Percutaneous mitral balloon commissurotomy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Mohammed A. Sbeih, M.D. [3]; Joanna J. Wykrzykowska, M.D.

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Synonyms and keywords: Balloon mitral valvuloplasty, PMBC, percutaneous mitral balloon valvotomy, percutaneous mitral balloon valvuloplasty, PMBV, mitral valvuloplasty, percutaneous mitral valvuloplasty, PMC, percutaneous mitral commissurotomy

Overview[edit]

The safety and efficacy of PMBC have been shown compared with surgical closed or open commissurotomy in patients with a favorable valve morphology with less than 2+ mitral regurgitation and no evidence of left atrium thrombus. PMBC is performed by addressing one or more balloon catheters across the mitral valve and inflating them, then splitting the commissures. Valve morphology including mobile and relatively thin valve leaflets, without calcium deposit, in the absence of significant subvalvular fusion are favorable for this procedure. An anatomic mitral morphology score can be used to determine suitability for PMBC and to evaluate the appearance of the commissures and degree of calcification. The outcome is also predicted by clinical factors including age, NYHA class, and presence or absence of atrial fibrillation. Older patients with lower gradients (<10 mm Hg) will not have a good outcome as patients with higher gradients, probably because of presence of other problems that cause symptoms, including LV diastolic dysfunction and LA noncompliance. PMBC should be performed only by experienced Heart team, with surgical backup for potential complications. Reported long-term follow-up shown 70% to 80% of patients are free of recurrent symptoms after PMBC at 10 years, and 30% to 40% are free of recurrent symptoms at 20 years.

Percutaneous Mitral Balloon Valvotomy (PMBV)[edit]

|CitationClass=journal }}</ref>

Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)
(Class I, Level of Evidence B):

PMC is recommended in symptomatic patients with favourable characteristics for PMC

(Class I, Level of Evidence C):

PMC is recommended in any symptomatic patients who are high risk for surgeryMitral valve surgery is recommended in symptomatic patients who are not appropriate for PMC in the absence of futility

(Class IIa, Level of Evidence C):

PMC should be considered as initial treatment in symptomatic patients with favourable clinical and anatomical characteristics for PMC
PMC should be considered in asymptomatic patients with suboptimal valve anatomy favourable clinical characteristics for PMC and:

The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{#invoke:Citation/CS1|citation CitationClass=journal

}}</ref>


Abbreviations: PMC: Percutaneous mitral commissurotomy; AF: Atrial fibrillation; LA: Left atrium; MVA:Mitral valve area ;

 
 
 
Management of clinically significant rheumatic mitral stenosis (MVA ≤ 1.5 cm2)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NO
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High risk of embolism or hemodynamic decompensation
 
 
 
 
Contraindication to PMC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
NO
 
 
NO
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PMC if favourable characteristics for PMC or contraindication for surgery
 
Exercise test
 
 
Contraindication or high risk for surgery
 
 
Surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptoms
 
 
 
Yes
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NO
 
Yes
 
 
PMC
 
 
Favourable anatomical characteristics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow-up
 
Contraindication to or unfavourable characteristics for PMC
 
 
 
 
 
 
NO
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NO
 
Yes
 
 
 
 
Surgery
 
 
PMC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PMC
 
Surgery
 
 
 
 
 
 
 
 
 
 
 
 

Abbreviations: PMC: Percutaneous mitral commissurotomy; MVA:Mitral valve area

The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{#invoke:Citation/CS1|citation CitationClass=journal

}}</ref>

Indications[edit]

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  • The new onset of atrial fibrillation (AF) may indicate proceeding with PMBC in the asymptomatic patient with a favorable valve morphology as follow:<ref name="pmid33332150">{{#invoke:Citation/CS1|citation

|CitationClass=journal }}</ref>

  • Lowering a high LA pressure after PMBC might be beneficial in restoring normal sinus rhythm.

Contraindications for percutaneous mitral commissurotomy in rheumatic mitral stenosis[edit]

|CitationClass=journal }}</ref>

Technique[edit]

The interventional cardiologist gains access to the mitral valve by making a puncture in the interatrial septum during cardiac catheterization.

  • Inflation and rapid deflation of a single balloon or a double-balloon opens the stenotic valve. This mechanism is similar to that of surgical commissurotomy.<ref name="pmid8448794">{{#invoke:Citation/CS1|citation

|CitationClass=journal }} </ref>

  • Transvenous transeptal technique is most commonly used with the Inoue balloon system.
  • Fossa ovalis lies usually at 1-7 o’clock but this orientation can be distorted in the presence of mitral stenosis where the interatrial septum becomes more flat, horizontal, and lower.
  • For the femoral vein approach a 70 cm Brockenbrough needle should be used or an 8 Fr Mullins sheath and advanced under fluoroscopic guidance with pressure monitoring.
  • The latter is necessary to monitor for punctures into adjacent structures such as the aorta.
  • Further catheter manipulation may be necessary to direct the catheter into the left ventricle through the mitral valve rather than towards one of the pulmonary veins.
  • The Mullins sheath is exchanged for a solid-core coiled 0.025-inch guidewire over which a 14 Fr dilator is placed.
  • This is exchanged for the Inoue balloon (24-30 mm) which inflates in three stages allowing for balloon self-positioning with the last inflation resulting in commissural splitting.
  • A transthoracic echocardiography should be done to measure the mitral valve area and assess the severity of regurgitation as a complication of the procedure.
  • PMBV should be stopped if adequate valve area has been achieved or if the severity of mitral regurgitation has been increased.

Outcome[edit]

  • Long-term follow-up has been shown an initial good result and free of recurrent symptoms in 70% to 80% of patients after PMBC at 10 years, and 30% to 40% are free of recurrent symptoms at 20 years.<ref name="pmid11447412">{{#invoke:Citation/CS1|citation

|CitationClass=journal }}</ref>

Complications[edit]

|CitationClass=journal }}</ref>

  • Mortality (0-0.5%)<ref name="pmid17253604">{{#invoke:Citation/CS1|citation

|CitationClass=journal }}</ref>

References[edit]

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