Percutaneous mitral balloon commissurotomy: Difference between revisions

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__NOTOC__
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{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; Joanna J. Wykrzykowska, M.D.
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; Joanna J. Wykrzykowska, M.D.
{{Mitral stenosis}}
{{Mitral stenosis}}


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==Overview==
==Overview==
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]] in the absence of [[left atrium thrombus]]. [[PMBC]] is performed by addressing one or more [[balloon catheters ]] across the [[mitral valve]] and inflating them, thereby splitting the [[commissures]]. [[Favorable]] [[valve morphology]] consists of mobile and relatively thin [[valve leaflets]], without [[calcium]] deposit, in the absence of significant [[subvalvular fusion]]. 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 as good an [[outcome]] as [[patients]] with higher [[ gradients]], probably because ofpresence of other problems that cause [[symptoms]], including [[LV diastolic dysfunction]] and [[LA]] noncompliance. [[PMBC ]] should be performed only by experienced Heat team, with immediate availability of surgical backup for potential [[complications]]. Reported lomg-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.
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]]) ==
== [[Percutaneous Mitral Balloon Valvotomy]] ([[PMBV]]) ==
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*[[PMBV]] is currently the standard of care in [[patients]] with severe [[rheumatic]] [[mitral stenosis]] and favorable [[valve]] [[anatomy]].
*[[PMBV]] is currently the standard of care in [[patients]] with severe [[rheumatic]] [[mitral stenosis]] and favorable [[valve]] [[anatomy]].
* [[PMBV]] is preferred to open [[surgery]] in [[symptomatic]] [[moderate]] to severe [[MS]], [[MVA]]≤ 1.5 cm², [[NYHA]] [[functional class]] 2-4, favorable [[valve anatomy]], lack of [[commisural calcification]], no or mild [[mitral regurgitation]], and no [[left atrium]] [[thrombosis]]. <ref name="pmid33889711">{{cite journal |vauthors=Abu Rmilah AA, Tahboub MA, Alkurashi AK, Jaber SA, Yagmour AH, Al-Souri D, Lewis BR, Nkomo VT, Erwin PJ, Reeder GS |title=Efficacy and safety of percutaneous mitral balloon valvotomy in patients with mitral stenosis: A systematic review and meta-analysis |journal=Int J Cardiol Heart Vasc |volume=33 |issue= |pages=100765 |date=April 2021 |pmid=33889711 |pmc=8050729 |doi=10.1016/j.ijcha.2021.100765 |url=}}</ref>
* [[PMBV]] is preferred to open [[surgery]] in [[symptomatic]] [[moderate]] to severe [[MS]], [[MVA]]≤ 1.5 cm², [[NYHA]] [[functional class]] 2-4, favorable [[valve anatomy]], lack of [[commisural calcification]], no or mild [[mitral regurgitation]], and no [[left atrium]] [[thrombosis]]. <ref name="pmid33889711">{{cite journal |vauthors=Abu Rmilah AA, Tahboub MA, Alkurashi AK, Jaber SA, Yagmour AH, Al-Souri D, Lewis BR, Nkomo VT, Erwin PJ, Reeder GS |title=Efficacy and safety of percutaneous mitral balloon valvotomy in patients with mitral stenosis: A systematic review and meta-analysis |journal=Int J Cardiol Heart Vasc |volume=33 |issue= |pages=100765 |date=April 2021 |pmid=33889711 |pmc=8050729 |doi=10.1016/j.ijcha.2021.100765 |url=}}</ref>
== 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines<ref name="pmid333321502">{{cite journal| author=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F | display-authors=etal| title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2021 | volume= 143 | issue= 5 | pages= e72-e227 | pmid=33332150 | doi=10.1161/CIR.0000000000000923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332150  }}</ref> ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1.   In symptomatic patients (NYHA class II, III, or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) and favorable valve morphology with less than moderate (2+) MR* in the absence of LA thrombus, PMBC is recommended if it can be performed at a Comprehensive Valve Center ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: A'']]).
2.   In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who 1) are not candidates for PMBC, 2) have failed a previous PMBC, 3) require other cardiac procedures, or 4) do not have access to PMBC, mitral valve surgery (repair, commissurotomy, or valve replacement) is indicated.([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B-NR'']]).
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |3.   In asymptomatic patients with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage C) and favorable valve morphology with less than 2+ MR in the absence of LA thrombus who have elevated pulmonary pressures (pulmonary artery systolic pressure >50 mm Hg), PMBC is reasonable if it can be performed at a Comprehensive Valve Center ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B-NR'']]).
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |4.   In asymptomatic patients with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage C) and favorable valve morphology with less than 2+/ MR* in the absence of LA thrombus who have new onset of AF, PMBC may be considered if it can be performed at a Comprehensive Valve Center([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C-LD'']]).
5.   In symptomatic patients (NYHA class II, III, or IV) with rheumatic MS and an mitral valve area >1.5 cm2, if there is evidence of hemodynamically significant rheumatic MS on the basis of a pulmonary artery wedge pressure >25 mm Hg or a mean mitral valve gradient >15 mm Hg during exercise, PMBC may be considered if it can be performed at a Comprehensive Valve Center.([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C-LD'']]).
6.   In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who have a suboptimal valve anatomy and who are not candidates for surgery or are at high risk for surgery, PMBC may be considered if it can be performed at a Comprehensive Valve Center.([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B-NR'']]).
|}
=== Recommendation for Nonrheumatic Calcific MS ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |1.   In severely symptomatic patients (NYHA class III or IV) with severe MS (mitral valve area ≤1.5 cm2, Stage D) attributable to extensive mitral annular calcification, valve intervention may be considered only after discussion of the high procedural risk and the individual patient’s preferences and values.([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C-LD'']])
|}


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{| style="cellpadding=0; cellspacing= 0; width: 800px;"
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|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with favourable clinical and anatomical characteristics for [[PMC]] <br>
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with favourable clinical and anatomical characteristics for [[PMC]] <br>
❑[[PMC]] should be considered in asymptomatic [[patients]] with suboptimal [[valve anatomy]] favourable clinicalcharacteristicsc for [[PMC]] and:
❑[[PMC]] should be considered in asymptomatic [[patients]] with suboptimal [[valve anatomy]] favourable clinical characteristics for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]])<br>
* High risk of [[hemodynamic]] decompensation ([[systolic]] [[pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]])<br>
|
|
|}
|}
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=== Indications ===
=== Indications ===
* Making decision on the type of treatment ([[PMC]] or [[surgery]]), as well as its timing, is based on [[clinical]] characteristics, [[anatomy]] of [[valve]] and [[subvalvular apparatus]], and local expertise.
* Making decision on the type of treatment ([[PMBV]] or [[surgery]]), as well as its timing, is based on [[clinical]] characteristics, [[anatomy]] of [[valve]] and [[subvalvular apparatus]], and local expertise.
* [[Intervention]] is indicated in [[patients]] with moderate-to-severe [[rheumatic]] [[mitral stenosis]] ([[valve area]] ≤1.5 cm2) in whom [[PMC]] has had a significant impact on its management.
* [[Intervention]] is indicated in [[patients]] with moderate-to-severe [[rheumatic]] [[mitral stenosis]] ([[valve area]] ≤1.5 cm2) in whom [[PMC]] has had a significant impact on its management.
* In [[Western]] countries, the [[incidence]] of [[rheumatic fever]]  and number of [[PMC]] is low. Howerer, over the years [[PBMV]] has been as a mainstream therapy, especially in [[developing countries]] with [[endemic]] [[rheumatic heart disease]].<ref name="pmid24859718">{{cite journal |vauthors=Badheka AO, Shah N, Ghatak A, Patel NJ, Chothani A, Mehta K, Singh V, Patel N, Grover P, Deshmukh A, Panaich SS, Savani GT, Bhalara V, Arora S, Rathod A, Desai H, Kar S, Alfonso C, Palacios IF, Grines C, Schreiber T, Rihal CS, Makkar R, Cohen MG, O'Neill W, de Marchena E |title=Balloon mitral valvuloplasty in the United States: a 13-year perspective |journal=Am J Med |volume=127 |issue=11 |pages=1126.e1–1126.e12 |date=November 2014 |pmid=24859718 |doi=10.1016/j.amjmed.2014.05.015 |url=}}</ref><ref name="pmid25870627">{{cite journal |vauthors=Aslanabadi N, Toufan M, Salehi R, Alizadehasl A, Ghaffari S, Sohrabi B, Separham A, Manafi A, Mehdizadeh MB, Habibzadeh A |title=Mitral regurgitation after percutaneous balloon mitral valvotomy in patients with rheumatic mitral stenosis: a single-center study |journal=J Tehran Heart Cent |volume=9 |issue=3 |pages=109–14 |date=2014 |pmid=25870627 |pmc=4393832 |doi= |url=}}</ref>
* In [[Western]] countries, the [[incidence]] of [[rheumatic fever]]  and number of [[PMBV]] is low. Howerer, over the years [[PBMV]] has been as a mainstay therapy, especially in [[developing countries]] with [[endemic]] [[rheumatic heart disease]].<ref name="pmid24859718">{{cite journal |vauthors=Badheka AO, Shah N, Ghatak A, Patel NJ, Chothani A, Mehta K, Singh V, Patel N, Grover P, Deshmukh A, Panaich SS, Savani GT, Bhalara V, Arora S, Rathod A, Desai H, Kar S, Alfonso C, Palacios IF, Grines C, Schreiber T, Rihal CS, Makkar R, Cohen MG, O'Neill W, de Marchena E |title=Balloon mitral valvuloplasty in the United States: a 13-year perspective |journal=Am J Med |volume=127 |issue=11 |pages=1126.e1–1126.e12 |date=November 2014 |pmid=24859718 |doi=10.1016/j.amjmed.2014.05.015 |url=}}</ref><ref name="pmid25870627">{{cite journal |vauthors=Aslanabadi N, Toufan M, Salehi R, Alizadehasl A, Ghaffari S, Sohrabi B, Separham A, Manafi A, Mehdizadeh MB, Habibzadeh A |title=Mitral regurgitation after percutaneous balloon mitral valvotomy in patients with rheumatic mitral stenosis: a single-center study |journal=J Tehran Heart Cent |volume=9 |issue=3 |pages=109–14 |date=2014 |pmid=25870627 |pmc=4393832 |doi= |url=}}</ref>
*Indications for [[PMBV]] have expanded to involve less suitable conditions including [[suboptimal valve anatomy]] and also [[palliative]] therapy in [[elderly]] [[patients]] who are poor [[surgical]] candidates.  
*Indications for [[PMBV]] have expanded to involve less suitable conditions including [[suboptimal valve anatomy]] and also [[palliative]] therapy in [[elderly]] [[patients]] who are poor [[surgical]] candidates.  
* The cost of intervention is lower than [[mitral valve replacement]] surgery.
* The cost of intervention is lower than [[mitral valve replacement]] surgery.




 
*To determine which [[patients]] would benefit from [[Percutaneous mitral balloon valvotomy]] ([[PMBV]]), a scoring system has been developed. Scoring is based on four [[echocardiogram|echocardiographic]] criteria:
*To determine which patients would benefit from [[Percutaneous mitral balloon valvotomy]] (PMBV), a scoring system has been developed. Scoring is based on four [[echocardiogram|echocardiographic]] criteria:
*[[Leaflet]] mobility
*[[Leaflet]] mobility
*[[Leaflet]] thickening
*[[Leaflet]] thickening
*[[Subvalvar thickening]]
*[[Subvalvar thickening]]
*[[Calcification]]
*[[Calcification]]
Individuals with a score of &ge; 8 tended to have suboptimal results. Superb results with valvotomy are seen in individuals with a crisp opening snap, score < 8, and no [[calcium]] in the commissures.
*Individuals with a score of &ge; 8 tended to have suboptimal results. Superb results with valvotomy are seen in individuals with a crisp opening snap, score < 8, and no [[calcium]] in the commissures.
 
* 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">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e72–e227 |date=February 2021 |pmid=33332150 |doi=10.1161/CIR.0000000000000923 |url=}}</ref>
:*  [[AF]] may be indicative of [[symptom]] onset, and progressive [[left atrium]] damage
:* [[AF]] increases the risk of [[thromboembolic]] events in [[patients]] with [[rheumatic]] [[mitral stenosis]].
:*  A shortened [[diastolic filling]] interval with [[AF]] and a rapid [[ventricular]] response further increase [[LV]] pressure.
:*  The presence of [[AF]] is associated with worse [[outcomes]] in [[patients]] with [[rheumatic]] [[mitral stenosis]] and with suboptimal results after [[PMBC]].
 
* Lowering a high [[LA]] pressure after [[PMBC]] might be beneficial in restoring normal [[sinus rhythm]].


===Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]===
===Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]===
*[[MVA]] >1.5 cm²
* Persistent [[Left atrial]] or [[left atrial appendage]] [[thrombus]]<ref name="pmid19106383">{{cite journal |vauthors=Nobuyoshi M, Arita T, Shirai S, Hamasaki N, Yokoi H, Iwabuchi M, Yasumoto H, Nosaka H |title=Percutaneous balloon mitral valvuloplasty: a review |journal=Circulation |volume=119 |issue=8 |pages=e211–9 |date=March 2009 |pmid=19106383 |doi=10.1161/CIRCULATIONAHA.108.792952 |url=}}</ref>
*[[Left atrial]] [[thrombus]]
*More than moderate [[mitral regurgitation]]
*More than mild [[mitral regurgitation]]
*Massive or bi-commissural [[calcification]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Severe concomitant [[aortic valve]] disease, or severe organic [[tricuspid stenosis]] or severe functional [[tricuspid regurgitation]] with enlarged annulus
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]
* Severe concomitant [[coronary artery disease ]] requiring [[bypass surgery]]


=== Technique ===
=== Technique ===


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">{{cite journal| author=Inoue K, Feldman T| title=Percutaneous transvenous mitral commissurotomy using the Inoue balloon catheter. | journal=Cathet Cardiovasc Diagn | year= 1993 | volume= 28 | issue= 2 | pages= 119-25 | pmid=8448794 | doi= | pmc= | url= }} </ref>
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">{{cite journal| author=Inoue K, Feldman T| title=Percutaneous transvenous mitral commissurotomy using the Inoue balloon catheter. | journal=Cathet Cardiovasc Diagn | year= 1993 | volume= 28 | issue= 2 | pages= 119-25 | pmid=8448794 | doi= | pmc= | url= }} </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 puncture into adjacent structures such as 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.
* [[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 ===
=== Outcome ===

Latest revision as of 03:46, 7 December 2022

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

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)

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[2]

Class I
1.   In symptomatic patients (NYHA class II, III, or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) and favorable valve morphology with less than moderate (2+) MR* in the absence of LA thrombus, PMBC is recommended if it can be performed at a Comprehensive Valve Center (Level of Evidence: A).

2.   In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who 1) are not candidates for PMBC, 2) have failed a previous PMBC, 3) require other cardiac procedures, or 4) do not have access to PMBC, mitral valve surgery (repair, commissurotomy, or valve replacement) is indicated.(Level of Evidence: B-NR).


Class IIa
3.   In asymptomatic patients with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage C) and favorable valve morphology with less than 2+ MR in the absence of LA thrombus who have elevated pulmonary pressures (pulmonary artery systolic pressure >50 mm Hg), PMBC is reasonable if it can be performed at a Comprehensive Valve Center (Level of Evidence: B-NR).
Class IIb
4.   In asymptomatic patients with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage C) and favorable valve morphology with less than 2+/ MR* in the absence of LA thrombus who have new onset of AF, PMBC may be considered if it can be performed at a Comprehensive Valve Center(Level of Evidence: C-LD).

5.   In symptomatic patients (NYHA class II, III, or IV) with rheumatic MS and an mitral valve area >1.5 cm2, if there is evidence of hemodynamically significant rheumatic MS on the basis of a pulmonary artery wedge pressure >25 mm Hg or a mean mitral valve gradient >15 mm Hg during exercise, PMBC may be considered if it can be performed at a Comprehensive Valve Center.(Level of Evidence: C-LD). 6.   In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who have a suboptimal valve anatomy and who are not candidates for surgery or are at high risk for surgery, PMBC may be considered if it can be performed at a Comprehensive Valve Center.(Level of Evidence: B-NR).

Recommendation for Nonrheumatic Calcific MS

Class IIb
1.   In severely symptomatic patients (NYHA class III or IV) with severe MS (mitral valve area ≤1.5 cm2, Stage D) attributable to extensive mitral annular calcification, valve intervention may be considered only after discussion of the high procedural risk and the individual patient’s preferences and values.(Level of Evidence: C-LD)


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 surgery ❑Mitral 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[3]


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[3]

Indications



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

Contraindications for percutaneous mitral commissurotomy in rheumatic mitral stenosis

Technique

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.[8]
  • 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

  • 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.[9]

Complications

References

  1. ↑ Abu Rmilah AA, Tahboub MA, Alkurashi AK, Jaber SA, Yagmour AH, Al-Souri D, Lewis BR, Nkomo VT, Erwin PJ, Reeder GS (April 2021). "Efficacy and safety of percutaneous mitral balloon valvotomy in patients with mitral stenosis: A systematic review and meta-analysis". Int J Cardiol Heart Vasc. 33: 100765. doi:10.1016/j.ijcha.2021.100765. PMC 8050729 Check |pmc= value (help). PMID 33889711 Check |pmid= value (help).
  2. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).
  3. ↑ 3.0 3.1 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
  4. ↑ Badheka AO, Shah N, Ghatak A, Patel NJ, Chothani A, Mehta K, Singh V, Patel N, Grover P, Deshmukh A, Panaich SS, Savani GT, Bhalara V, Arora S, Rathod A, Desai H, Kar S, Alfonso C, Palacios IF, Grines C, Schreiber T, Rihal CS, Makkar R, Cohen MG, O'Neill W, de Marchena E (November 2014). "Balloon mitral valvuloplasty in the United States: a 13-year perspective". Am J Med. 127 (11): 1126.e1–1126.e12. doi:10.1016/j.amjmed.2014.05.015. PMID 24859718.
  5. ↑ 5.0 5.1 Aslanabadi N, Toufan M, Salehi R, Alizadehasl A, Ghaffari S, Sohrabi B, Separham A, Manafi A, Mehdizadeh MB, Habibzadeh A (2014). "Mitral regurgitation after percutaneous balloon mitral valvotomy in patients with rheumatic mitral stenosis: a single-center study". J Tehran Heart Cent. 9 (3): 109–14. PMC 4393832. PMID 25870627.
  6. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).
  7. ↑ Nobuyoshi M, Arita T, Shirai S, Hamasaki N, Yokoi H, Iwabuchi M, Yasumoto H, Nosaka H (March 2009). "Percutaneous balloon mitral valvuloplasty: a review". Circulation. 119 (8): e211–9. doi:10.1161/CIRCULATIONAHA.108.792952. PMID 19106383.
  8. ↑ Inoue K, Feldman T (1993). "Percutaneous transvenous mitral commissurotomy using the Inoue balloon catheter". Cathet Cardiovasc Diagn. 28 (2): 119–25. PMID 8448794.
  9. ↑ Aviles RJ, Nishimura RA, Pellikka PA, Andreen KM, Holmes DR (July 2001). "Utility of stress Doppler echocardiography in patients undergoing percutaneous mitral balloon valvotomy". J Am Soc Echocardiogr. 14 (7): 676–81. doi:10.1067/mje.2001.112585. PMID 11447412.
  10. ↑ Fawzy ME (February 2007). "Percutaneous mitral balloon valvotomy". Catheter Cardiovasc Interv. 69 (2): 313–21. doi:10.1002/ccd.21008. PMID 17253604.

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