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Page 14 of 24 Palacios Mini-invasive Surg 2020;4:73 I http://dx.doi.org/10.20517/2574-1225.2020.72

Table 4. Clinical long-term follow-up after PMV
Author # Patients Age Follow up (years) Survival Event-free
Palacios et al. [10] 879 55 12 87% 53%
Lung et al. [22] 1,024 49 10 85% 56%
Hernandez et al. [17] 561 53 7 95% 69%
Orrange et al. [64] 132 44 7 83% 65%
Reyes et al. [65] 30 29 7 100% 90%
Stefanadis et al. [35] 441 44 9 98% 75%
[1]
Modified from Palacios IF. Percutaneous mitral balloon valvuloplasty for patients with rheumatic mitral stenosis . PMV: percutaneous
mitral balloon valvuloplasty

LONG-TERM RESULTS
We are now able to analyze follow-up data up to 15 years [9,12-14,16] . Several large single-center series confirm
the late efficacy of PMV in a large population comprising a variety of patient subsets [Table 4]. Late
outcome after PMV differs according to the quality of the immediate results. In a series of 879 patients
undergoing PMV at the Massachusetts General Hospital, we reported a completed follow-up in 575 (96%)
of patients with Echo-Sc ≤ 8 and in 269 (97%) of patients with Echo-Sc > 8 . For the entire population,
[9]
there were 110 (12.5%) deaths (25 of which were non-cardiac), 234 (26.6%) mitral valve replacements
(MVRs), and 54 (6.14%) redo PMVs, accounting for a total of 398 (45.3%) patients with combined events
(death, MVR, or redo PMV). Of the remaining 446 patients that were free of combined events, 418 (94%)
were in New York Heart Association (NYHA) class I or II. Follow-up events occurred less frequently in
patients with Echo-Sc ≤ 8 and included 51 (8.4%) deaths, 155 (25.8%) MVRs, and 39 (6.49%) redo PMVs,
accounting for a total of 245 (40.7%) patients with combined events at follow-up. Of the remaining 330
patients who were free of combined events, 312 (95%) were in NYHA class I or II. Follow-up events
in patients with Echo-Sc > 8 included 59 (21.2%) deaths, 79 (28.4%) MVRs, and 15 (5.4%) redo PMVs,
accounting for a total of 153 (55.03%) patients with combined events at follow-up. Of the remaining 116
patients who were free of any event, 105 (91%) were in NYHA class I or II . Figures 12, 13, and 14 show
[9]
the Kaplan-Meier survival and event free survival estimates for all patients, subdivided by patients with
Echo-Sc ≤ 8 and > 8 and patients with Echo-Sc ≥ 12 [Figure 14].

Although adverse events (death, mitral valve surgery, and redo PMV) were low within the first 5 years of
follow-up, a progressive number of events occurred beyond this period. Nevertheless, survival (82% vs.
57%) and event-free survival (57.4% vs. 43.1%) at 12-year follow-up was greater in patients with Echo-Sc ≤ 8
compared to patients with Echo-Sc > 8 (P < 0.0001). Cox regression analysis identified post-PMV mitral
regurgitation ≥ grade 3 +, Echo-Sc > 8, older age, prior surgical commissurotomy, NYHA functional class
IV, pre-PMV mitral regurgitation ≥ 2 +, and higher post-PMV pulmonary artery pressure as independent
predictors of combined events at long-term follow-up .
[9]
PMV VS. SURGICAL COMMISSUROTOMY
Several studies have compared the immediate and early follow-up results of PMV vs. open or closed
surgical commissurotomy. These initial trials results of PMV vs. surgical commissurotomy are encouraging
and favor PMV for the treatment of patients with rheumatic mitral stenosis with suitable mitral valve
morphology [10,21-23,47] . Thus, it seems reasonable to recommend PMV for patients with Echo-Sc ≤ 8,
especially if they have other favorable characteristics (age < 45 years, ≤ 2 + MR, and no previous mitral
surgery). The question remains as to which procedure, MVR or PMV, is more suitable for patients with
Echo-Sc > 8. A successful PMV result is obtained in 56.4% of these patients, and only 43.1% of them were
free of combined events at the 12-year follow-up. Because a good immediate outcome was achieved in 61%
of patients with Echo-Sc between 9 and 11 and 39% were free of combined events at 5- year follow-up [Figure 13],
PMV might be considered the first choice in these patients if they are free of other risk variables.