Figure 1
Flow diagram. Of 334 patients who underwent mitral valve replacement or percutaneous mitral valvuloplasty, 302 with rheumatic MV disease were initially eligible for the study. Forty-two patients who had prosthetic MV were excluded. Additionally, 14 patients were lost to follow-up, leaving 246 with outcomes data available for analysis.
Figure 2
A: Type of mitral valve dysfunction in patients undergoing percutaneous mitral valvuloplasty. B: Type of mitral valve dysfunction in patients undergoing surgical mitral valve replacement.
Table 1
Baseline characteristics of patients with rheumatic mitral valve disease who underwent percutaneous mitral valvuloplasty (PMV) or surgical mitral valve replacement (MVR).
| VARIABLES* | PERCUTANEOUS VALVULOPLASTY* (n = 156) | SURGICAL VALVE REPLACEMENT (n = 90) | P-VALUE | |
|---|---|---|---|---|
| Age (years) | 42.7 ± 12.1 | 45.6 ± 14.3 | 0.095 | |
| Body surface area (m2) | 1.67 ± 0.2 | 1.66 ± 0.2 | 0.835 | |
| Gender | Female | 138 (88) | 60 (67) | <0.001 |
| Male | 18 (12) | 30 (33) | ||
| NYHA funcional class | I/II | 87 (56) | 49 (54) | 0.676 |
| III/IV | 69 (44) | 41 (46) | ||
| Previous valvuloplasty† | 59 (38) | 13 (14) | <0.001 | |
| Atrial fibrillation | 32 (21) | 34 (38) | 0.003 | |
| Hypertension | 38 (42) | 44 (28) | 0.025 | |
| Diabetes | 5 (3) | 7 (8) | 0.109 | |
| Coronary artery disease | 2 (1) | 2 (2) | 0.574 | |
| Previous stroke | 20 (13) | 11 (12) | 0.892 | |
| Heart rate (bpm) | 73.8 ± 12.6 | 76.4 ± 11.9 | 0.159 | |
| Systolic blood pressure (mmHg) | 115.7 ± 16.3 | 120.1 ± 18.4 | 0.111 | |
| Diastolic blood pressure (mmHg) | 74.1 ± 10.2 | 73.0 ± 11.2 | 0.547 | |
| Medication | ||||
| Diuretics | 101 (65) | 78 (87) | 0.001 | |
| Beta-blockers | 106 (68) | 65 (72) | 0.550 | |
| ACE inhibitors | 36 (23) | 45 (50) | <0.001 | |
| Anticoagulants | 41 (26) | 25 (28) | 0.709 | |
[i] * Values are expressed as the mean value ± SD, or absolute numbers (percentage).
† Mitral valvuloplasty included either percutaneous (n = 42) or surgical intervention (n = 26) or both (4).
ACE: angiotensin-converting-enzyme.
Table 2
Echocardiographic features of patients with rheumatic mitral valve disease stratified according to the type of valve intervention.
| PERCUTANEOUS VALVULOPLASTY* (n = 156) | SURGICAL VALVE REPLACEMENT (n = 90) | P VALUE | |
|---|---|---|---|
| LA diameter (mm) | 49.9 ± 6.1 | 56.3 ± 9.9 | <0.001 |
| LVDd (mm) | 48.1 ± 6.1 | 55.9 ± 8.8 | <0.001 |
| LVSd (mm) | 31.1 ± 4.9 | 38.0 ± 7.2 | <0.001 |
| LVEF (%) | 63.8 ± 7.3 | 60.2 ± 9.6 | 0.003 |
| Mean gradient (mmHg) | 11.1 ± 5.2 | 11.3 ± 5.7 | 0.768 |
| Mitral valve area (cm2)† | 1.0 ± 0.3 | 1.3 ± 0.6 | <0.001 |
| Moderate/severe TR | 32 (20) | 28 (31) | 0.055 |
| Moderate/severe MR | 6 (4) | 67 (74) | <0.001 |
| SPAP (mmHg) | 51.4 ± 18.3 | 50.2 ± 16.5 | 0.661 |
| Echocardiographic score | 7.0 ± 1.3 | 10.0 ± 1.9 | <0.001 |
[i] * Patients who underwent surgical valvuloplasty (commissurotomy) instead of surgical valve replacement during the time of the study were not included.
† Mitral valve area was calculated by planimetry.
LA = left atrium; LVDd = left ventricular end-diastolic diameter; LVEF = left ventricular ejection fraction; LVSd = left ventricular end-systolic diameter; MR = mitral regurgitation; SPAP = systolic pulmonary artery pressure; TR = tricuspid regurgitation.
Table 3
Clinical endpoints according to the type of valve intervention.
| PERCUTANEOUS VALVULOPLASTY* (n = 156) | SURGICAL VALVE REPLACEMENT (n = 90) | P VALUE | |
|---|---|---|---|
| All-cause mortality | 3 (1.9) | 9 (10) | |
| Cardiovascular death | 3 (1.9) | 7 (7.8) | |
| MV replacement | 20 (12.8) | 2 (2.2) | <0.001 |
| Repeat PMV | 7 (4.5) | 0 | |
| Stroke | 1 (0.6) | 3 (3.3) |
[i] * Values are expressed as absolute numbers (percentage).
MV = mitral valve; PMV = percutaneous mitral valvuloplasty.
Table 4
Univariable Cox proportional-hazards analysis for predicting cardiac death and composite outcome.
| VARIABLES | ALL-CAUSE MORTALITY | COMPOSITE OUTCOME | ||
|---|---|---|---|---|
| HR (95% CI) | p-VALUE | HR (95% CI) | p-VALUE | |
| PMV | 0.303 (0.105–0.875) | 0.027 | 1.473 (0.782–2.777) | 0.231 |
| Age (years) | 1.063 (1.020–1.107) | 0.004 | 1.024 (1.001–1.049) | 0.045 |
| NYHA class III/IV | 2.144 (1.075–4.275) | 0.030 | 2.661 (1.415–5.006) | 0.002 |
| Atrial fibrillation | 4.201 (1.523–11.589) | 0.006 | 1.383 (0.750–2.551) | 0.299 |
| LVEF (%) | 0.926 (0.880–0.975) | 0.004 | 0.980 (0.946–1.014) | 0.246 |
| Moderate/severe MR | 2.602 (0.819–8.272) | 0.105 | 0.844 (0.435–1.637) | 0.616 |
| Severe TR | 3.622 (1.267–10.354) | 0.016 | 1.401 (0.699–2.810) | 0.342 |
| Previous valvuloplasty | 0.345 (0.074–1.603) | 0.174 | 0.693 (0.358–1.339) | 0.275 |
[i] CI = confidence interval; HR = hazard ratio; LVEF = left ventricular ejection fraction; MV = mitral valve; NYHA = New York Heart Association; PMV = percutaneous mitral valvuloplasty; TR = tricuspid regurgitation.
Figure 3
Kaplan-Meier survival curves comparing composite outcomes between patients who underwent percutaneous mitral valvuloplasty (PMV) and surgical mitral valve replacement (MVR). The selected endpoint was a composite outcome of death, repeat PMV, need for cardiac surgery, and stroke.
Table 5
Multivariable Cox proportional-hazards analysis for predicting death and composite outcome.
| VARIABLES | ALL-CAUSE MORTALITY | COMPOSITE OUTCOME | ||
|---|---|---|---|---|
| HR (95% CI) | p-VALUE | HR (95% CI) | p-VALUE | |
| PMV | 0.351 (0.105–1.263) | 0.111 | 1.619 (0.803–3.263) | 0.226 |
| Age (years) | 1.081 (1.030–1.135) | 0.002 | 1.032 (1.005–1.061) | 0.020 |
| NYHA class III/IV | 2.519 (0.761–8.342) | 0.130 | 2.103 (1.087–4.067) | 0.023 |
| Atrial fibrillation | 1.867 (0.514–6.788) | 0.343 | 0.398 (0.119–1.328) | 0.134 |
| LVEF (%) | 0.933 (0.880–0.990) | 0.021 | 0.959 (0.903–1.018) | 0.169 |
| Severe TR | 1.995 (0.606–6.571) | 0.256 | 0.801 (0.249–2.569) | 0.708 |
[i] CI = confidence interval; HR = hazard ratio; LVEF = left ventricular ejection fraction; MV = mitral valve; NYHA = New York Heart Association; PMV = percutaneous mitral valvuloplasty; TR = tricuspid regurgitation.
Figure 4
Kaplan-Meier survival curves comparing survival rates between patients who underwent percutaneous mitral valvuloplasty (PMV) and surgical mitral valve replacement (MVR). The selected endpoint was all-cause mortality.
Central Figure.