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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 3, May/June 2016
AFRICA
147
Comparison of two different techniques for balloon
sizing in percutaneous mitral balloon valvuloplasty:
which is preferable?
Ahmet Tastan, Ali Ozturk, Omer Senarslan, Erdem Ozel, Samet Uyar, Emin Evren Ozcan, Omer Kozan
Abstract
Background:
Percutaneous balloon mitral valvuloplasty
(BMV) is an important option for the treatment of mitral
valve stenosis. The crux of this process is choosing the appro-
priate Inoue balloon size. There are two methods to do this.
One is an empirical formula based on the patient’s height, and
other is to choose according to the maximal inter-commissural
distance of the mitral valve provided by echocardiography.
Methods:
The study, performed between January 2006 and
December 2011, included 128 patients who had moderate to
severe mitral stenosis and whose valve morphology was suit-
able for BMV. Patients were randomised into two groups. One
group was allocated to conventional height-based balloon
reference sizing (the HBRS group) and the other was allocated
to balloons sized by the echocardiographic measurement of
the diastolic inter-commissural diameter (the EBRS group).
Results:
BMV was assessed as successful in 60 (92.3%)
patients in the HBRS group and in 61 (96.8%) in the EBRS
group (
p
=
0.03). The mean of the calculated balloon refer-
ence sizes was significantly higher in the HBRS than in the
EBRS group [26.3
±
1.2 mm, 95% confidence interval (CI):
26.1–26.6 vs 25.2
±
1.1, 95% CI: 25.0–25.4, respectively;
p
=
0.007). Final mitral valve areas (MVA) were larger and mitral
regurgitation (MR)
>
2
+
was less in the EBRS group (
p
=
0.02
and
p
=
0.05, respectively).
Conclusions:
EBRS is a method that is independent of body
structure. Choosing Inoue balloon size by measuring maxi-
mal diastolic annulus diameter by echocardiography for BMV
may be an acceptable method for appropriate final MVA and
to avoid risk of significant MR.
Keywords:
mitral balloon valvuloplasty, balloon size, echocardi-
ography
Submitted 16/3/15, accepted 26/7/15
Published online 26/1/16
Cardiovasc J Afr
2016; 27: 147–151
www.cvja.co.zaDOI: 10.5830/CVJA-2015-062
Although both the incidence and prevalence of rheumatic heart
disease have seen a dramatic decrease in recent years, it is still the
leading cause of mitral valve stenosis. It is known that rheumatic
changes are present in 99% of stenotic mitral valves excised at
the time of mitral valve surgery.
1
Mitral valve stenosis is the most serious sequel of rheumatic
fever and it has unfavourable effects on survival rates and quality
of life. The disease is endemic in developing countries, including
Middle Eastern countries.
2
Long-term left heart obstruction
causes unwanted structural and haemodynamic deterioration.
Medical therapy neither treats the disease nor modifies its
course.
1
In addition medical therapy is routinely given to reduce
symptoms and to prevent thromboembolic complications, or to
avoid recurrent rheumatic fever.
Since the first publication of the Inoue balloon in 1984, balloon
mitral valvuloplasty (BMV) has become the procedure of choice
all over the world because of its lower cost and morbidity rate.
3
Successfully applied BMV improves the haemodynamics and
symptoms related to mitral valve stenosis, and has favourable
impacts on early and long-term survival of patients.
4,5
According to recently published valvular heart disease
guidelines, BMV is recommended for symptomatic patients with
moderate to severe mitral valve stenosis. Candidate patients
for BMV should have a suitable valve structure with no mitral
regurgitation (MR). BMV should not be administered to a
patient with thrombus in the cardiac chambers. The main
purpose of BMV is to provide an adequate mitral valve area
(MVA) of
>
1.5 cm
2
with no significant MR (MR not more than
2/4 in over 80% of patients).
6
Despite high technical expertise
in BMV, MR remains a major procedure-related complication.
7
Many studies have shown that acute procedural results,
including final MVA and post-procedural MR, independently
predict the long-term outcome after BMV.
8
The incidence of
severe MR after BMV reported in the literature varies between
1.4 and 7.5%.
9,10
BMV is recommended for symptomatic patients
with suitable valvular morphology who have moderate to severe
mitral stenosis (MVA
<
1.5 cm
2
) and also for asymptomatic
patients with pulmonary artery systolic pressure of
>
50 mmHg
at rest or
>
60 mmHg with exercise.
11
The aim of this procedure is to provide adequate valve area
while protecting the mitral valve apparatus. For this purpose,
selection of the appropriate balloon size is one of the most critical
factors for BMV.
12
There are two basic methods to decide the size
of the Inoue balloon. One is the use of an empirical formula to
calculate inflated balloon catheter diameter based on the height
of the patient [size
=
0.1
×
height (cm)
+
10].
13,14
Differences
between body habitus, heart orientation and configuration of
the cardiac skeleton are combined to calculate balloon diameter
using a height-based formula. Therefore, different results can be
obtained, even in patients with the same height.
Department of Cardiology, Sifa University Faculty of
Medicine, Izmir, Turkey
Ahmet Tastan, MD
Ali Ozturk, MD
Omer Senarslan, MD,
dromersen@yahoo.comErdem Ozel, MD
Samet Uyar, MD
Emin Evren Ozcan, MD
Department of Cardiology, Dokuz Eylul University Faculty
of Medicine, Izmir, Turkey
Omer Kozan, MD