Predictors of successful percutaneous transvenous mitral commissurotomy using the Bonhoeffer Multi-Track system in patients with moderate to severe mitral stenosis: Can we see beyond the Wilkins score?

To the Editor,

We read the original investigation entitled “Predictors of successful percutaneous transvenous mitral commissurotomy using the Bonhoeffer Multi-Track system in patients with moderate to severe mitral stenosis: Can we see beyond the Wilkins score?” by Farman et al. (1) published in the Anatol J Cardiol 2015; 15: 373-9. with great interest. We would like to touch on some points regarding this article.

Undoubtedly, several factors such as appropriate patient selection, proper echocardiographic imaging, and use of suitable techniques may affect the success of mitral balloon valvuloplasty (MBV) (2).

The Wilkins valve score is the main topic of this study (1, 3). It is well known that an increase in the valve score leads to reduced MBV success. However, the report solely indicated that the valve score was <8 in both groups. Emphasizing the numerical values of the valve score in the successful and failed valvuloplasty cases and if present, mentioning the difference between them would be more illuminative. We believe that a valve score of <8 in both groups does not mean that the two groups will have similar success rates. The success rate will quite likely decrease with the increasing valve score (3).

Although two-dimensional transthoracic echocardiography (TTE) is widely used as the first-line imaging method to evaluate the structure of the mitral valve, recently 3D echocardiography and even transesophageal (TEE) 3D echocardiography gained popularity in assessing the structure of the valve structure and presence of a possible thrombus in the left atrial appendix. (2). An accurate echocardiographic evaluation is crucial in the decision phase of MBV. The statement “patients with a clot in the left atrium (LA) were excluded from the study” points that some patients underwent transesophageal echocardiographic evaluation. However, it is not stated how many of them were examined by TEE. It can also be estimated from the statements in the manuscript that TTE was used in calculating the Wilkins valve score. However, TEE is recommended in the evaluation of the Wilkins valve score and commissural anatomy (4). Therefore, the assessment of the valve structure via TEE even if 3D TEE is not available would be more suitable.

Considering that the mitral valve structure was also evaluated via fluoroscopy, the calculation of lung and Cormier score (5) would make the report more interesting. Furthermore, although recent studies depicted that asymmetrical commissural fusion deteriorates the success of MBV, the frequency of this entity in successful and failed MBV groups was not mentioned in the study (3). We hope that the authors are willing to comment on these issues.