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Palacios Mini-invasive Surg 2020;4:73 I http://dx.doi.org/10.20517/2574-1225.2020.72 Page 19 of 24

PMV NYHA class IV (P = 0.046) as independent predictors of combined events at follow-up. The presence
of atrial fibrillation per se should not be the only determinant in the decision process regarding treatment
options in patients with rheumatic mitral stenosis. The presence of an Echo-Sc less than or equal to 8
primarily identifies a subgroup of patients in atrial fibrillation in whom percutaneous balloon valvotomy
is likely to be successful and provide good long-term results. Therefore, in this group of atrial fibrillation
[54]
patients, PMV should be the procedure of choice for the treatment of rheumatic mitral stenosis .

PMV IN PATIENTS WITH AORTIC REGURGITATION
[56]
Sanchez-Ledesma et al. examine the effect of concomitant aortic regurgitation (AR) on PMV procedural
success, short-term, and long-term clinical outcome in 676 procedures performed. Of which, 361 (53.4%)
had no AR, 287 (42.5%) mild AR, and 28 (4.1%) moderate AR. There were no differences between groups
in the pre-procedure characteristics, procedural success, or in the incidence of in-hospital adverse events.
At a median follow-up of 4.11 years, there was no difference in the overall survival rate (P = 0.22), MVR
rate (P = 0.69), or redo PMV incidence (P = 0.33). The rate of AVR was higher in the moderate AR group
(0.9% vs. 1.9% vs. 13%, P = 0.003). Mean time to AVR was 4.5 years and did not differ significantly between
patients with no AR, mild AR, or moderate AR (2.9 ± 2.1 vs. 5.7 ± vs. 4.1 ± 2.5 years, P = 0.46). They
concluded that concomitant AR at the time of PMV does not influence procedural success and is not
associated with inferior outcome. A minority of patients with MS and moderate AR who undergo PMV will
require subsequent AVR on long-term follow-up. Thus, patients with rheumatic MS and mild to moderate
[56]
AR remain good candidates for PMV .

THE DOUBLE-BALLOON VS. THE INOUE TECHNIQUES OF PMV
Today the Inoue approach of PMV is the technique more widely used. There was controversy as to
whether the double-balloon or the Inoue technique provided superior immediate and long-term results.
We compared the immediate procedural and the long-term clinical outcomes after PMV using the
double-balloon technique (n = 659) and Inoue technique (n = 233). There were no statistically significant
differences in baseline clinical and morphologic characteristics between the double-balloon technique and
Inoue technique patients. Although the post-PMV MVA was larger with the double-balloon technique (1.94
± 0.72 vs. 1.81 ± 0.58; P < 0.01), success rate (71.3% vs. 69.1%; P = not significant), incidence of greater than
grade 3 + MR (9% vs. 9%), and in-hospital complications were similar. Furthermore, as shown in Figure 16
long-term and event-free survival were similar with both techniques [57,58] . In conclusion, both the Inoue and
the double-balloon techniques are equally effective techniques of PMV. The procedure of choice should be
performed based on the interventionist experience with the technique [57,58] .

FOLLOW-UP OF THE BEST PATIENTS
In patients identified as optimal candidates for PMV, this technique results in excellent immediate and
long-term outcome. Optimal candidates for PMV are those patients meeting the following characteristics:
(1) age 45 years old or younger; (2) normal sinus rhythm; (3) Echo-Sc ≤ 8; (4) no history of previous
surgical commissurotomy; and (5) pre- PMV MR ≤ 1 + Sellers grade [10,50] . From 879 consecutive patients
undergoing PMV at the Massachusetts General Hospital, the authors identified 136 patients with optimal
[10]
pre-procedure characteristics . In these patients, PMV results in an 81% success rate and a 3.4% incidence
of major in-hospital combined events (death and/or MVR). In these patients, PMV results in a 95% survival
and 61% event-free survival at the 12-year follow-up [10,29,55] .

PMV IN PATIENTS WITH PULMONARY ARTERY HYPERTENSION
Patients with mitral stenosis with severe pulmonary hypertension constitute a high-risk subset for surgical
commissurotomy or valve replacement. The degree of pulmonary artery hypertension before PMV is
inversely related to the immediate and long-term outcome of PMV . Chen and colleagues divided 564
[59]