Percutaneous mitral balloon commissurotomy
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)
- 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. [6]
| 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): | |
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❑ PMC is recommended in symptomatic patients with favourable characteristics for PMC | |
| (Class I, Level of Evidence C): | |
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❑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): | |
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❑PMC should be considered as initial treatment in symptomatic patients with favourable clinical and anatomical characteristics for PMC
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| The above table adopted from 2021 ESC Guideline[7] |
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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[7] |
|---|
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.
- 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.[8]
- 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.
- 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.
Contraindications for percutaneous mitral commissurotomy in rheumatic mitral stenosis
- MVA >1.5 cm²
- Left atrial thrombus
- More than mild mitral regurgitation
- Severe or bi-commissural calcification
- Absence of commissural fusion
- Severe concomitant aortic valve disease, or severe combined tricuspid stenosis and tricuspid regurgitation requiring surgery
- Concomitant coronary artery disease requiring bypass surgery
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.[9]
- 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
- Complications are usually less than 5% of cases 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 The indication for invasive treatment with either a mitral valve replacement or valvuloplasty is NYHA functional class III or IV symptoms.
- PMBV versus open and closed surgical commissurotomy
Some trials showed that the outcome after PMBV is better than the surgical commissurotomy approach.[10] 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.[11]
- PMBV versus mitral valve replacement combined with tricuspid valve repair
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.[12]
- 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
References
- ↑ Carroll JD, Feldman T (1993). "Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis". JAMA. 270 (14): 1731–6. PMID 8411505.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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). - ↑ 7.0 7.1 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). - ↑ 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.
- ↑ Inoue K, Feldman T (1993). "Percutaneous transvenous mitral commissurotomy using the Inoue balloon catheter". Cathet Cardiovasc Diagn. 28 (2): 119–25. PMID 8448794.
- ↑ 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.
- ↑ 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.
- ↑ 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.