Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : OC14 - OC18 Full Version

Percutaneous Transvenous Mitral Commissurotomy in Middle Aged Indian Population- A Cross-sectional Study

Published: July 1, 2021 | DOI:
Jayanty Venkata Balasubramaniyan, RH Lakshmi, Phalgun Badimela, Jayanty Sri Satyanarayana Murthy

1. Assistant Professor, Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. 2. Consultant, Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. 3. Senior Resident, Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. 4. Professor, Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India.

Correspondence Address :
Jayanty Venkata Balasubramaniyan,
22/12, G S T Road, Guindy, Chennai, Tamil Nadu, India.


Introduction: Mitral Stenosis (MS) is a chronic complication seen among patients with Rheumatic Heart Disease (RHD). Percutaneous Transvenous Mitral Commissurotomy (PTMC) is a non surgical intervention indicated exclusively for MS with favourable valve morphology.

Aim: To determine the outcomes of PTMC in middle aged Indian population in relation to clinical and haemodynamic parameters.

Materials and Methods: This retrospective cross-sectional study conducted at a tertiary care hospital in Chennai, Tamil Nadu, between 1994 and 2019. Study was based on analysis of data from 82 patients diagnosed with MS, that underwent successful PTMC. Patients in the age group of 40 to 60 years with symptomatic MS {Mitral Valve Area (MVA) <1.5 cm2 on echocardiogram} were included in this study. Successful PTMC was defined in terms of MVA >1.5 cm2. Participants were divided into two groups based on Wilkins score of 8 as a cut-off. The continuous variables of the study subjects were described and interpreted by averages and compared between the groups by independent t-test. The pre, post and follow-up characteristics were analysed by averages and interpreted by paired t-test and confirmed by repeated measures of ANOVA.

Results: Group A with Wilkin’s score ≤8 showed better results in terms of functional status improvement [New York Heart Association (NYHA) classification], MVA, mean gradient across mitral valve and Pulmonary Arterial Pressure (PAP) with p-values <0.05 after a mean follow-up period of one year.

Conclusion: Long-term outcomes of PTMC is better in patients with lower Wilkin’s score than those with higher scores in terms of functional status improvement, maintenance of MVA and mitral valve mean gradient pressure. These factors favour the optimal utilisation of PTMC as an alternative to surgery especially among middle aged population.


Mitral stenosis, Mitral valve area, Rheumatic heart disease, Wilkin’s score

Acute Rheumatic Fever (RF), a disease of poverty associated with other poor health social determinants is commonly seen in low income countries (1). It is not uncommon to see many young adults in these low-income settings with Rheumatic Heart Disease (RHD), which is a sequela of acute RF (2). The delayed immune response of Group A streptococcal pharyngitis results in several non-suppurative complications, of which RF and RHD are the most common especially in developing countries, particularly amidst children and young adults (3),(4). An estimated 4.71 lac cases of acute RF have been reported by WHO throughout the world annually with about 33,6000 of them in the age group of 5-14 years of age (5). It has been projected that 6•1 million years of potential life lost before age 70 years in 1990 was caused by acute RF/RHD of which 5.5 million occurred in less developed countries (6). The World Health Report in 2004 estimated that 5.9 million disability-adjusted life years lost during 2002 was attributed to RHD alone (7). Though the incidence of RHD in recent times has seen a decline especially in Developed countries yet it ceases to be a common problem in developing countries especially like India which contributes to about 25-50% of newly diagnosed cases of RHD all over the world. RF is still the cause of mitral valve disease worldwide with the majority of them living in the developing world (79%) (8).

Mitral Stenosis is one of the most common complication of RS. MS is a progressive condition whose symptoms worsen due to increased heart rate and increased cardiac output resulting from increase of trans-mitral gradients (9). In developed countries an average time of more than nine years was noted for progression from mild to severe with a latency of 20-40 years after an episode of RF (10),(11). Longitudinal studies based on echo-cardiography showed the average decrease in MVA to be around 0.09 cm2/year with higher trans mitral gradients and Wilkin’s echocardiographic scores (>8) which point towards a more rapid and progressive course (12),(13). In a combined analysis of 759 unoperated patients with MS series with ten year follow-up an overall survival rate of only around 50% but with survival rates of more than 80% was seen among mildly symptomatic patients (14). This ten-year survival becomes less than 15% in the event of untreated MS (15). In developing countries, recurrence of RF is a crucial issue, because of persistence of predisposing factors and poor access to diagnostic and prophylactic measures (16).

Treatment options can be decided between medical management or PTMC or surgery based on the nature and severity of the disease. Since 1984, PTMC has become an important alternative for surgery (17). PTMC is one of the nonsurgical commissurotomy in the patients with haemodynamically significant MS (18). Its clinical applications are widely accepted and reported in a large series (19),(20),(21),(22). In patients with suitable anatomy of the valve, the results of PTMC were equal to open and closed surgical mitral valvotomy (23),(24). PTMC has been widened its application to situations where other alternatives such as surgical commissurotomy is not advisable, like in elderly with calcific MS (25).

This study was intended to throw light upon PTMC as a procedure which has lost its importance especially following introduction of advanced surgical procedures for management of MS. Studies that assess the utility of PTMC as the procedure of choice in developing countries especially among middle aged population with MS are limited. This study highlights the outcome of PTMC in individuals with symptomatic MS in terms of clinical and haemodynamic outcomes.

Material and Methods

This was a retrospective cross-sectional study done in the Department of Cardiology at a tertiary care centre in Chennai, Tamil Nadu, India for 25 years time duration from 1994-2019. Ethics committee approval was obtained (Ref No: CSP-MED/2019/Mar/35/21) and written informed consent from all the participants for the procedure was obtained stating that the results will be used for research in future. Eighty-two patients with MS who underwent successful PTMC between 1994 and 2019 were selected.

Inclusion criteria: Patients of both sex with symptomatic MS (MVA <1.5 cm2) who underwent successful PTMC within the study period were included in the study.

Exclusion criteria: Patients with mild MS (MVA >1.5 cm2), Grade II Mitral Regurgitation (MR) or more, Left Atrium (LA) or Left Atrial Appendage (LAA) thrombus, Congestive cardiac failure, Wilkin’s score >12, and patients who needed surgery were excluded.


Evaluation of all patients for functional disability was done using NYHA classification (26). ECG, transthoracic echocardiography, transesophageal echocardiography was done as a part of preprocedural evaluation was done using the self-positioning single balloon (Inoue-Balloon Catheter) under strict aseptic precautions through femoral venous approach under local anesthesia. Balloon size was decided based on the following formula.

Balloon size (mm)={Height in Cm/10}+10

Inflation was started at 1-2 mm less than maximum diameter and stopped if optimal results were not achieved with the maximum balloon diameter. The interatrial septum was traversed using balloon catheter tip and the stiffening cannula was used for passing the balloon portion into the LA which was then maneuvered into the left ventricle. The balloon was inflated using diluted contrast material to the point of disappearance of waist. As per the hospital protocol, Haemodynamic parameters post PTMC such as MVA, PPA were considered for analysis. Post procedure MR severity was graded based on Seller’s classification from Grade 0 to Grade 4 which was assessed using Cine left ventriculography in Right Anterior Oblique (RAC) view (27). Valve morphology was reassessed using Wilkin’s score with data from complete echo doppler study repeated after 24 hours using Trans Thoracic Echocadiogram (TTE) and Trans Esophageal Echocardiogram (TEE) (28). MVA was reassessed using pressure half time based on the average of three cardiac cycle recordings. Other parameters included for the study were peak and mean trans mitral pressures and pulmonary artery pressures Successful PTMC was defined in terms of MVA >1.5 cm2 and MR of less than Grade II. The data was analysed in two groups based on the valve morphology using Wilkin’s score. Group A comprised data from patients with Wilkin’s score of ≤8 and Group B comprised of data from patients with Wilkin’s score of >8. Follow-up assessment data at the end of one year included echocardiographic hematological parameters like MVA, mean and peak gradients, PA pressures.

Statistical Analysis

The continuous variables of the study subjects were described and interpreted by averages and compared between the groups by independent t-test. The pre, post and follow-up characteristics were analysed by averages and interpreted by paired t-test and confirmed by Repeated measures of ANOVA. The above statistical procedures were under taken with the help of the statistical package namely IBM SPSS statistics-20. The p-values less than or equal to 0.05 (p≤0.05) were considered as statistically significant.


A total of 82 patients aged more than 40 years, who underwent PTMC were included in the study. Group A included 56 patients with Wilkin’s score of ≤8 and Group B included 26 patients with Wilkin’s score of >8. Mean age in group A was 46.6±5.8 and in group B was 44.9±5.0. The difference in age was not statistically significant (p=0.206) The mean age of the participants was 46.1±5.6 years with range of 40-61 years (Table/Fig 1).

This study revealed that there was a significant improvement in functional status (NYHA classification) of the patient post PTMC in both the groups, but in group B the functional status in follow-up did not sustain, though it was not statistically significant (p=0.228). The mean MVA pre procedure in group A was 0.9 cm2, post PTMC the mean MVA in group A was 2.1 cm2 and on follow-up the mean MVA in group A was 1.8 cm2 (p<0.001). The mean difference in MVA in group B during, pre, post and follow-up visits was statistically significant (p<0.001) implying that restenosis rate in group B (with area loss of 0.3 cm2) was more significant than in group A (with area loss of 0.5 cm2). The difference in mean gradients in group A during pre, post and follow-up visits and in group B during was also statistically significant (p<0.05). Difference in PAP in group A and group B during pre, post and follow-up visits respectively was also statistically significant (p<0.05). These data indicate that improvement in MVA, mean gradients and PAPs was sustainable better in group A than in group B (Table/Fig 2). Sustainability is shown by the significant persisting difference in haemodynamic values between the groups during follow-up (Table/Fig 3).

All haemodynamic parameters (NYHA, MVA, MG PAP) following PTMC have better outcome in those with Wilkins score ≤8 compared to those with scores >8 as evident from the trends and these are reflected in the follow-up period also (Table/Fig 4), (Table/Fig 5), (Table/Fig 7). These findings favour PTMC as a procedure of choice especially in individuals with lesser Wilkin’s score compared to those with scores above 8.


The present study brings out the clinical and haemodynamic outcomes of middle-aged Indian population who have undergone PTMC for MS. In this study a lower Wilkins score was a better predictor of long-term outcome especially in terms of functional status improvement, maintenance of MVA and mitral valve mean gradient pressure for those undergoing PTMC. A study by Palacios IF et al., revealed that lower Wilkin’s scores (<8) had significant impact on the immediate outcome, post PTMC, similar to the present study (29). There are other studies, which revealed that mitral anatomy as the best predictor of outcome of PTMC, though a good result could also be obtained in higher Wilkin’s score (18),(19),(20),(21). Ongoing rheumatic process along with abnormal turbulences will cause further fusion of commissures, valve thickening and calcification in post PTMC. This study revealed there is a significant decrease in mean MVA on follow-up in both the groups but more in group A, than group B. Restenosis is defined as 50% loss of area gain, but in the patients with poor initial outcome, restenosis can be defined with only a mild area loss. The percentage of restenosis were variable in different studies. A study by Devi YP et al., in India has shown that the influence of several factors like pre PTMC left atrial size, MVA, subvalvular fusion was more important for occurrence of restenosis 10 years after successful PTMC than by immediate post PTMC parameters (30). This study also highlights the importance of pre-PTMC Wilkin’s score and Atrial Fibrillation (AF) as reliable predictors of restenosis. In RHD with mitral valve involvement, disease progression is the result of abnormal turbulences generated by the deformed valve and/or low-grade progressive subclinical rheumatic process.

In a study by Hernandez R et al., the event free survival rate at seven years post PTMC was 69% which confirms the beneficial effect of the procedure on a long-term basis. Also, patients with lower Wilkins scores and good results had about 88% probability of being disease free for seven years. The study also revealed that the restenosis rate in Spanish patients was 10%, 18% and 39%, at four, five and seven years, respectively (13). A study on the rate of restenosis by Claire B et al., in American patients has shown the incidence to the value of 40% by six years. This study points towards MVA as a strong predictive factor of late functional results of PTMC namely restenosis and is dependent on age with prognostic impact being higher with young patients and decreasing as age advances with no significance after 70 years of age. MVA , especially after PTMC has been shown to vary according to cardiac output. which makes other valve stenosis indexes add to the prognostic value of MVA after PMC. Late functional results in particular restenosis, is highly dependent on follow-up mitral valve function determined by valve function immediately after PMC and is assessed by final MVA and gradient followed by progressive restenosis. One important factor that influences restenosis is age, because it indirectly reflects the heart valve disease duration which in turn is responsible for the structural changes of the mitral valve (31). Restenosis was encountered in a study by Fawzy ME et al., among 17.4% of patients who had underwent successful PMC and post-PTMC Cox regression analysis identified that Wilkin’s score of > 8 as a predictor of restenosis. The study also demonstrated the restenosis-free probability at seven years as 81%, at 10 years as 68%, and at 13 years as 51% and a low Wilkin’s score of <8 as a predictor of being free from restenosis comparable to the present study (13),(32). A 10-year period follow-up study on restenosis following successful PTMC by Devi YP et al., showed that restenosis was influenced more by pre PTMC left atrial size, MVA, subvalvular fusion than on immediate post PTMC parameters (30).

The changes in Mean trans mitral gradients and pulmonary artery pressures immediately post PTMC in this study were significant. A study by Chen C-R et al., revealed PA pressures reduced from 51.2±14.8 to 33.9±8.8 mm Hg (33). The importance of PA pressures comparing with Wilkin’s valve morphology scores needs to be defined in future. Multivariate analysis of previous studies showed that pre-PMV MVA, less degree of pre-PMV MR, younger age, and Wilkin’s score <8 as independent predictors of procedural success. This was comparable to the present study results, with MVA, PAP and Wilkin’s score <8 having a better outcome among those with successful PMC. Higher NYHA functional class is an independent predictor of poor functional results during long-term follow-up. However, in the present study no classification of NYHA was done and comparison made between different classes of NYHA and outcome post procedure and follow-up (34),(35).


The data was collected from only one clinical setting; hence the findings cannot be generalised to the whole population. The convenient sampling method used in this study could be a potential source of bias especially in the allocation of groups, but the groups were similar in terms of age distribution and other haemodynamic parameters. The limitations of the sampling method employed could be overcome in view of the low resource settings and the low volume turn out of patients especially in a developing country.


The PTMC a time-tested procedure for management of MS especially following RF has been neglected in the recent years with advent of modern surgical techniques. The current study highlights this procedure especially among symptomatic individuals with MS especially for Wilkins grade ≤8 for whom surgery is not indicated. This procedure is especially of vital importance in developing countries where the incidence of Rheumatic MS is higher and chances of restenosis is high among middle aged population who are the most productive group in the population of a country.


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Date of Submission: Aug 27, 2020
Date of Peer Review: Oct 14, 2020
Date of Acceptance: Jan 21, 2021
Date of Publishing: Jul 01, 2021

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

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