title: Subvalvular apparatus and adverse outcome of balloon valvotomy in rheumatic mitral stenosis.
abstract: BACKGROUND
  Balloon mitral valvotomy (BMV) is a well-established therapeutic modality for rheumatic mitral stenosis (RMS). However, there are chances of procedural failure and the more ominous post-procedural severe mitral regurgitation. There are only a few prospective studies, which have evaluated the pathogenic mechanisms for these major complications of BMV, especially in relation to the subvalvular apparatus (SVA) pathology.
  
  
  METHODS
  All symptomatic patients of RMS suitable for BMV by echocardiographic criteria in a span of 1 year were selected. In addition to the standard echocardiographic assessment of RMS (Wilkins score and score by Padial et al.), a separate grading and scoring system was assigned to evaluate the severity of the SVA pathology. The SVA score was 'I', when none of the two SVAs had severe disease, 'II' when one of the two SVAs has severe disease, and 'III' when both SVAs had severe disease. With these scoring systems, the outcomes of BMV (successful procedure, failure, and post-procedural mitral regurgitation) were analyzed. Emergency valve replacement was performed depending on clinical situation, and in cases of replacement, the pathology of the excised mitral valves were compared with echocardiographic findings.
  
  
  RESULTS
  Of the 356 BMVs performed in a year, 43 patients had adverse outcomes in the form of failed procedure (14 patients) and mitral regurgitation (29 patients). Forty-one among these had a SVA score of III. The sensitivity and specificity of the MR score was lesser than the SVA score (sensitivity 0.34 vs. 1.00, specificity 0.92 vs. 0.99, respectively). The mitral valvular morphology in 39 patients who underwent post-procedural valve replacements correlated well with echocardiography findings.
  
  
  CONCLUSIONS
  It is important to assess the degree of SVA pathology in the conventional echocardiographic assessment for RMS, as BMV would have adverse events when both SVAs were severely diseased.
authors.affiliation: Department of Cardiology, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai 400012, India. Electronic address: drparag@gmail.com.
authors.forename: Parag
authors.initials: P
authors.lastname: Bhalgat
authors.affiliation: Department of Cardiology, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai 400012, India.
authors.forename: Shrivallabh
authors.initials: S
authors.lastname: Karlekar
authors.affiliation: Department of Cardiology, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai 400012, India.
authors.forename: Santosh
authors.initials: S
authors.lastname: Modani
authors.affiliation: Department of Cardiology, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai 400012, India.
authors.forename: Ashish
authors.initials: A
authors.lastname: Agrawal
authors.affiliation: Department of Cardiology, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai 400012, India.
authors.forename: Charan
authors.initials: C
authors.lastname: Lanjewar
authors.affiliation: Department of Cardiology, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai 400012, India.
authors.forename: Ashish
authors.initials: A
authors.lastname: Nabar
authors.affiliation: Department of Cardiology, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai 400012, India.
authors.forename: Prafulla
authors.initials: P
authors.lastname: Kerkar
authors.affiliation: Department of Cardiothoracic Surgery, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai 400012, India.
authors.forename: Nandu
authors.initials: N
authors.lastname: Agrawal
authors.affiliation: Department of Cardiac Pathology, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai 400012, India.
authors.forename: Pradeep
authors.initials: P
authors.lastname: Vaideeswar
mesh_terms: D000328:Adult; D063126:Balloon Valvuloplasty / Q000009:adverse effects*; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging*; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000209:etiology*; D008946:Mitral Valve Stenosis / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D011446:Prospective Studies; D012214:Rheumatic Heart Disease / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D013997:Time Factors
keywords: Balloon mitral valvotomy; Pathogenesis of mitral regurgitation; Post-valvotomy mitral regurgitation; Rheumatic mitral stenosis