Persistent Pulmonary Artery Hypertension in Patients Undergoing Balloon Mitral Valvotomy

Abstract

Pulmonary artery pressure (PAP) is known to regress after successful balloon mitral valvotomy (BMV). Data of persistent pulmonary artery hypertension (PPAH) following BMV is scarce. We analyzed the clinical, echocardiographic, and hemodynamic data of 701 consecutive patients who have undergone successful BMV in our institute from 1997 to 2003. Data of 287 patients who had PPAH (defined by pulmonary artery systolic pressure [PASP] of ≥ 40 mmHg at one year following BMV) were compared to the data of 414 patients who did not have PPAH. Patients who had PPAH were older (39.9 ± 9.9 years vs. 29.4 ± 10.1; P < 0.001). They had higher prevalence of atrial fibrillation (AF; 21.9 vs. 12.1%, P < 0.05), moderate or severe pulmonary artery hypertension (PAH) defined as PASP more than 50 mmHg (43.5 vs. 33.8%, P = 0.00), anatomically advanced mitral valve disease as assessed by Wilkin's echocardiographic score > 8 (33.7 vs. 23.2%, P < 0.001), and coexistent aortic valve disease (45.6 vs. 37.9%, P < 0.001) at the baseline. Those patients with PPAH had comparatively lower immediate postprocedural mitral valve area (MVA). On follow-up of more than five years, the occurrence of restenosis (39.3 vs. 10.1%, P = 0.000), new onset heart failure (14% vs. 4%, P < 0.05) and need for reinterventions (9.5% vs. 2.8%, P < 0.05) were higher in the PPAH group. Patients with PPAH were older, sicker, and had advanced rheumatic mitral valve disease. They had higher incidence of restenosis, new onset heart failure, and need for reinterventions on long term follow-up. PPAH represents an advanced stage of rheumatic valve disease and indicates chronicity of the disease, which may be the reason for the poorer prognosis of these patients. Patients with PPAH requires intense and more frequent follow-up.

Reply

“…5 Patients with AF had a higher mean pulmonary pressure as reported by us. 1 In addition, there is an established link between PH and inflammation.…”

Operable patent ductus arteriosus even with differential cyanosis: a case of patent ductus arteriosus and mitral stenosis

“…5 In a minority of patients with pulmonary artery hypertension, the regression is suboptimal, and this may be due to inadequate relief of mitral stenosis, or long-standing structural changes; however, the cause is not clearly delineated. 6 The pulmonary artery hypertension from mitral stenosis may cause reversal of shunt in patients with coexisting patent ductus arteriosus or ventricular septal defects even if the changes in lung vasculature are not irreversible. It is therefore conceivable, as in this patient, to have right-to-left shunt from patent ductus arteriosus that does not mean irreversible or inoperable status.…”

“…A rapid regression is described following Balloon Mitral Valvotomy in the initial weeks, although it may continue for months 5 . In a minority of patients with pulmonary artery hypertension, the regression is suboptimal, and this may be due to inadequate relief of mitral stenosis, or long-standing structural changes; however, the cause is not clearly delineated 6 . The pulmonary artery hypertension from mitral stenosis may cause reversal of shunt in patients with coexisting patent ductus arteriosus or ventricular septal defects even if the changes in lung vasculature are not irreversible.…”

The Burden of Pulmonary Hypertension in Resource-Limited Settings

“…In resource-limited settings, treatment of RHD-associated mitral valve disease via surgery or mitral balloon valvuloplasty may not be possible due to expenses and resources. Even with intervention, PVD may persist in patients with advanced RHD [92]. Screening programs to identify children at risk for RHD and echocardiographic surveillance are thus important to prevent the development of advanced disease.…”