CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 1, January – April 2024 18 AFRICA 2, and bilateral commissural fusion to guide our decision. For unfavourable clinical characteristics the definition is: old age, NYHA functional class IV, severe pulmonary hypertension, atrial fibrillation and history of commissurotomy.14,15 In this study, severe pulmonary hypertension was defined as a right ventricular systolic pressure > 70 mmHg measured from the maximum tricuspid regurgitation jet velocity, as previously described.26 A TEE was done on the day of PBMV to rule out left atrial or left atrial appendage thrombus. In four patients, the procedure was performed under local anaesthesia and moderate sedation, utilising TTE and fluoroscopy. In eight patients, TEE was used while the patient was under general anaesthesia and mechanical ventilation. While recognising that TEE adds to procedure time and complexity, the aim was to expose the local team to the two methods, fluoroscopy and TEE-guided approach. Vascular accesses were right femoral vein with 8F sheaths upsized to 12F for the Inoue balloon, left femoral vein with 7F sheath for the Swan–Ganz catheter, and left femoral artery with 5F sheaths for angiographic pigtail catheter. Transseptal puncture was done by an anterograde approach using a Brockenbrough needle via the trans-septal sheath and at anterior–posterior projection. Intravenous heparin at a dose of 100 IU/kg body weight was given immediately after septal puncture. The Inoue balloon stepwise technique was used in all patients and performed as previously described.27 Balloon sizing was based on patient height, as previously described.28 The haemodynamic parameters were recorded before and after PBMV. A successful PBMV was defined as improvement in mitral valve area (MVA) to ≥ 1.5 cm2 without complications, including mitral regurgitation of > 2/4 grade. One day after the procedure, echocardiography was done to evaluate the MVA and mitral regurgitation (MR). Fig. 1 shows the local team performing TEE before PBMV as part of pre-procedural patient preparation. Statistical analysis The collected data was checked for quality. Coding was done before entry. The analysis was done using Statistical Package for Social Sciences (SPSS) version 28.0. Continuous data are presented as mean with standard deviation (SD) when distributed normally, and as median with range when skewed. Categorical data are reported as counts and percentages. The chi-squared and Fisher’s exact tests were used to compare categorical data. The t-test was used to compare the difference between continuous variables. A p-value < 0.05 was considered statistically significant. Results Forty-three (14.8%) out of 290 patients enrolled in the Tanzania Mitral Stenosis (TAMS) study were evaluated for eligibility for PBMV at JKCI from August 2019 to May 2022 (Fig. 2). The interventions were done in August 2019 and May 2022, skipping the years 2020 and 2021 due to restrictions on travelling because of the COVID-19 pandemic. Fig. 3 shows the map of Tanzania illustrating the residence of 290 patients enrolled in the TAMS study. Most of the patients were residing in the northern zone of the country. As shown in Table 1, there was a female predominance (32, 74.4%). The median age of the patients was 31 years (range 11–68). Twenty-five (58.1%) patients were single, 21 (48.8%) had primary education, 23 (53.5%) were not employed, 38 (88.4%) were from outside Dar es Salaam, 24 (55.8%) had income < 42$ per month, 25 (58.1%) had a national health insurance, and 34 (79.1%) had lived in a clean environment during childhood. Four (9.3%) patients were first diagnosed with RHD during pregnancy. The mean duration of symptoms before diagnosis was 43.26 ± 30.03 months. Two patients presented with symptomatic MS at the age of six and eight years, respectively. Nine (20.9%) patients had atrial fibrillation (AF) and all were on anticoagulants, four (9.3%) patients had a stroke, and seven (16.3%) had hypertension. The mean right ventricular systolic pressure derived from the Fig. 1. A photograph showing pre-procedural TEE. Total RHD-MS 290 Initial evaluation, eligible PBMV 43 PBMV done 12 Successful 10 Failed 2 Excluded (MVA > 1.5 cm2, asymptomatic, unfavourable characteristics 247 *Re-evaluation –17 unfavourable characteristics – 11 were on a waiting list – 3 died *These patients were excluded from PBMV due to technical and logistical reasons. Fig. 2. A flow chart diagram showing patients’ recruitment. RHD-MS, rheumatic heart disease–mitral stenosis; MVA, mitral valve area; PBMV, percutaneous balloon mitral valvuloplasty.
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