Pulmonary hypertension before and
after balloon mitral Valvuloplasty
Mandal I1
1Dr Indrajit Mandal, M.D.(Pediatric Medicine), D.M.(Cardiology),
Assistant Professor, Department of Cardiology, N.R.S. Medical College
and Hospital, Kolkata, West Bengal, India.
Address for
correspondence: Dr Indrajit Mandal, Email:
drindumandal@gmail.com
Abstract
Objective:
To testify effectiveness of BMV in mitral stenosis to resolve pulmonary
hypertension. Material
and Method: The study was conducted at N.R.S Medical
College and Hospital over 18 months with 39 patients of severe mitral
stenosis with pulmonary hypertension. They were followed up at 48hours,
1 month and 6 month after BMV. Result:
20.51% patients had mild, 41.02% patients had moderate and 38.46%
patients had severe pulmonary hypertension before BMV. Mean mitral
valve area before and after BMV were 0.89±0.11cm and
1.89±0.21cm respectively. Mean transmitral gradient was
15.43±2.3mm 0f Hg before and 7. 86±2.25 mm of Hg
after BMV. On 3rd day, before discharge PASP became normal in 1 patient
in mild group although improvement was not statistically significant
(p=0.234) but statistically significant improvement of PSBP was seen in
both moderate and severe groups (p=0.001). At 1m follow up PASP came
down to normal in 3 patients of mild group (p=0.106). 5 of moderate and
1 patient of severe groups also improved to have PSBP ˂25 mm of Hg, the
finding was statistically significant in both groups (p=0.001). The
improvement in all three groups at final check up at 6m was
statistically significant (p=0.001). 5 patients in each mild and
moderate and 2 in severe group were found to have normal PASP. Conclusion: In spite
of significant risk, BMV is worth doing in patients with pulmonary
hypertension due to mitral stenosis as there is not only dramatic
relief of PH of cardiac causes but also improvement of PH due to
pulmonary pathology to some extent.
Key words:
Pulmonary hypertension, Balloon mitral valvuloplasty, pulmonary
arterial systolic pressure
Manuscript received:
2nd March 2017, Reviewed:
10th March 2017
Author Corrected:
17th March 2017, Accepted
for Publication: 23rd March 2017
Introduction
Pulmonary Hypertension (PH) is no more an orphan disease. Indeed a
number of recent discoveries have improved our understanding of the
disease, helped guide patient management. It is a complex and
multidisciplinary disorder [1]. PH, a hemodynamic abnormality, occurs
in a number of conditions and characterized by increased right
ventricular after-load and work [2]. The World Health Organization
divides pulmonary hypertension (PH) into five groups, based on the
cause of the condition [3]. Type 2 includes pulmonary hypertension due
to left heart disease. Left heart valvular disease increases pulmonary
hypertension due back pressure. One of the important cause of left
heart valvular heart disease is RHD. According to RHD global registry
(REMEDY), which is currently ongoing in almost 30 centres in Africa,
Middle East and India, incidence of RHD — a chronic heart
condition caused by rheumatic fever -- is much higher in India than
what is presently believed. A study conducted by AIIMS in and around
Delhi to see prevalence of RHD among children in northern India had
found prevalence of 20.4/1000 school children as against 1 per 1000
children earlier believed [4]. Dr K Srinath Reddy, the new president of
the World Heart Federation said that though India feels it has managed
to control RHD, the prevalence of the disease is still high in states
like Uttar Pradesh and Bihar [4]. Socio-economic and environmental
factors like poverty, overcrowding, poor housing, under-nutrition and
shortage of resources for health care, delayed diagnosis and low-level
awareness are responsible for high incidence of rheumatic fever thus
rheumatic heart disease in the developing countries[5]. In developing
countries, RF accounts for up to 60% of all cardiovascular disease in
children and young adults [6,7]. The order of involvement of valves in
RHD was mitral (60.2%), followed by aortic, tricuspid and pulmonary
valves [8]. RHD mainly affects mitral valve and mitral stenosis is a
common occurrence. If left untreated sooner or later MS will lead to
PH. Although pulmonary hypertension is a life threatening condition but
it improves following of correction of causative pathology. Relief of
mitral stenosis often reverses the pulmonary hypertension. Two
treatment options are available in our Govt. medical college hospital,
a tertiary care centre, BMV and open heart valvotomy. BMV is a
minimally invasive procedure and symptoms of mitral valve stenosis
typically improve right after a balloon valvuloplasty. So BMV became
the best treatment option if condition permits. According to various
studies the prediction of outcome following PBMV is multifactorial and
based not only on morphological characteristics of the valve but also a
number of clinical and procedural variables, including age, functional
class, effective balloon dilating area, and the final valve area and
lastly the experience of the clinical team [9-12]. Moreover treatment
expenses are made affordable by our state govt. by declaring free
treatment for all at all govt. hospitals. So there is ample scope to
diminish the disease load and human suffering in our vicinity. I have
undertaken the study to testify the effectiveness of Balloon Mitral
Valvuloplasty in mitral stenosis to resolve the pulmonary hypertension.
Materials
and Method
This Analytical and Longitudinal study was undertaken at NilRatan
Sirkar Medical College and Hospital over 1year 6 months, November 2014
to April 2016. Total 39 patients of severe mitral stenosis with varying
degree of pulmonary hypertension were included. The patients were
initially attended OPD. They were asked questions related to symptoms,
thoroughly examined and investigated after recruitment not only to
establish the diagnosis but also to assess grading i,e severity of the
mitral stenosis and pulmonary hypertension. The patients were also
assessed for any other valve involvement. The cases were selected
considering both clinical and morphological variables.
Statistical Analysis: statistical analysis was done using IBM SPSS
Statistics 20. Continuous variables were expressed as mean ±
standard deviation. Results were compared using Non parametric related
sample Wilcoxon Signed Rank Test. P value ˂0.05 was considered
significant.
Results
and Analysis
After operation they were followed up at 48hr, 1 months and 6 months.
The mean age the patients were 21.97 ± 5.65 yrs. 29 patients
were female and 10 of them were male. 27 people came from rural area 12
of them were from urban mostly slum area. 13 patients belonged to
socioeconomic background below poverty line, 19 of them were from lower
income group and rest 7 persons belonged to middle income group. 7
female patients and 2 male patients had atrial fibrillation. 3 patients
had previous surgical valvulotomy and 2 had previous BMV. Mitral
stenosis and aortic stenosis were coexistence in 1 patient. The
patients were classified according to New York Heart Association [13].
10 (25.64%) had grade II heart disease, 9 (23.07%) of them had grade IV
and rest 20 i.e. 51.28% had grade III heart disease. Mitral valve
Morphologic Score in 18 (46.15%) patients was ˂8. It was 10 in 8
(20.51%) patients. 6 (15.38%) patients had MVMS 11 and rest 7 (17.94%)
had score 12. Left Ventricular Ejection Fraction was ≥ 55% in 21
(53.84%) patient, ˂55% in 11(28.2%), ≤35% in 7 (17.94%)
patients. Total 26 patients has associated MR. 11(42.30%) of them had
trivial MR. 13 (50%) patients was associated with grade 1 MR and only 2
(7.69%) patients had grade 2 MR. Mean mitral valve area
before and after BMV were 0.89±0.11cm and
1.89±0.21cm respectively. Mean transmitral gradient before
BMV was 15.43±2.3 mm of Hg which came down to 7.
86±2.25 mm of Hg after BMV. 8 (20.51%) patients had mild
pulmonary hypertension. Moderate hypertension was detected in 16
(41.02%) patients whereas as much as 15 (38.46%) patients had severe
pulmonary hypertension. On the day of discharge, echocardiographic
findings revealed that there was overall improvement in all three
groups. PASP was lowered to become normal in 1 (0.39%) individual of
mild PH group, the improvement was not statistically significant (p=
0.234). Statistically significant improvement was seen among 7 (17.94%)
of 16 subjects with moderate PH who showed to have mild PSBP, p=0.001).
Of 15 (38.46%) patient of severe hypertension 10 (25.64%) patients were
improved to be allotted to moderate PH and for the rest 5 patient PASP
was also decreased which was statistically significant (p=0.001) . At
1m follow up echocardiographic evaluation depicted 3 (7.69%) cases of
mild PH group had normal PASP, (p=0.106). Among 16 (41.02%) patients of
moderate PH category, 5 (12.82%) subjects were fortunate enough to have
normal PSBP, 9 (23.07%) patients showed mild PH and only 2 (5.12%) were
still remained in moderate PH group. (p=0.001). PSBP reverted back to
normal in 1 (2.56%) case, became mild in 7 (17.94%) patients, moderate
in 6 (15.38%) cases of severe PH group. (p=0.001) Final follow-up at 6m
5 (12.82%) of each mild and moderate PH categories while 2 (5.12%)
patients of severe PH group had normal PSBP. 10 (25.64%) cases of each
moderate and severe groups improved to have mild PH. The improvement
was statistically significant, (p=˂0.05). 2 (5.12%) patients of mild
group, 1(2.56%) case of each moderate and severe group were not
improved much. Those who did not improved had associated pulmonary
causes of PH.
Table 1: demographic
profile of the patients (n=39)
Table-2: distribution of
patients according to NYHA grading, MVMS, LVEF and Associated MR
Table-3: mitral valve
area and transmitral gradient before and after BMV
|
Mitral valve area
|
Transmitral
gradient
|
|
Before BMV
|
After BMV
|
Before BMV
|
After BMV
|
|
Mean
0.89±0.11cm
|
Mean
1.89±0.21cm
|
Mean
15.43±2.3
|
Mean
7.86±2.25
|
Table-4: severity of
pulmonary hypertension before and 48hrs, 1month, 6months after BMV
|
PH
before BMV
|
PH
48 after BMV
|
PH
1month after BMV
|
PH
6months after BMV
|
|
SN
|
Mild
|
Mod
|
Sev
|
Mild
|
Mod
|
Sev
|
Mild
|
Mod
|
Sev
|
Mild
|
Mod
|
Sev
|
|
1
|
27
|
42
|
56
|
26
|
29
|
53
|
26
|
35
|
44
|
37
|
29
|
38
|
|
2
|
29
|
41
|
57
|
27
|
31
|
54
|
29
|
33
|
39
|
29
|
31
|
39
|
|
3
|
35
|
51
|
59
|
32
|
48
|
56
|
37
|
29
|
49
|
26
|
26
|
49
|
|
4
|
32
|
50
|
56
|
38
|
43
|
52
|
36
|
34
|
43
|
|
30
|
35
|
|
5
|
26
|
43
|
58
|
39
|
39
|
54
|
27
|
32
|
49
|
|
29
|
39
|
|
6
|
39
|
42
|
59
|
26
|
28
|
57
|
|
32
|
38
|
|
29
|
38
|
|
7
|
27
|
49
|
56
|
28
|
44
|
52
|
|
38
|
49
|
|
35
|
39
|
|
8
|
31
|
45
|
58
|
|
42
|
54
|
|
49
|
39
|
|
47
|
39
|
|
9
|
|
47
|
56
|
|
42
|
52
|
|
46
|
34
|
|
33
|
29
|
|
10
|
|
41
|
56
|
|
38
|
51
|
|
39
|
34
|
|
32
|
47
|
|
11
|
|
43
|
57
|
|
30
|
55
|
|
37
|
52
|
|
34
|
39
|
|
12
|
|
42
|
59
|
|
30
|
57
|
|
|
39
|
|
|
41
|
|
13
|
|
49
|
56
|
|
49
|
54
|
|
|
43
|
|
|
56
|
|
14
|
|
53
|
59
|
|
51
|
57
|
|
|
56
|
|
|
|
|
15
|
|
53
|
58
|
|
48
|
58
|
|
|
|
|
|
|
|
16
|
|
50
|
|
|
48
|
|
|
|
|
|
|
|
Mild
|
Statisticsa
|
|
|
Pre_OP
|
OP_48
|
OP_1m
|
OP_6m
|
|
Mean
|
30.7500
|
30.0000
|
28.0000
|
26.0000
|
|
Median
|
30.0000
|
27.5000
|
26.5000
|
24.0000
|
|
Std.
Deviation
|
4.49603
|
5.73212
|
5.70714
|
4.95696
|
|
Minimum
|
26.00
|
24.00
|
22.00
|
22.00
|
|
Maximum
Std
error mean
|
39.00
1.590
|
39.00
2.027
|
37.00
2.018
|
37.00
1.753
|
Moderate
|
Statisticsa
|
|
|
Pre_OP
|
OP_48
|
OP_1m
|
OP_6m
|
|
Mean
|
46.3125
|
40.0000
|
32.3750
|
29.2500
|
|
Median
|
46.0000
|
42.0000
|
32.5000
|
29.0000
|
|
Std.
Deviation
|
4.39270
|
8.07465
|
8.33367
|
6.47560
|
|
Minimum
|
41.00
|
28.00
|
22.00
|
22.00
|
|
Maximum
Std
error mean
|
53.00
1.098
|
51.00
2.019
|
49.00
2.083
|
47.00
1.619
|
Severe
|
Statisticsa
|
|
|
Pre_OP
|
OP_48
|
OP_1m
|
OP_6m
|
|
Mean
|
57.3333
|
54.4000
|
42.1333
|
38.4000
|
|
Median
|
57.0000
|
54.0000
|
43.0000
|
39.0000
|
|
Std.
Deviation
|
1.29099
|
2.19740
|
8.21033
|
8.53397
|
|
Minimum
|
56.00
|
51.00
|
24.00
|
24.00
|
|
Maximum
Std
error mean
|
59.00
0.333
|
58.00
0.567
|
56.00
2.120
|
56.00
2.203
|
Discussion
The study reflected a significant improvement of pulmonary hypertension
following BMV. Umesan et al in their study observed a sustained fall in
pulmonary pressure at follow up [14]. Pulmonary pressures fall soon
after relief of the MS due to fall of left atrial pressure and because
elevated pulmonary vascular resistance is usually due to reactive
vasoconstriction as opposed to permanent histopathologic changes
[15-16]. Funjan MM et al also observed in their study that BMV is an
effective procedure in patients with MS and reactive pulmonary
hypertension [17]. Mohamed Eid Fawzy in his study reported that
immediately following valvotomy, the PASP normalized in one group and
in other groups, pulmonary hypertension decreased slightly with further
substantial regression occurring overtime. Severe pulmonary
hypertension normalized over 6–12 months in patients with
successful PMBV [18-21]. When we scrutinized minutely pulmonary causes
were found out in those patients who did not improve following BMV.
Conclusion
Although Balloon Mitral Valvuloplasty for mitral stenosis is associated
with significant risk in presence Pulmonary hypertension but it is
worth doing BMV as it improves dramatically the pulmonary hypertension
secondary to heart pathology and also to some extent pulmonary
hypertension due pulmonary pathology.
Abbreviation
BMV- Balloon Mitral Valvuloplasty
BPL – Below Poverty Line
LVEF- Left Ventricular Ejection Fraction
MR- Mitral Regurgitation
Mod - Moderate
MS - Mitral Stenosis
MVMS- Mitral Valve Morphologic Score
NYHA- New York Heart Association
PH- Pulmonary Hypertension
PASP- Pulmonary Arterial Systolic Pressure
S/E- Socio-economic condition
Sev- Severe
Funding:
Nil, Conflict of
interest: None initiated
Permission from IRB:
Yes
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How to cite this article?
Mandal I. Pulmonary hypertension before and after balloon mitral
Valvuloplasty. Int J Med Res Rev 2017;5(03):279-284.
doi:10.17511/ijmrr. 2017.i03.11.