Percutaneous mitral balloon commissurotomy: Difference between revisions

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== Percutaneous Mitral Balloon Valvotomy (PMBV) ==
== Percutaneous Mitral Balloon Valvotomy (PMBV) ==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[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]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] <br>
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* 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>
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=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 |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}
<span style="font-size:85%">'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;
</span>
<br>


=== Indications ===
=== Indications ===

Revision as of 05:27, 3 June 2022

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]; 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

Overview

The development of this approach was done by Inoue in 1984 and Lock in 1985 for the treatment of mitral stenosis.[1][2] For a long time, surgical commissurotomy and open valve replacement were the only methods by which mitral stenosis could be corrected.[3] PMBV can be performed in chronically symptomatic patients, patients who present emergently with cardiac arrest or pulmonary edema and in asymptomatic patients who plan on childbearing or major noncardiac surgery.[4][5] There is improvement in the mortality rates for mitral stenosis by intervention by percutaneous mitral balloon valvotomy or surgery. Mitral valvuloplasty is a minimally invasive therapeutic procedure to correct an uncomplicated mitral stenosis by dilating the valve using a balloon. Under local anaesthetic, a catheter with a special balloon is passed from the right femoral vein, up the inferior vena cava and into the right atrium. The interatrial septum is punctured and the catheter passed into the left atrium using a "trans-septal technique". The balloon is sub-divided into 3 segments and is dilated in 3 stages. 1st the distal portion (lying in the left ventricle) is inflated and pulled against the valve cusps. Second the proximal portion is dilated, in order to fix the centre segment at the valve orifice. Finally the central section is inflated. This should take no longer than 30 seconds since full inflation obstructs the valve and causes congestion, leading to circulatory arrest and flash pulmonary edema.

Percutaneous Mitral Balloon Valvotomy (PMBV)

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 suboptimal anatomy and favourable clinical characteristics for PMC
PMC should be considered in asymptomatic patients with favourable clinical and anatomical characteristicsc for PMC and:

The above table adopted from 2021 ESC Guideline[6]


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

Indications

In asymptomatic patients, intervention is recommended in moderate to severe MS and pulmonary hypertension (pulmonary artery systolic pressure >50 mmHg at rest or >60 mmHg with exercise). When intervention is indicated in patients with rheumatic MS, the 2006 ACC/AHA guidelines recommend that Percutaneous mitral balloon valvotomy (PMBV) is preferred to surgery if the valve morphology is favorable and the patient does not have left atrial thrombus or moderate to severe (3+ to 4+) mitral regurgitation. Valve repair is performed if possible and preferred over valve replacement which has higher perioperative mortality and morbidity. Valve repair includes both open commissurotomy and placement of an annuloplasty ring after direct visualization of the valve.[4]

The decision of whether valvuloplasty is superior to surgery depends on age (<60 favors valvuloplasty), and Cath/ECHO findings (e.g. LVEDP, degree of mobility, thickening and calcification). The average end result for the mitral valve surface area with both strategies is about 2 cm2. Moderate or greater MR (mitral regurgitation) and LA thrombus are contraindications to valvuloplasty.

Mitral stenosis is amenable to percutaneous mitral valvuloplasty if the echocardiography demonstrates :

  • Thickening confined to valve tips.
  • Good mobility of Anterior mitral valve leaflet.
  • Little chordal involvement.
  • No more than trivial mitral regurgitation.
  • No left atrial thrombus.
  • No commissural calcification.

To determine which patients would benefit from Percutaneous mitral balloon valvotomy (PMBV), a scoring system has been developed. Scoring is based on four echocardiographic criteria:

  • Leaflet mobility.
  • Leaflet thickening.
  • Subvalvar thickening.
  • Calcification.

Individuals with a score of ≥ 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.

In summary, PMBC is indicated in the following conditions:

  1. Mitral stenosis due to rheumatic disease is becoming less common in the US but is very prevalent worldwide
  2. Symptoms of shortness of breath and valve area or less than 1.5 cm2 are indications for commissurotomy
  3. Unlike with the surgical approach, elevated pulmonary pressures or depressued LV function are not contraindications
  4. Wilkins score that describes valve anatomy is the best predictor of procedural success: it assigns points for leaflet mobility, valvular and subvulvular thickening and calcification degree (score of < 8 makes the patient a favorable candidate); Thus good quality echocardiogram is essential before qualifying the patient for the procedure
  5. Contraindications include presence of left atrial appendage clot, moderate to severe mitral regurgitation or other indications for open heart surgery

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.[7]

  • 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.

Outcome

  • PMBV versus open and closed surgical commissurotomy

Some trials showed that the outcome after PMBV is better than the surgical commissurotomy approach.[8] Long term outcome studies showed that the mitral valve area was less in closed commissurotomy compared to other approaches, also the rate of restenosis was higher for closed commissurotomy approach.[9]

Some trials showed that the outcome after mitral valve replacement combined with tricuspid valve repair (if the patient has tricuspid regurgitation) is better than PMBV in patients with severe mitral stenosis and severe tricuspid regurgitation.[10]

  • Results of the commisurotomy should be assessed with hemodynamics and echocardiography
  • If second inflation is needed mitral regurgitation should be assessed
  • In general increasing valve area to greater than 1 cm2/m2 is an acceptable result
  • Usually the valve area doubles and the pulmonary pressures degrease immediately
  • 5 year survival is in the 90% range

Complications

  • Usually less than 5% with low mortality
  • Failure to puncture the interatrial septum is the most common reason for aborted procedure
  • Most common complication is development of severe mitral regurgitation
 
 
 
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[6]

References

  1. Carroll JD, Feldman T (1993). "Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis". JAMA. 270 (14): 1731–6. PMID 8411505.
  2. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N (1984). "Clinical application of transvenous mitral commissurotomy by a new balloon catheter". J Thorac Cardiovasc Surg. 87 (3): 394–402. PMID 6700245.
  3. Lock JE, Khalilullah M, Shrivastava S, Bahl V, Keane JF (1985). "Percutaneous catheter commissurotomy in rheumatic mitral stenosis". N Engl J Med. 313 (24): 1515–8. doi:10.1056/NEJM198512123132405. PMID 4069160.
  4. 4.0 4.1 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
  5. Lokhandwala YY, Banker D, Vora AM, Kerkar PG, Deshpande JR, Kulkarni HL; et al. (1998). "Emergent balloon mitral valvotomy in patients presenting with cardiac arrest, cardiogenic shock or refractory pulmonary edema". J Am Coll Cardiol. 32 (1): 154–8. PMID 9669264.
  6. 6.0 6.1 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).
  7. Inoue K, Feldman T (1993). "Percutaneous transvenous mitral commissurotomy using the Inoue balloon catheter". Cathet Cardiovasc Diagn. 28 (2): 119–25. PMID 8448794.
  8. Patel JJ, Shama D, Mitha AS, Blyth D, Hassen F, Le Roux BT; et al. (1991). "Balloon valvuloplasty versus closed commissurotomy for pliable mitral stenosis: a prospective hemodynamic study". J Am Coll Cardiol. 18 (5): 1318–22. PMID 1918709.
  9. Turi ZG, Reyes VP, Raju BS, Raju AR, Kumar DN, Rajagopal P; et al. (1991). "Percutaneous balloon versus surgical closed commissurotomy for mitral stenosis. A prospective, randomized trial". Circulation. 83 (4): 1179–85. PMID 2013139.
  10. Song H, Kang DH, Kim JH, Park KM, Song JM, Choi KJ; et al. (2007). "Percutaneous mitral valvuloplasty versus surgical treatment in mitral stenosis with severe tricuspid regurgitation". Circulation. 116 (11 Suppl): I246–50. doi:10.1161/CIRCULATIONAHA.107.678151. PMID 17846312.

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