Concurrent Percutaneous Valvuloplasty of Mitral and Tricuspid Valve Stenoses

Percutaneous balloon mitral valvuloplasty (BMV) has been established as an effective alternative to surgery for the treatment of mitral stenosis (MS) in selected patients since its introduction by Inoue et al. in 1984.¹ It affords an event-free survival rate greater than 90% at 5–7 years.² Acute and long-term results are comparable for balloon valvuloplasty and open surgical commissurotomy,³ and are occasionally associated with complications such as death in 0–1% of cases, moderate or severe valvular regurgitation in 3–5% of cases, and systemic embolization in 1–3% of cases.⁴ However, to reduce the cost of the procedure, a new device for mitral valvuloplasty called a metallic valvulotome has been recently introduced and has shown good results.⁵ Similarly, tricuspid stenosis (TS) can also be successfully dilated by means of balloon valvotomy.⁶ Although combined mitral and tricuspid stenoses are rarely seen, when they exist together, concurrent percutaneous balloon valvuloplasty can be an alternative to surgical treatment in suitable cases.^3,7–11 However, experience of valvuloplasty for patients with combined MS and TS is very limited. We report the immediate and intermediate follow-up results of 2 patients with rheumatic tricuspid and mitral valve stenosis who were successfully treated by two different techniques of single-stage valvuloplasty with good results and recovery. To our knowledge, this is the first time that the metallic valvulotome and the Inoue balloon were used simultaneously in a single procedure for valvotomy of MS and TS, respectively. Case Report. Between June 2000 and March 2002, two female patients, aged 25 and 21 years, with combined mitral and tricuspid stenosis were diagnosed using transthoracic 2-dimensional (2-D) Doppler echocardiogram at the National Institute of Cardiovascular Diseases (NICVD) in Karachi, Pakistan. Each patient was subjected to concurrent double-valve dilatation in a single procedure using the metallic valvulotome for MS and the Inoue balloon catheter for TS. Clinical examination revealed signs of severe MS and TS with severe pulmonary hypertension and congestive heart failure (CHF). An electrocardiogram (ECG) showed sinus rhythm and right atrial enlargement. A transthoracic 2-dimensional (2-D) Doppler echocardiogram revealed bi-atrial enlargement without any evidence of clot. Both mitral and tricuspid valves were thickened and dome-shaped, with a restricted opening showing severe MS (mitral valve area [MVA] = 0.6 cm2 in the first patient and 0.7 cm2 in the second patient), and severe TS (tricuspid valve area [TVA] = 0.8 cm2 in the first patient, and 1.1 cm2 in the second patient). Mild tricuspid regurgitation (TR) secondary to pulmonary hypertension was observed, which did not contraindicate tricuspid dilatation. Cardiac catheterization and procedure. Following the baseline right and left heart catheterization, percutaneous mechanical mitral commissurotomy (PMMC) using the metallic valvulotome (Commissurotomy Kit, Bolton Medical, S.A., France) was first performed (Figure 1) in both cases by the technique described earlier.⁵ There was an immediate decrease in the mean transmitral pressure gradient from 26 mmHg to 8 mmHg in patient 1, and from 20 mmHg to 8 mmHg in patient 2 (Table 1). Following successful PMMC, the tricuspid valve was dilated using an Inoue balloon. For patient 1, the J-stylet was used to direct and float the Inoue balloon7,12 across the tricuspid valve into the right ventricle (Figure 2), while for patient 2, the “over-the-wire” technique10,12 was used by placing the guidewire in the left lower lobe of the pulmonary artery (Figure 3). Stepwise dilatation was employed in both cases until the waist disappeared. The mean transtricuspid gradient declined from 8 mmHg to 2 mmHg in patient 1, and from 10 mmHg to 2 mmHg in patient 2. The mean left and right atrial pressures decreased from 28 mmHg to 8 mmHg and from 11 mmHg to 4 mmHg in patient 1, and from 24 mmHg to 5 mmHg and 9 mmHg to 2 mmHg in patient 2, respectively (Table 1). There were no procedural complications and the patients remained stable. A Doppler echocardiogram was performed immediately after the procedure and showed well-opened mitral and tricuspid valves with a MVA of 1.8 cm2 and 2.1 cm2 and a TVA of 3.0 cm2 and 3.2 cm2 in patients 1 and 2, respectively. Follow-up. Both patients showed remarkable symptomatic improvement with NYHA functional class II status. A follow-up transthoracic 2-D Doppler echocardiogram at 3 months, 6 months, 1 year, and 2 years showed sustained benefit in both patients. Discussion Concurrent percutaneous balloon valvuloplasty can be an alternative to surgical commissurotomy in patients with combined mitral and tricuspid stenoses.^3,7,10,12,13 Instead of using a single Inoue balloon for both MS and TS valvuloplasty, we opted for the first time to perform percutaneous mechanical mitral commissurotomy (PMMC) for MS, and to employ the Inoue balloon technique for TS to compare the effectiveness of these two techniques when employed in a single procedure. Before the introduction of PMMC,⁵ the commonly used technique was balloon mitral valvuloplasty (BMV) using either the Inoue balloon technique or the double-balloon technique.^1,14 In one meta-analysis,¹⁴ the MVA reached an average of 1.84 cm2 with the Inoue technique, and 1.93 cm2 with the double-balloon technique. Also, the immediate results of BMV^14,15 showed that the post-valvotomy valve areas achieved are slightly less with the Inoue technique than with the double-balloon technique. Nevertheless, economic consideration is the main limitation of BMV, particularly in developing countries. PMMC has proven to be a cost-effective procedure with comparable results to BMV, and provides a lower risk of embolic stroke and other complications such as mitral regurgitation (MR) and transatrial shunting.⁵ Similarly, the double-balloon technique to treat tricuspid stenosis is expensive, and the use of over-sized balloons not only increases the risk of tricuspid regurgitation (TR),¹⁶ but requires longer fluoroscopy times as well. However, valvuloplasty using the Inoue balloon to treat tricuspid stenosis has shown promising results.^7,12 We successfully dilated mitral and tricuspid stenoses using a metallic valvulotome for MS and an Inoue balloon catheter for TS in a single procedure. The results of tricuspid valvulotomy using a “flow-guided” Inoue balloon and an “over-the-wire” balloon technique are the same; however, the latter requires longer procedural and fluoroscopy times and is more expensive. The presence of TR secondary to pulmonary hypertension due to MS was not a contraindication for simultaneous tricuspid valvotomy, and because of stepwise dilatation, the degree of TR was not affected. During the follow-up period, which was 24 months for each patient, clinical and echocardiographic data showed maintenance of the valvular opening. Several reports have also confirmed that the final valve area is a significant predictor of favorable long-term outcomes.^17–19 The reason we selected two different techniques to treat TS was to compare the results of the two in association with PMMC. We did not find any difference in the results, as both were effective. However, the “over-the-wire” technique was found to be more expensive and time-consuming. In conclusion, percutaneous valvuloplasty for combined MS and TS can be safely performed by employing the PMMC technique for MS and the Inoue balloon technique for TS. Concurrent use of these two techniques exposes no additional risk to the patient, is well-tolerated, and provides sustained, successful results.

1. Inoue K, Owaki T, Nakanura T, et al. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984;87:394–402. 2. Iung B, Vahanian A. The long-term outcome of balloon valvuloplasty for mitral stenosis. Curr Cardiol Rep 2002;4:118–124. 3. Sancarktar O, Kumbasar SD, Semiz E, Yalcinkaya S. Late results of combined percutaneous balloon valvuloplasty of mitral and tricuspid valves. Cathet Cardiovasc Diagn 1998;45:246–250. 4. Mayes CE, Cigarroa JE, Lange RA, Hillis LD. Percutaneous mitral balloon valvuloplasty. Clin Cardiol 1999;22:501–503. 5. Cribier A, Eltchaninoff H, Koning R, et al. Percutaneous mechanical mitral commissurotomy with a newly designed metallic valvulotome immediate results of the initial experience in 153 patients. Circulation 1999;99:793–799. 6. Zaibag AM, Ribeiro P, Kasab AS. Percutaneous balloon valvuloplasty in tricuspid stenosis. Br Heart J 1987; 57:51–53. 7. Bahl, VK, Chandra S, Mishra S. Concurrent balloon dilatation of mitral and tricuspid stenosis during pregnancy using an Inoue balloon. Int J Cardiol 1997;59:199–202. 8. Sharma S, Loya YS, Daxini BV, Sundaram U. Concurrent double balloon valvotomy for combined rheumatic mitral and tricuspid stenosis. Cathet Cardiovasc Diagn 1991;23:42–46. 9. Sobrino N, Calvo OL, Merino JL, et al. Percutaneous balloon valvuloplasty for concurrent mitral, aortic and tricuspid rheumatic stenosis. Eur Heart J 1995;16:711–713. 10. Bahl VK, Chandra S, Sharma S. Combined dilatation of rheumatic mitral and tricuspid stenosis with Inoue balloon catheter. Int J Cardiol 1993;15:178–181. 11. Shrivastava S, Radhakrishnan S, Dev V. Concurrent balloon dilatation of tricuspid and calcific mitral valve in a patient of rheumatic heart disease. Int J Cardiol 1988;20:133–137. 12. Bahl VK, Chandra S, Goel A, et al. Versatility of Inoue balloon catheter. Int J Cardiol 1997;59:75–83. 13. Bethencourt A, Medina A, Hernandez E, Coello I, Goicolea J, Laraudogoitia E et. al. Combined percutaneous balloon valvuloplasty of mitral and tricuspid valves. Am Heart J 1990;119:416–418. 14. Vahanian A, Cormier B, Iung B. Percutaneous transvenous mitral commissurotomy using the Inoue balloon: International experience. Cathet Cardiovasc Diagn 1994;2:8–15. 15. Chen CR, Cheng TO. Percutaneous balloon mitral valvuloplasty by the Inoue technique: A multicenter study of 4832 patients in China. Am Heart J 1995;129:1197–1203. 16. Ribeiro PA, Al Zaibag M, Al Kasab S, et al. Percutaneous double balloon valvulotomy for rheumatic tricuspid stenosis. Am J Cardiol 1988;61:660-662. 17. Iung B, Cormier B, Ducimetiere P, et al. Functional results 5 years after successful percutaneous commissurotomy in a series of 528 patients and analysis of predictive factors. J Am Coll Cardiol 1996;27:407–414. 18. Cohen DJ, Kuntz RE, Gordon SP, et al. Predictors of long-term outcome after percutaneous balloon mitral valvuloplasty. N Engl J Med 1992; 327:1329–1335. 19. Orange SE, Kawanishi DT, Lopez BM, et al. Actuarial outcome after catheter balloon commissurotomy in patients with mitral stenosis. Circulation 1997;95:382–389.