title: The echo score revisited: Impact of incorporating commissural morphology and leaflet displacement to the prediction of outcome for patients undergoing percutaneous mitral valvuloplasty.
abstract: BACKGROUND
  Current echocardiographic scoring systems for percutaneous mitral valvuloplasty (PMV) have limitations. This study examined new, more quantitative methods for assessing valvular involvement and the combination of parameters that best predicts immediate and long-term outcome after PMV.
  
  
  RESULTS
  Two cohorts (derivation n=204 and validation n=121) of patients with symptomatic mitral stenosis undergoing PMV were studied. Mitral valve morphology was assessed by using both the conventional Wilkins qualitative parameters and novel quantitative parameters, including the ratio between the commissural areas and the maximal excursion of the leaflets from the annulus in diastole. Independent predictors of outcome were assigned a points value proportional to their regression coefficients: mitral valve area ≤1 cm(2) (2), maximum leaflets displacement ≤12 mm (3), commissural area ratio ≥1.25 (3), and subvalvular involvement (3). Three risk groups were defined: low (score of 0-3), intermediate (score of 5), and high (score of 6-11) with observed suboptimal PMV results of 16.9%, 56.3%, and 73.8%, respectively. The use of the same scoring system in the validation cohort yielded suboptimal PMV results of 11.8%, 72.7%, and 87.5% in the low-, intermediate-, and high-risk groups, respectively. The model improved risk classification in comparison with the Wilkins score (net reclassification improvement 45.2%; P<0.0001). Long-term outcome was predicted by age and postprocedural variables, including mitral regurgitation, mean gradient, and pulmonary pressure.
  
  
  CONCLUSIONS
  A scoring system incorporating new quantitative echocardiographic parameters more accurately predicts outcome following PMV than existing models. Long-term post-PMV event-free survival was predicted by age, degree of mitral regurgitation, and postprocedural hemodynamic data.
authors.affiliation: Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.C.P.N., T.C.T., M.D.H., A.E.W., J.H.); School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil (M.C.P.N.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (S.E., R.d.L., R.M., I.C.-G., I.I., I.F.P.); and Massachusetts General Hospital Biostatistics Center, Harvard Medical School, Boston, MA (H.Z.).
authors.forename: Maria Carmo P
authors.initials: MC
authors.lastname: Nunes
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Tan
authors.forename: Sammy
authors.initials: S
authors.lastname: Elmariah
authors.forename: Rodrigo
authors.initials: R
authors.lastname: do Lago
authors.forename: Ronan
authors.initials: R
authors.lastname: Margey
authors.forename: Ignacio
authors.initials: I
authors.lastname: Cruz-Gonzalez
authors.forename: Hui
authors.initials: H
authors.lastname: Zheng
authors.forename: Mark D
authors.initials: MD
authors.lastname: Handschumacher
authors.forename: Ignacio
authors.initials: I
authors.lastname: Inglessis
authors.forename: Igor F
authors.initials: IF
authors.lastname: Palacios
authors.forename: Arthur E
authors.initials: AE
authors.lastname: Weyman
authors.forename: Judy
authors.initials: J
authors.lastname: Hung
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D063126:Balloon Valvuloplasty; D018572:Disease-Free Survival; D015150:Echocardiography, Doppler / Q000379:methods* / Q000592:standards; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging* / Q000601:surgery*; D008946:Mitral Valve Stenosis / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000601:surgery*; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012307:Risk Factors; D055815:Young Adult
keywords: balloon valvuloplasty; echocardiography; mitral valve stenosis