1. Mohamed Eid Fawzy, FRCP, FACC, FESC October 6 University Cairo, EGYPT
Prevalence of Severe Pulmonary Hypertension in 531 Consecutive Patients with Severe Mitral Stenosis, Impact of Mitral Balloon Valvuloplasty on Severe Pulmonary Hypertension and Concomitant Severe Tricuspid Regurgitation
Mohamed Eid Fawzy, FRCP, FACC, FESC
October 6 University Cairo, EGYPT

2. Objectives
The prevalence of severe pulmonary hypertension (P.H.T) in patients with severe mitral stenosis (M.S) remains unknown. The aim of this study is to identify the prevalence of severe pulmonary hypertension in 531 consecutive patients with severe (MS) and evaluate the impact of mitral balloon valvuloplasty (M.B.V) on severe pulmonary hypertension and concomitant severe tricuspid regurgitation (TR).

3. Methods
MBV was successfully performed in 531 consecutive patients. Of these patients, 82 patients (15%) had severe PHT at baseline (group A), defined as pulmonary artery systolic pressure (PASP) at rest >65 mmHg, compared to the remaining 449 patients, who served as controls (group B).

4. Methods Cardiac Catheterization
Right and left cardiac catheterization were carried out, the following hemodynamic measurements were
obtained before and immediately after MBV using
Inoue Balloon Technique. The pulmonary artery systolic (PAP) and mean pressure, cardiac index (C.I), mitral mean gradient, left atrial pressure (LAP),
pulmonary vascular resistance (PVR), mitral valve area (MVA) were calculated using A. Micro-Siemens Computer (manufactured by Siemens-Elema A.B.,Solna, Sweden).

5. ECHOCARDIOGRAPHIC EXAMINATION
All patients underwent Echo and Doppler study before
MBV, immediately after and at 3 months and
yearly there after. The mitral mean gradient (MG), MVA,
pulmonary artery systolic pressure were calculated.

6. Statistical Analysis
Invasive and echocardiographic data obtained before and immediately after MBV, and also at long-term follow up, were compared using Student’s t-test (paired, two-tailed) for continuous data. Kaplan-Meier estimates were used to determine freedom from restenosis and event-free survival (survival with freedom from redo MBV, MVR, cardiac death or NYHA class III or IV) for both groups. Only patients with successful MBV were included in the analysis.

7. Results No immediate or late death was encountered.
Severe pulmonary hypertension was encountered in 82 pts (15%) PAP > 65 mmHg.

8. Patient baseline characteristics.
_________________________________________________________
Parameter Group A Group B p-value
(n = 82) (n = 449)
_________________ 15%___________________________
Age (years)* 29 ± ±
Female gender (n) 67 (82) 318 (71) 0.042
Echo score* ± ±
Previous surgery (n)
Tricuspid regurgitation (n)
Moderate 33 (40%) 42 (9.3) <0.0001
Severe 10 (12%) 20 (4.4) <0.001
Baseline catheter MR (n)
Grade
Grade
Baseline atrial fibrillation (n) 10 (12%) 61(13.5%) 0.73
Pregnant (n) 14 (17%) 15 (3.3%)
*Value are mean ± SD.
Values in parentheses are percentages.

9. Baseline and immediately post-MBV catheter hemodynamic results.
________________________________________________________________
Parameter Group A (Group B) p-value
(n = 82) (n = 449)
___________________________ _ (15%)__________________________________
Mean LAP (mmHg)
Baseline 28 ± ± 4.6 <0.0001
Post-MBV ± 4.5*** 14.7 ± 3.65*** 0.13
Mitral mean gradient (mmHg)
Baseline ± ±
Post-MBV 5.6 ± 2.2*** 5.4 ± 2.0*** 0.30
Mitral valve area cm2
Baseline ± ± 0.19 <
Post-MBV 1.7 ± 0.44*** 1.85 ± 0.54*** 0.007
Cardiac index (l/min/m2)
Baseline ± ±
Post-MBV ± 0.76*** 2.95 ± 0.75*** 0.30
PASP (mmHg)
Baseline ± ± 12.1 <
Post-MBV 58 ± 17.7*** 37 ± 9.8*** <
PVR (dyne/s/cm-5)
Baseline ± ± 183 <
Post-MBV 477 ± 350** 195 ± 151** <
Mitral regurgitation (grade)
1 18 (22%) 103 (23%) 0.90
2 4 (4.8%) 28 (5.7%)

10. Baseline, immediately post-MBV and final follow up echocardiographic data
_______________________________________________________________
Group A Group B p-value
(n = 82) (n = 449)
Doppler mean gradient (mmHg)
Baseline ± ± 2.6 <0.0001
Post-MBV 5.4 ± 1.3*** 5.2 ± 1.4*** 0.06
Follow up ± 3.4* 6 ± 3*** 0.08
Doppler MVA (cm2)
Baseline ± ± 0.17 <0.0001
Post-MBV ± 0.24*** 1.98 ± 0.28*** 0.81
Follow up ± 0.16*** 1.54 ± 0.4*** 0.93
2D echo MVA (cm2)
Baseline ± ±
Post-MBV ± 0.18*** 1.97 ± 0.3*** 0.01
Follow up ± 0.48*** 1.6 ± 0.40*** 0.13
Doppler PASP (mmHg)
Baseline 79 ± ± 9.2 <0.0001
Follow up ± 7.53*** 31 ±8.4*** 0.008
Severe TR
Baseline 10 (12%) 20 (4%) <0.0001
Follow up (2%)
Moderate TR
Baseline 33 (40%) 42(9%) 0.544
Follow up 12 (14%) 34 (7%) -

11. Procedure-related complications (n = 531)
_________________________________________________________
Parameter Group A Group B p-value
(n = 82) (n = 449)
Mortality 0 0
Post-procedure ASD 25 (30%) 113 (25%) 0.23
Cerebral embolism 0 3 NS
Pericardial tamponade 0 5 NS
Values in parentheses are percentages.
ASD: Atrial septal defect; NS: No significant difference.

14. Ao →
Ao →
PA →
PA →
Before M.B.V.
Immediately After

20. Conclusion
The prevalence of severe pulmonary hypertension in patients with severe M.S was 15%.
M.B.V is a safe and effective technique in treating patients with severe M.S with severe pulmonary hypertension, the latter condition being normalized over 6-12 months period with regression of concomitant severe TR.