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Background:Rheumatic Heart Disease (RHD) is a condition in which damage to heart valves is caused by rheumatic inflammation. The mitral valve (MV) was mostly damaged, and 25% patients with RHD only have their MV impaired. Nowadays epidemiology research shows that the incidence of the rheumatic heart disease is decreasing in our country. However, the proportion of elderly patients with mitral stenosis (MS) becomes larger in clinic for delaying of incidence age. Thus, the treatment of elderly patients with MS becomes an important cardiologic problem. Presently the Rheumatic Mitral Stenosis (MS) could be treated by surgery or the Percutaneous Mitral Balloon Valvuloplasty (PBMV). With the enrichment of experience and improvement of procedure technique, the PBMV becomes the prior choice in young MS patients. The efficacy and safety of PBMV have been confirmed in young patients by published reports, but are still unclear in elderly ones because of short follow-up and rare reports. Furthermore, there is also a debate on whether age would be an independent predictor of long-term outcomes for controversial results. Therefore, a retrospective study including 491 patients was carried out, in which the clinic characteristics and outcomes of the two groups (elderly patients vs. young or adult patients) were compared. We also investigated the risk factors which would effect the long-term outcome, to provide theoretical basis for the clinical application of PBMV in elderly MS patients.Objective:1. Analyzing the clinical features and ultrasonic cardiogram characteristics of elderly patients and young or adult patients who underwent PBMV;2. Comparing the acute procedural results and complications of PBMV in elderly patients and in young or adult patients;3. Comparing the long-term results of PBMV in elderly patients and in young or adult patients;4. Investigating the predict factors of efficacy and safety, and identifying whether age is an independent predictor of long-term outcome.Material and Methods:The data of 491 patients who underwent PBMV (repeat-PBMV was excluded) in Linyi People’s Hospital of Shandong Provincial from January 2002 to January 2010 were prospectively collected. The elderly group (age> 60) contained 96 patients (mean age:64.2±3.14), and 395 patients (mean age:45.5±9.7) were included in the young or adult groups (age< 60). Data of each patient such as baseline clinical features, preprocedural and postprocedural ultrasonic cardiogram characteristics, and intraoperative hemodynamic parameter were recorded. The NYHA functional class, repeat-PBMV, mitral valve replacement (MVR), death, mitral valve orifice area (MVOA), restenosis were also evaluated during follow-up. All the data were analyzed retrospectively.Results:1. Gender, preprocedural NYHA functional.class, left ventricular ejection fraction (LVEF) and history of previous surgical commissurotomy did not differ between the 2 groups. The elderly group had more incidence of coronary artery disease (6.3% vs. 0.5%, P=0.001) and atrial fibrillation (51% vs.33.2%, P=0.001). The baseline mitral regurgitation was more serious in the elderly (0.93±0.67 vs.0.65±0.62, P=0.001). The mitral valve scores were significantly higher in the elderly groups (7.9±1.8 vs. 6.9±1.9, P=0.001). And valves of elderly patients were significantly less mobile as graded by Wilkin’s echo score (2.0±0.4 vs.1.8±0.3, P=0.005), more leaflet thickening (2.3±0.5 vs.2.1±0.3, P=0.003), and more calcified (1.9±0.7 vs.1.7±0.4, P=0.001). Preprocedurally, there were no differences between the two groups in MVOA and left atrial pressure (LAP), while the mean transvalvular pressure gradient (MVG) was significantly higher in the young and adult patients.2. The rate of procedural success was similar in young or adult groups and elderly group (92.7% vs.97%, P=0.072). Pericardial tamponade, severe mitral regurgitation, embolism in 24 hours and death occurred at a similar rate in both groups. However, the diameter of final balloon dilatation was smaller in the elderly group than that in the young or adult group (24.9±1.12 vs.25.4±1.35, P=0.002); while the failure rates of valvuloplasty were similar in two groups. The elderly group had a significantly higher postprocedural mean left atrial pressure (16.2±5.2 vs.15.1±4.1, P=0.027), but a similar MVG with the young or adult group. The final valve area (1.91±0.22 vs.2.01±0.18,P=0.001) and the increase of valve area were smaller in elderly group. The extent of mitral regurgitation after PBMV was comparable in the two groups.3. The rate of follow-up was similar in two groups (95.5% vs.94.5%, P=1.00). Follow-up time ranged 12-96 months, and the mean follow-up time was similar in the two groups (39.9±24.6 months vs.41.2±21.8 months, P=0.658). By the end of follow-up, MVA was still smaller in elderly groups (1.61±0.21 cm2 vs.1.67±0.21 cm2, P=0.013), but the incidence of restenosis (23.5% vs.19.9%, P=0.495) and adverse events (27.4% vs.18.6%, P=0.098) were comparable. The improvement of cardiac function was greater in the young or adult patients (NYHA function class 1.80±0.77 vs.2.07±0.77, P=0.004), while the rate of worse events combined with NYHA functional class III or IV was significantly higher in elderly group (34.1% vs. 21.3%,P=0.016).4. By multivariate analysis, it was found that age was not an independent risk factor of outcome, however, the atrial fibrillation (OR:2.116,95% CI:1.246-3.592, P=0.006), preprocedural cardiac functional class (OR:2.263,95% CI:1.355-3.777, P=0.002), Wilkins scores (OR:1.232,95% CI:1.061-1.429,P=0.006), MVA after PBMV (OR:0.056,95% CI:0.010-0.313, P=0.001), mitral regurgitation after PBMV (OR:1.725,95%CI:1.121-2.664, P=0.013), and postprocedural mean LAP (OR: 1.113,95% CI:1.008-1.229, P=0.034) could be independent risk factors which predict worse events combined with NYHA functional classⅢorⅣ.Conclusion:1. Compared with young or adult patients, there are more coronary artery disease, more atrial fibrillation, higher mitral valves scores and more mitral regurgitation in the elderly patients;2. Through improvements of procedure technique, the elderly patients achieved similar acute procedural efficacy of PBMV with the young or adult patients. Though the safety and complication of PBMV were comparable in two groups, the diameter of final balloon dilatation and MVA were smaller in the elderly patients than those in young or adult patients;3. Though the elderly patients gained smaller MVA than young patients after PBMV, the rate of restenosis and adverse events was similar in two groups. In elderly group, the improvement of cardiac function (New York Heart Association function class) was less, while the incidence of adverse events combined with NYHA functional class III was more;4. Multivariate analysis showed that age was not an independent risk factor of outcome, however, the Wilkins scores, atrial fibrillation, preprocedural cardiac functional, MVA and mitral regurgitation after PBMV could be predictors of long-term efficacy.In sum, PBMV was safe and effective in elderly MS patients, and age was not the limiting factor for PBMV. However, the analysis should be regarded with some caution for different procedure in clinical practice.
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