Usefulness of Short-Term Symptomatic Status as a Predictor of Mid- and Long-Term Outcome After Balloon Mitral Valvuloplasty Lynette A. Yates, RN, Roger E. Peverill, MBBS, PhD, Richard W. Harper, MBBS, and Joseph J. Smolich, MBBS, PhD A lthough the increase in mitral valve area pro- duced in patients with mitral stenosis by balloon mitral valvuloplasty (BMV) has a rapid benefit on hemodynamics, 1–4 improvements in subjective patient symptoms, peripheral muscle oxygenation, and exer- cise tolerance require several months to become fully manifest. 4–8 On this basis, this study examined the proposition that the short-term symptomatic status of patients after BMV, reflected in the New York Heart Association (NYHA) classification obtained at an ini- tial 3-month follow-up, was a predictor of longer term outcome, independent of patient baseline characteris- tics and procedural variables. ••• The study population consisted of 137 consecutive patients with mitral stenosis who underwent BMV between December 1989 and December 1997 using the single Inoue balloon technique. 9 Five patients were excluded from analysis because of failure to cross the mitral valve with the Inoue balloon (n = 3) or incomplete data sets (n = 2). Baseline demographic data were obtained by interview and examination of hospital records; a baseline NYHA classification was performed as part of the clinical workup. Patients underwent M-mode, 2-dimensional, and Doppler transthoracic echocardiography within 48 hours before BMV to assess mitral valve area, mitral valve morphology, left atrial diameter, and the extent of other valvular diseases. Measurements were per- formed according to the recommendations of the American Society of Echocardiography. 10 Mitral valve area was primarily obtained with the pressure half-time method, 11 but planimetry was used in 10% of cases in which velocity envelopes were of less than optimal quality. Mitral valve morphology was quan- titated by an experienced echocardiographer using the echocardiographic scoring system (“echo score”) of Wilkins et al, 12 which was derived by assessing 4 morphologic characteristics (valve calcification, sub- valvular morphology, valve thickness, and valve mo- bility) and grading each on a scale from 0 (normal) to 4 (severely abnormal). After its introduction at our institution in 1991, 109 patients also underwent ex- amination with transesophageal echocardiography be- fore BMV to exclude a left atrial thrombus. Transtho- racic echocardiographic assessment of mitral valve area and transmitral pressure gradient was repeated 2 days after BMV. BMV was performed as previously described. 13 A 7.5Fr Swan-Ganz catheter was inserted to measure pulmonary arterial pressures and thermodilution car- diac output, while a 6Fr polymer pigtail catheter was inserted into the left ventricle for pressure measure- ment and ventriculography. Before and after BMV, mitral regurgitation was graded during left ventricular cineangiography on a scale of 0 to 4 using standard criteria. Coronary angiography was performed in se- lected patients based on an individual coronary artery disease risk assessment. After atrial transseptal punc- ture, an 8Fr transseptal catheter was advanced into the left atrium and the mean gradient across the mitral valve was obtained by simultaneous recordings of the left atrial and left ventricular pressures. The mitral valve was subsequently dilated using an Inoue balloon catheter, with balloon size (24 to 30 mm) selected according to patient body surface area. Cardiac output and pressure measurements were repeated after com- pletion of balloon dilatation. There was no occurrence of in-hospital stroke, myocardial infarction, or death related to the BMV procedure. Initial follow-up after BMV was at 3 months, when an NYHA classification was determined for use in outcome analysis. Subsequent follow-up information was obtained annually via mailed questionnaire or telephone interview, or from the family doctor or referring cardiologist in the event of no patient re- sponse. Follow-up was concluded in March 1998, with a follow-up period of at least 3 months unless a prior event occurred. Median duration of follow-up was 41 months (range 3 to 108). For patients who died, the cause of death was obtained by examination of hospital records or contact with the patient’s doctor. Statistical analyses were performed using Statisti- cal Package for the Social Sciences, version 9.0.1 (SPSS Inc., Chicago, Illinois). In the analysis, fol- low-up was terminated after occurrence of an end- point event, defined as NYHA class III or IV symp- toms, repeat BMV, mitral valve surgery, or death from all causes. Where several end-point events occurred, follow-up was stopped at the first end point. Two patients who underwent repeat BMV were included in the analysis twice, once after an end point was reached after initial valvuloplasty, and again after the second procedure. Five patients who were lost to follow-up at a median interval of 49 months (range 13 to 77) after BMV were withdrawn from analysis as of the last follow-up. From the Centre for Heart and Chest Research, Department of Medi- cine, Monash University and Monash Medical Centre, Clayton, Vic- toria, Australia. Dr. Smolich’s address is: Cardiology Unit, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Austra- lia. E-mail: joe.smolich@med.monash.edu.au. Manuscript received May 4, 2000; revised manuscript received and accepted October 23, 2000. 912 ©2001 by Excerpta Medica, Inc. All rights reserved. 0002-9149/01/$–see front matter The American Journal of Cardiology Vol. 87 April 1, 2001 PII S0002-9149(00)01539-3