Predictors of the Development of Significant Mitral Regurgitation Following Repeated Percutaneous Balloon Mitral Valvuloplasty in Middle-Aged and Elderly Patients

Document Type : Original Article


Cardiology Department, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt


Background: We aimed to identify the predictor of developing significant mitral regurgitation (MR) after repeated percutaneous balloon mitral valvuloplasty (PBMV) via the Inoue Balloon Technique in middle-aged and elderly patients.
Methods: This prospective study was performed on 40 patients presenting to the cardiology department with severe symptomatic mitral restenosis following previous PBMV via the Inoue Balloon Technique. Informed written consent was obtained from all the patients. MR was evaluated before and after PBMV and subsequently at short-term follow-up.
Results:The study population was aged above 45 years. The 40 patients recruited were divided into 2 main groups: Group A comprised 28 patients who did not develop an increase in the grade of MR at follow-up and Group B consisted of 12 patients who developed at least a 1-grade increase in MR at follow-up. The results were compared before, after, and at short-term follow-up between the 2 study groups. The forward stepwise logistic regression analysis identified the presence of preprocedural Grade I MR as the most important independent predictor of the development of MR after PBMV (p = 0.01). No significant difference was observed between the study groups concerning symptomatic and hemodynamic improvements after PBMV.
Conclusions: The presence of preprocedural Grade I MR may be the most independent predictor of a rise in the MR grade following repeated PBMV in middle-aged and elderly patients. (Iranian Heart Journal 2020; 21(4): 118-130)






  1. Carapetis J. R., Steer A. C., Mulholland E. K., et al. "The global burden of group A streptococcal diseases." The Lancet Infectious Diseases. (2005);5 (11): 685–694.
  2. Inoue K, Owaki T, Nakamura T, et al. "Clinical application of transvenous mitral commissurotomy by a new balloon catheter." J Thorac Cardiovasc Surg. (1984); 87 (3): 394–402.
  3. Herrmann H. C., Wilkins G. T., Abascal V. M., et al. "Percutaneous balloon mitral valvotomy for patients with mitral stenosis. Analysis of factors influencing early results." J Thorac Cardiovasc Surg. (1988); 96 (1):33–38.
  4. S. A., Ramadan M. M., Osama M. "A novel technique for multitrack percutaneous balloon mitral valvoplasty." Int Heart J. (2013); 54 (4): 196–201.
  5. U. A. Kaul, S. Singh, G. S. Kalra et al., “Mitral regurgitation following percutaneous transvenous mitral commissurotomy: a single-center experience,” J Heart Valve Dis (2000); 9 (2): 262–268.
  6. E. Garbarz, B. Iung, B. Cormier, et al. “Echocardiographic criteria in the selection of patients for percutaneous mitral commissurotomy," echocardiography. (1999); 16 (7):  711–721.
  7. Abascal VM, Wilkins GT, O'Shea JP, et al. "Prediction of successful outcome in 130 patients undergoing percutaneous balloon mitral valvotomy." Circulation. (1990); (82): 448-456.
  8. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. (2015);16(3):233-71.
  9. Nishimura RA, Rihal CS, Tajik AJ, et al. Accurate measurement of the transmitral gradient in patients with mitral stenosis: A simultaneous catheterization and Doppler echocardiographic study. J Am Coll Cardiol (1994); 24 (1): 152-158
  10. Armstrong, W: Echocardiography. In Braunwald's Heart Disease 7th edition.; 2005.ISBN 9781455751341
  11. Sutaria N, D. B. Northridge, T.R.D. Shaw."Significance of commissural calcification on outcome of mitral balloon valvotomy". (2000); 84(4):398-402.
  12. Lau KW, Hung JS. A simple balloon-sizing method in Inoue-balloon percutaneous transvenous mitral Commissurotomy. Cathet Cardiovasc Diagn.(1994); (33): 120–129.
  13. R. Hernandez, C. Macaya, C. Banuelos, et al., “Predictors, mechanisms and outcome of severe mitral regurgitation complicating percutaneous mitral valvotomy with the Inoue balloon,”    Am. J. Cardiol. (1992); 70(13): 1169–1174.
  14. Padial L R, Freitas N, Sagie A, et al. echocardiography can predict which patients will develop severe mitral regurgitation after percutaneous mitral valvotomy. JAm Coll Cardiol. (1996); 27.(5): , 1225-1231.
  15. A. M. Zaki, H. H. Kasem, S. Bakhoum et al., “Comparison of early results of percutaneous metallic mitral commissurotomy with Inoue balloon technique in patients with high mitral echocardiographic scores,” Catheterization and Cardiovascular Interventions. (2002); 57( 3): 312–317.
  16. H. Kasem, S. Bakhoum, M. Mokhtar, et al." Comparison of the immediate results of percutaneous mitral Commissurotomy using the metallic valvotomy versus Inoue balloon technique,” Eur Heart J. (2000); 89 (1); 620.
  17. N. E. Mezilis, M. Y. Salame, and G. D. G. Oakley, “Predicting mitral regurgitation following percutaneous mitral valvotomy with the Inoue balloon: comparison of two echocardiographic scoring systems,” Clinical Cardiology. (1999); 22 (7): 453–458.
  18. Mi-Jeong Kim, Jae-Kwan Song, Jong-Min Song, et al. Long-Term Outcomes of Significant Mitral Regurgitation After Percutaneous Mitral Valvuloplasty.Circulation Interventional Cardiology. (2006); 114 (25) 
  19. T. Feldman, “Hemodynamic results, clinical outcome, and complications of Inoue balloon mitral valvotomy,” Catheterization and Cardiovascular Diagnosis. (1994); 2; 2–7.
  20. Palacios IF, Sanchez PL, Harrell LC, et al. Which patients benefit from percutaneous mitral balloon valvuloplasty? Prevalvuloplasty and post-valvuloplasty variables that predict long-term outcome. Circulation. (2002); 105: 1465–1471.
  21. I. Palacios, P. C. Block, S. Brandi, et al., “Percutaneous balloon valvotomy for patients with severe mitral stenosis,” Circulation. (1987); 75 (4): 778–784.
  22. R. Arora, M. Nair, S. Rajagopal et al., “Percutaneous balloon mitral valvuloplasty in children and young adults with rheumatic mitral stenosis,” Am Heart J. (1989); 118 (5): 883–887.
  23. Abdelfatah A. Elasfar and Hatem F. Elsokkary, “Predictors of Developing Significant Mitral Regurgitation Following Percutaneous Mitral Commissurotomy with Inoue Balloon Technique,” Cardiology Research and Practice. (2011) ; 5: 55-75.
  24. Nunes MC, Tan TC, Elmariah S, et al. "The echo score revisited: Impact of incorporating commissural morphology and leaflet displacement to the prediction of outcome for patients undergoing percutaneous mitral valvuloplasty."  Circulation. (2014); 129: 886-895.
  25. T. Mailer, R. Petitclerc, J. Lesperance, et al., “Mitral regurgitation assessed by echo-Doppler after percutaneous mitral valvuloplasty,” Circulation. (1989); 80 (2): 16.
  26. Y. Cho, S. J. Tahk, W. H. Shin, Y. S. Jang, et al. “Percutaneous mitral balloon valvotomy with mitral stenosis. Factors influencing mitral regurgitation,” J Am Coll Cardiol. (1999); 15 (2): 42.
  27. Iung B, Cormier B, Ducimetiere P, et al. Immediate results of percutaneous mitral Commissurotomy. A predictive model on a series of 1514 patients. Circulation.  (1996); 94(9):  2124–2130.
  28. Rifaie O, Esmat I, Abdel-Rahman M, et al. Can a novel echocardiographic score better predict outcome after percutaneous balloon mitral valvuloplasty? Echocardiography. (2009); (26): 119–127.
  29. Anwar AM, Attia WM, Nosir YF, et al. Validation of a new score for the assessment of mitral stenosis using real-time three-dimensional echocardiography. J Am Soc Echocardiogr: Official Publication of the American Society of Echocardiography. (2010); 23 (1): 13–22.