Mitral valve operation after percutaneous transvenous mitral commissurotomy (PTMC): An evaluation of PTMC indications based on intraoperative findings

Six patients underwent open heart surgery for mitral valve disease after percutaneous transvenous mitral commissurotomy (PTMC) because of recurrent mitral stenosis (MS) in 4, moderate mitral regurgitation (MR) in 1, and acute severe MR in 1. These 6 patients were the only such observed cases out of a total of 86 patients who presented with PTMC in our hospital between October 1989 and May 1995. The duration of the subjective symptoms related to heart failure was 24.1 +/- 11.6 years, ranging from 3 to 30 years. Four of the six patients had had a previous surgical commissurotomy [closed mitral commissurotomy (CMC) in 2 and open mitral commissurotomy (OMC) in 2] from 24 to 30 years earlier (mean 28 years). The intraoperative findings of the 4 with residual MS included severe thickening, calcification on anterior and posterior leaflets, and bilateral commissures. Five patients were noted to have shortening and adhesion in the mitral subvalvular apparatus. Two patients with moderate to severe tears on the anterior leaflets and another two patients with tears on the posterior leaflet were also noticed; however, these leaflets were not severely thickened. It was possible to split and repair the fused commissure in one patient, but the other five required MVR due to severe subvalvular lesions. Therefore, if a patient has bilateral commissural calcification or has less thickend leaflets with severe subvalvular thickening and fusion with a small MVA measuring less than 0.8 cm(2) and a MS score of more than 8, the OMC procedure is considered to provide good long-term clinical results. The decision to perform either PTMC or OMC should only be made based on meticulous echo Doppler findings and a hemodynamic evaluation of the mitral valve.