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Logo of mjafiGuide for AuthorsAbout this journalExplore this journalMedical Journal, Armed Forces India
 
Med J Armed Forces India. 2001 July; 57(3): 269.
Published online 2011 July 21. doi:  10.1016/S0377-1237(01)80074-5
PMCID: PMC4925091

MITRAL STENOSIS: HAS BALLOON DILATATION REPLACED SURGERY?

Dear Editor,

Rheumatic heart disease still remains a major health problem in India and other developing countries [1]. Mitral stenosis (MS), one of its common manifestations largely affects children and young adults, the most cherished and productive segment of our society. MS is a progressive disease and is usually fatal unless mechanical intervention relieves the obstruction.

In 1925, Henry Suttar relieved MS when he inserted his finger through the atrial appendage-the first true commisurotomy! However, this report was treated with skepticism. Charles Bailey in 1948, followed later by Dwight Harken and Russel Brock rekindled interest in closed heart operations, performed successful valvotomies and thus paved the way for modern heart surgery [2]. The largely favourable results obtained with closed mitral valvotomy (CMV), made this a routine procedure and is still being performed in many parts of the world [3]. The advent of cardiopulmonary bypass permitted the surgical repair of a stenotic mitral valve under direct vision, resulting in a more effective and safer valvotomy than was possible with CMV.

In June 1982, Inoue, a cardiac surgeon from Japan, developed a double lumen coaxial balloon catheter and successfully dilated the stenosed mitral valve by means of a transseptal puncture and thus began the era of catheter based dilation of MS-percutaneous transvenous mitral commissurotomy (PTMC) [4].

In recent past, several large studies have demonstrated excellent haemodynamic and long term results of PTMC for MS patients with low rate of complications [5, 6]. Given the experience and success of procedure, the cardiologists have now expanded the indications for PTMC ranging from restenosis after CMV, patients with atrial fibrillation, associated mild to moderate aortic regurgitation and MS patients with pregnancy in second trimester.

Though potential major complications of PTMC including cardiac perforation, systemic emboli and valvular apparatus damage sometimes can occur, these incidents have been reduced to minimum by the experience gained worldover. Since RHD is quite prevalent in India, and PTMCs being performed here are enormous, a Non Coronary Cardiac Intervention Registry of India has been formulated in 1996 under the auspices of Cardiological Society of India with the aim of collecting National data from all centres performing various Non Coronary Cardiological Interventions. 29 cardiological centres in India performed over 15,000 PTMCs with low levels of complications till 1996 [6].

Since early studies began to report excellent immediate and long term results, it was logical to compare efficacy of PTMC with well established CMV and Open Mitral Commissurotomy (OMV). Reyes et al compared PTMC with OMV with a follow up of 3 years. In view of better results with PTMC, lower costs and elimination of need for thoracotomy, PTMC was advised for all patients of MS with favourable Mitral Valve Anatomy [7]. Recently, a new miniatured metallic commissurotome similar to Tubb's dilator used by surgeons for CMV, has been developed by Alain Criber et al, and metallic commissurotomy has been done in a few centres with good results [8]. It may prove an effective, reliable and less costly method for relieving mitral stenosis in future.

PTMC first performed by Inoue in 1982 was a rational progression from four decades of experience with blunt surgical dilation of CMV. Though few patients of MS with unfavourable anatomy will continue to require OMV/Valve replacement, yet excellent results, lower costs and elimination of drawbacks of thoracotomy and cardiopulmonary bypass indicate that PTMC is the treatment of choice for patients with tight and pliable rheumatic mitral stenosis. Thus, appropriate method of producing mechanical relief of mitral stenosis has come full circle from closed surgical commissurotomy to open mitral valvotomy to closed balloon valvotomy after 50 years of pioneering work done by Charles Bailey and his colleagues.

References

1. Padmavati S. Present status of rheumatic fever and rheumatic heart disease in India. Indian Heart Journal. 1972;47:395–398. [PubMed]
2. Harken DE. The surgical treatment of mitral stenosis. N Eng J Med. 1948;239:801–809. [PubMed]
3. Sharma JK. A pre and post operative study of patients of Mitral Stenosis undergoing closed mitral valvotomy with special reference to pulmonary function tests. Univ of Pune; Punc: 1986. (Dissertation)
4. Inoue K, Owaki T, Nakamura T. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg. 1984;87:394–402. [PubMed]
5. Chen CR, Cheng TO. Percutaneous balloon mitral valvuloplasty by the Inoue technique: A multicentre study of 4832 patients in China. American Heart J. 1995;129:1197–1203. [PubMed]
6. Bahal VK, Raju BS, Panja Mantosh, Arora R, Ramesh SS, Satyavan Sharma. Non Coronary Cardiac Interventions; The Second report of the Non Coronary Cardiac Interventions Registry of the Cardiological Society of India. Indian Heart Journal. 1998;50:99–104. [PubMed]
7. Vincent PR, Raju BS, Wynne J, Stephenson LW, Raju R, Fromm BS. Percutaneous Balloon Valvuloplasty compared with Open Surgical Commissurotomy for mitral stenosis. N Eng J Med. 1994;331:961–967. [PubMed]
8. Arora R, Kalra GS, Singh S, Verma P, Satish OS, Nigam M. Non Surgical mitral commissurotomy using metallic commissurotome. Indian Heart Journal. 1998;50:91–95. [PubMed]

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