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Effect of percutaneous transvenous mitral commissurotomy on brain natriuretic peptide in mitral stenosis in tertiary care hospitals of Peshawar.

Byline: Fahad Mahmood Ahmad, Roshan Ali and Adnan Mahmood Gul


The current study was planned to determine the effect of percutaneous transvenous mitral commissurotomy (PTMC) on brain natriuretic peptide (BNP) levels in mitral stenosis patients. It was conducted at the Postgraduate Medical Institute, Lady Reading Hospital, Peshawar, and Rehman Medical Institute Laboratory, Peshawar, Pakistan, from December 2013 to June 2014. Of the 100 patients, 63(63%) were females. The patients' age ranged from 14 to 58 years. Patients diagnosed with isolated mitral valve stenosis or with grade 1 or with grade 2 mitral regurgitation were randomly selected. BNP values before and after 24 hours of PTMC were calculated. The statistical analysis of the echocardiographic variables and BNP levels showed an increase in mitral valve area, drop in pulmonary artery systolic pressure, left atrium diameter and reduction in BNP levels (p 1.2 mg/dl), transoesophageal echocardiography (TOE) showing left atrial thrombus, recent thromboembolic event, pregnant woman on clinical and urine examination, and those needing simultaneous coronary angioplasty were excluded. Non-probability consecutive sampling was employed to collect the blood samples of the patients.

A fibrosed obstructed mitral valve was opened with the help of a few wires and a balloon. The balloon was inflated at different volumes according to patient height till optimal valve dilation was achieved. The procedure was performed within 30 minutes by an experienced cardiologist. Blood samples stored at 2-8AdegC were tested within 24 hours of collection. Pre- and post-PTMC blood samples were centrifuged to obtain the plasma of the sample and the blood plasma stored at 2-8AdegC was tested for BNP levels within 24 hours. The architect BNP assay is a chemiluminescent microparticle immunoassay (CMIA) used for the quantitative determination of human brain natriuretic peptide in human ethylenediaminetetraacetic acid (EDTA) plasma on ARCHITECT I system. The 8K28

ARCHITECT BNP Reagent Kit (Abbott Laboratories, Peshawar) was run on the ARCHITECT I system; it comprised microparticles, conjugate and specimen diluent. The reagents within ARCHITECT I system that were used for the BNP test were ARCHITECT wash buffer containing phosphate buffered saline solution, pre-trigger solution containing 1.32% (w/v) hydrogen peroxide and trigger solution containing 0.35N sodium hydroxide. Other materials used to run the test were septum, reaction vessels and sample cups. Each BNP control single sample was tested and it was ensured that the assay control values lie within the concentration ranges given in the control package insert and the calibrators should be priority loaded. The ARCHITECT BNP kit was loaded on the ARCHITECT I system. Calibrators and controls were prepared and were mixed gently before use. The blood samples were loaded and run on the ARCHITECT I system.

The biological principles of the procedure included the combining of sample and anti-BNP coated paramagnetic microparticles in the first step. BNP present in the sample was bound to the anti-BNP coated microparticles. To make a reaction mixture anti-BNP acridinium labelled conjugate was added after washing in the second step. Pre-trigger and trigger solutions were added to the reaction mixture following another wash cycle. The resultant chemiluminescent reaction was measured in relative light units (RLUs). A direct relationship was found between the amount of BNP present in the sample and the relative light units detected by the ARCHITECT I system optics. The patients' pre-and post-echocardiographic variables and BNP levels were analysed using SPSS 20, and a paired t-test was applied to the datasheet to calculate mean and standard deviation (SD). P<0.05 was considered statistically significant.

Table: Descriptive statistics (n=100).

Pre and Post PTMC###Minimum###Maximum###Mean###Std. Deviation###P-value


MVA (Pre) cm2###0.50###2.20###0.969###0.349###0.000

MVA (Post) cm2###1.00###3.00###1.841###0.450

PASP (Pre) mmHg###25.00###120.00###61.640###21.069###0.000

PASP (Post) mmHg###30.00###75.00###47.200###10.738

LAD (Pre) cm3###3.20###7.00###5.017###0.824###0.000

Left Atrium Diameter (Post) cm3###1.90###6.40###4.559###0.716

BNP (Pre) pg/ml###13.20###903.00###140.863###149.656###0.000

BNP (Post) pg/ml###14.30###590.70###96.143###103.339

There were 100 patients in the study. Echocardiographic assessment of the patients after PTMC showed mean mitral valve area (MVA) increased from 0.969+-0.349 cm2 to 1.841+-0.450 cm2 (p<0.001), mean pulmonary artery systolic pressure dropped from 61.640+-21.069 mmHg to 47.200+-10.738 mmHg (p1.5 cm2. In a study, PTMC procedure gave a high rate of success, with 93.6% of the patients achieving MVA >1.5 cm2.19 The insignificant increase in the size of left atrium in a few cases can only be explained on the ground that echo is a subjective tool and even minimal changes in probe placement from different window sites in the same person some time can result into different size readings. In one study, the plasma BNP levels decreased after a successful PTMC.20

In the current study, the small group of patients having increased post-procedural mitral regurgitation with increased BNP levels can be readily explained because of acute volume overload secondary to mitral regurgitation.


BNP values can be used as a significant tool to comment on the success of PTMC procedure along with other parameters like mitral valve area, pulmonary artery systolic pressure and left atrium size. The success of the PTMC procedure can easily be inferred from the decrease in the levels of BNP.

Acknowledgements: We are grateful to Khyber Medical University for providing financial support. We also acknowledge the support and help from the Cardiology Department of the Lady Reading Hospital, Peshawar, and Rehman Medical Institute Laboratory, Peshawar.

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: Khyber Medical University, Peshawar, provided the funding that helped us purchase the BNP kit.


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Publication:Journal of Pakistan Medical Association
Geographic Code:9PAKI
Date:May 31, 2018
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