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Palacios Mini-invasive Surg 2020;4:73 I http://dx.doi.org/10.20517/2574-1225.2020.72 Page 17 of 24

of comorbid diseases (cardiac and noncardiac), the two-year event-free survival was reduced to 29% as
compared with 86% in patients without comorbid diseases. Cox regression analysis identified Echo-Score (P
= 0.03), post-PMV mitral valve area (P = 0.003), post-PMV mitral regurgitation grade (P = 0.02) and post-
PMV pulmonary artery pressure (P = 0.0001) as independent predictors of event-free survival after repeat
PMV. We concluded that repeat PMV for post-PMV mitral restenosis results in good immediate and long-
term outcome, particularly in patients with restenosis due to commissure fusion, low echocardiographic
scores, and absence of comorbid diseases. Although the results are less favorable in patients with
suboptimal characteristics, repeat PMV has a palliative role if the patients are not or very high surgical
[49]
candidates .

PMV AND AGE
[24]
Sanchez et al. reported the impact of age in the immediate and long-term outcome of PMV. For purpose
of analysis, these patients were divided into four age groups: group 1 (≤ 35 years), group 2 (36-55 years),
group 3 (56-75 years), and group 4 (> 75 years). The incidence of atrial fibrillation, calcified valves under
fluoroscopy, higher echocardiographic score, NYHA class IV, and pre-PMV MR increased with patient’s
2
2
2
age. As patients became older, a lower post-PMV mitral valve area (2.1 ± 0.7 cm , 2.0 ± 0.6 cm , 1.8 ± 0.6 cm ,
and 1.6 ± 0.6 cm ; P < 0.0001) and progressive decrease in procedural success (81.4%, 80.5%, 65.3%, and
2
53%; P < 0.0001) were observed. Younger age was identified as an independent predictor of PMV success
by multiple stepwise logistic regression [odds ratio: 3.33; confidence interval (CI): 1.41-7.69, P = 0.006].
Furthermore, age was identified as an independent predictor of long-term events by Cox regression
analysis [risk ratio: 1.02; CI: 1.01-1.03, P < 0.00001]. However, the effect of age seemed to be blunted by
the morphology of the valve at follow-up, as patients with Echo-Sc greater than8 in groups 2, 3, and 4
presented similar combined event-free survival (death, mitral valve replacement, or redo PMV). They
concluded that age is an important predictor of immediate and long-term outcomes after PMV, particularly
in patients with optimal mitral valve morphology [20,24,50] .

PMV AND PREGNANCY
Surgical mitral commissurotomy has been performed in pregnant women with severe mitral stenosis.
Because the risk of anesthesia and surgery for the mother and the fetus are increased, this operation is
[51]
reserved for those patients with incapacitating symptoms refractory to medical therapy . Under these
conditions, PMV can be performed safely after the twentieth week of pregnancy with minimal radiation
to the fetus [51,52] . Because of the definite risk in women with severe mitral stenosis of developing symptoms
during pregnancy, PMV should be considered when a patient is considering becoming pregnant and has
evidence of severe mitral stenosis. Esteves et al. reported that PMV can be performed during pregnancy
[52]
without significant maternal risk or fetal morbidity or mortality. They report the results of 71 consecutive
pregnant women with severe rheumatic mitral stenosis and severe congestive heart failure (New York Heart
Association class III and IV) referred for PMV. All patients underwent clinical and obstetric evaluations,
electrocardiography, and 2-dimensional and Doppler echocardiography. PMV was successful in all patients,
2
2
resulting in a significant increase in mitral valve area from 0.9 ± 0.2 cm to 2.0 ± 0.3 cm (P < 0.001). At
the end of pregnancy, 98% of the patients were in New York Heart Association functional class I or II.
At a mean follow-up of 44 ± 31 months, the total event-free survival rate was 54%. The mean gestational
age at delivery time was 38 ± 1 weeks. Preterm deliveries occurred in 9 patients (13%), including 2 twin
pregnancies. The remaining 66 of 75 newborns (88%) had normal weight (mean 2.8 ± 0.6 kg) at delivery.
At long-term follow-up of 44 ± 31 months after birth, the 66 children exhibited normal growth and
development and did not show any clinical abnormalities. They concluded that during pregnancy PMV is
safe and effective, has a low morbidity and mortality rate for the mother and the fetus, and has favorable
long-term results in pregnant women with rheumatic mitral stenosis in New York Heart Association
functional class III or IV [51,52] .