the anterior mitral leaflet. This corroborates our findings that, in the presence of severe fusion, more pressure is required to split the commissures and then areas that offer lesser resistance can "give way." Hence, in the presence of severe commissural fibrosis detected by echocardiography, especially in the presence of calcified leaflets and thin anterior leaflets, and given the fact that valvular disease tends to be underestimated by echocardiography, PTMC carries an increased risk of leaflet tear.

	References

Top References

 

1. Varma PK, Theodore S, Neema PK, Ramachandran P, Sivadasanpillai H, Nair KK, et al. Emergency surgery after percutaneous transmitral commissurotomy. operative versus echocardiographic findings, mechanism of complications, and outcomes. J Thorac Cardiovasc Surg. 2005;130:772-776.[Abstract/Free Full Text]
   
2. Bahl VK, Chandra S, Takwar KK, Kaul U, Manchanda SC, Sharma S, et al. Influence of subvalvular fibrosis on results and complications of percutaneous mitral commissurotomy with use of the Inoue balloon. Am Heart J. 1994;127:1554-1558.[Medline]
   
3. Kaul UA, Singh S, Kalra GS, Nair M, Mohan JC, Nigam M, et al. Mitral regurgitation following percutaneous transvenous mitral commissurotomy. J Heart Valve Dis. 2000;9:262-266.[Medline]
   
4. Agarwal BL, Kapoor A, Singh R, Tewary S, Radhakrishnan S, Shrivastava S, et al. Predictive accuracy of commissural morphology and its role in determining the outcome following Inoue balloon mitral valvotomy. Indian Heart J 2002;54:39-45.[Medline]
   
5. Fatkin D, Roy P, Morgan JJ, Feneley MP. Percutaneous balloon mitral valvotomy with the Inoue single-balloon catheter. commissural morphology as a determinant of outcome. J Am Coll Cardiol. 1993;21:390-397.[Abstract]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Praveen Kerala Varma Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Varma, P. K. Articles by Neema, P. K. Search for Related Content PubMed Articles by Varma, P. K. Articles by Neema, P. K. Related Collections Valve disease Related Article