Percutaneous transvenous mitral commissurotomy: hemodynamic and initial outcome differences between atrial fibrillation and sinus rhythm in rheumatic mitral stenosis patients.
BACKGROUND
Atrial fibrillation (AF) occurs frequently in severe rheumatic mitral stenosis (MS) and has been reported to be a predictor of poor outcome after percutaneous transvenous mitral commissurotomy (PTMC). Nevertheless, according to observations in our catheterization laboratory, patients with sinus rhythm (SR) seem to have a higher pulmonary artery pressure than AF.


OBJECTIVE
To determine 1) the hemodynamic differences between MS patients with AF and SR before and after PTMC and 2) the success rate and difference in outcome between both groups.


METHODS
A total of 145 patients who had undergone PTMC with the Inoue balloon technique in King Chulalongkorn Memorial Hospital between 1993 and 1997 were enrolled. The data were presented as mean +/- SD. Student t-test was used to compare the difference in hemodynamic and outcome between the AF and SR groups.


RESULTS
Fifty-six patients (38.6%) were in the AF group. The AF patients were older (42.0 +/- 11.3 vs 32.4 +/- 8.7 yr., p < 0.0001), had a larger left atrium (49.2 +/- 6.1 vs 45.3 +/- 4.9 mm, p < 0.001) and a higher valvular calcification score (1.8 +/- 0.6 vs 1.5 +/- 0.6, p = 0.02) than the SR group. There was no significant difference between baseline heart rate and overall MV score index. The hemodynamic data showed that the SR group had higher systolic (59.9 +/- 26.0 vs 47.4 +/- 16.8 mmHg, p < 0.05), diastolic (28.1 +/- 12.8 vs 22.7 +/- 9.2 mmHg, p < 0.05) and mean (40.1 +/- 17.1 vs 32.7 +/- 11.8 mmHg, p < 0.05) pulmonary artery (PA) pressure than the AF group. After successful PTMC, the SR group exhibited a more favorable change in all PA pressures and the transmitral valvular gradient (10.0 +/- 6.5 vs 6.7 +/- 6.5 mmHg, p < 0.01) than the AF group. Procedural success rates were 98 per cent in the AF and 96 per cent in the SR group (p = ns). Transthoracic colour-flow echocardiographic imaging detected atrial septal defects in 18.2 per cent and 7.5 per cent (p = 0.08) of the AF and SR groups, respectively. There was no systemic embolization, peri-procedural death or emergency surgery in both groups.


CONCLUSIONS
Patients with MS and AF were older, had a larger LA and lower pre-PTMC PA pressure than the patients who had MS and SR. In addition, patients with SR had a more favourable PA and LA pressure reduction than patients with AF.
Srimahachota
S
S
Cardiac Center, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
Boonyaratavej
S
S
Wannakrairoj
M
M
Udayachalerm
W
W
Sangwattanaroj
S
S
Ngarmukos
P
P
Chayanont
D
D
D000328:Adult; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D002404:Catheterization / Q000379:methods*; D016009:Chi-Square Distribution; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008946:Mitral Valve Stenosis / Q000503:physiopathology / Q000601:surgery*; D012214:Rheumatic Heart Disease / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome