Percutaneous mitral balloon commissurotomy: Difference between revisions

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__NOTOC__
__NOTOC__
{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]
{{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}}
{{SK}} Balloon mitral valvuloplasty, PMBC, percutaneous mitral balloon valvotomy, percutaneous mitral balloon valvuloplasty, PMBV, mitral valvuloplasty, percutaneous mitral valvuloplasty, PMC, percutaneous mitral commissurotomy


==Overview==
==Overview==
The development of this approach was done by Inoue in 1984 and Lock in 1985 for the treatment of mitral stenosis.<ref name="pmid8411505">{{cite journal| author=Carroll JD, Feldman T| title=Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis. | journal=JAMA | year= 1993 | volume= 270 | issue= 14 | pages= 1731-6 | pmid=8411505 | doi= | pmc= | url= }} </ref><ref name="pmid6700245">{{cite journal| author=Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N| title=Clinical application of transvenous mitral commissurotomy by a new balloon catheter. | journal=J Thorac Cardiovasc Surg | year= 1984 | volume= 87 | issue= 3 | pages= 394-402 | pmid=6700245 | doi= | pmc= | url= }} </ref> For a long time, surgical commissurotomy and open valve replacement were the only methods by which mitral stenosis could be corrected.<ref name="pmid4069160">{{cite journal| author=Lock JE, Khalilullah M, Shrivastava S, Bahl V, Keane JF| title=Percutaneous catheter commissurotomy in rheumatic mitral stenosis. | journal=N Engl J Med | year= 1985 | volume= 313 | issue= 24 | pages= 1515-8 | pmid=4069160 | doi=10.1056/NEJM198512123132405 | pmc= | url= }} </ref> 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.<ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172  }} </ref><ref name="pmid9669264">{{cite journal| author=Lokhandwala YY, Banker D, Vora AM, Kerkar PG, Deshpande JR, Kulkarni HL et al.| title=Emergent balloon mitral valvotomy in patients presenting with cardiac arrest, cardiogenic shock or refractory pulmonary edema. | journal=J Am Coll Cardiol | year= 1998 | volume= 32 | issue= 1 | pages= 154-8 | pmid=9669264 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9669264  }} </ref> There is improvement in the mortality rates for mitral stenosis by intervention by percutaneous mitral balloon valvotomy or surgery.
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]]) ==


=== Indications ===
*[[PMBV]] is currently the standard of care in [[patients]] with severe [[rheumatic]] [[mitral stenosis]] and favorable [[valve]] [[anatomy]].
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.<ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172  }} </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>


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.
== 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> ==


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


* Thickening confined to valve tips.
{| class="wikitable"
* Good mobility of Anterior mitral valve leaflet.
|-
* Little chordal involvement.
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
* No more than trivial [[mitral regurgitation]].
|-
* No left atrial [[thrombus]].
| 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'']]).
* No commissural calcification.
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'']]).
 
|}
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 thickening.
*Subvalvar thickening.
*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.
 
===Contraindications===
* Mitral regurgitation +2
* Left atrium [[thrombus]]
* Severe calcifications of the mitral valve
 
=== 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>


* 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.
{| class="wikitable"
 
=== 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.<ref name="pmid1918709">{{cite journal| author=Patel JJ, Shama D, Mitha AS, Blyth D, Hassen F, Le Roux BT et al.| title=Balloon valvuloplasty versus closed commissurotomy for pliable mitral stenosis: a prospective hemodynamic study. | journal=J Am Coll Cardiol | year= 1991 | volume= 18 | issue= 5 | pages= 1318-22 | pmid=1918709 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1918709  }} </ref> 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.<ref name="pmid2013139">{{cite journal| author=Turi ZG, Reyes VP, Raju BS, Raju AR, Kumar DN, Rajagopal P et al.| title=Percutaneous balloon versus surgical closed commissurotomy for mitral stenosis. A prospective, randomized trial. | journal=Circulation | year= 1991 | volume= 83 | issue= 4 | pages= 1179-85 | pmid=2013139 | doi= | pmc= | url= }} </ref>
 
*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]].<ref name="pmid17846312">{{cite journal| author=Song H, Kang DH, Kim JH, Park KM, Song JM, Choi KJ et al.| title=Percutaneous mitral valvuloplasty versus surgical treatment in mitral stenosis with severe tricuspid regurgitation. | journal=Circulation | year= 2007 | volume= 116 | issue= 11 Suppl | pages= I246-50 | pmid=17846312 | doi=10.1161/CIRCULATIONAHA.107.678151 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17846312  }} </ref>
 
==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>==
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Percutaneous mitral balloon commissurotomy is recommended for symptomatic patients with severe [[MS]] (mitral valve area ≤1.5 cm2, stage D) and favorable valve morphology in the absence of left atrial thrombus or moderate-to-severe [[MR]].  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
| 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"
{| class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Percutaneous mitral balloon commissurotomy is reasonable for asymptomatic patients with very severe [[MS]] (mitral valve area ≤1.0 cm2, stage C) and favorable valve morphology in the absence of left atrial thrombus or moderate-to-severe [[MR]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| 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'']]).
|}
|}


{|class="wikitable"
=== 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]]
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Percutaneous mitral balloon commissurotomy may be considered for asymptomatic patients with severe [[MS]] (mitral valve area ≤1.5 cm2, stage C) and valve morphology favorable for percutaneous mitral balloon commissurotomy in the absence of left atrial thrombus or moderate-to-severe [[MR]] who have new onset of [[AF]].  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| 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'']])
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Percutaneous mitral balloon commissurotomy may be considered for symptomatic patients with mitral valve area greater than 1.5 cm2 if there is evidence of hemodynamically significant [[MS]] based on pulmonary artery wedge pressure greater than 25 mm Hg or mean mitral valve gradient greater than 15 mm Hg during exercise.  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Percutaneous mitral balloon commissurotomy may be considered for severely symptomatic patients (NYHA class III to IV) with severe [[MS]] (mitral valve area ≤1.5 cm2, stage D) who have a suboptimal valve anatomy and who are not candidates for surgery or at high risk for surgery. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
|}


==2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=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 |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==


===Percutaneous Mitral Balloon Valvotomy Indications (DO NOT EDIT)<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=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 |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| 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)'''


{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Percutaneous mitral balloon valvotomy]] is effective for symptomatic patients (NYHA functional class II, III, or IV), with moderate or severe [[mitral stenosis]] and valve morphology favorable for [[Percutaneous mitral balloon valvotomy]] in the absence of left atrial [[thrombus]] or moderate to severe [[mitral regurgitation]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|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>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Percutaneous mitral balloon valvotomy]] is effective for asymptomatic patients with moderate or severe [[mitral stenosis]] and valve morphology that is favorable for [[Percutaneous mitral balloon valvotomy]] who have [[pulmonary hypertension]] (pulmonary artery systolic pressure greater than 50 mm Hg at rest or greater than 60 mm Hg with exercise) in the absence of left atrial thrombus or moderate to severe [[mitral regurgitation]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|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>


{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Percutaneous mitral balloon valvotomy]] is not indicated for patients with mild [[mitral stenosis]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|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>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' [[Percutaneous mitral balloon valvotomy]] should not be performed in patients with moderate to severe [[mitral regurgitation]] or left atrial thrombus.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
❑[[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 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>
|-
|}
|}


{|class="wikitable"
 
|-
<span style="font-size:85%">'''Abbreviations:'''
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
|-
'''AF:''' [[Atrial fibrillation]];
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Percutaneous mitral balloon valvotomy]] is reasonable for patients with moderate or severe [[mitral stenosis]] who have a nonpliable calcified valve, are in NYHA functional class III-IV, and are either not candidates for surgery or are at high risk for surgery.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;
</span>
<br>
{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | |  F  | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I  | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W  | | | |K  | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P  | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R  | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}
 
<span style="font-size:85%">'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]
</span>
<br>
 
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm 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>
|-
|}
|}


{|class="wikitable"
=== Indications ===
|-
* 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.
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
* [[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 [[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>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Percutaneous mitral balloon valvotomy]] may be considered for asymptomatic patients with moderate or severe [[mitral stenosis]] and valve morphology favorable for [[Percutaneous mitral balloon valvotomy]] who have new onset of [[atrial fibrillation]] in the absence of left atrial thrombus or moderate to severe [[mitral regurgitation]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
*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.
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Percutaneous mitral balloon valvotomy]] may be considered for symptomatic patients (NYHA functional class II, III, or IV) with [[mitral valve]] area greater than 1.5 cm2 if there is evidence of hemodynamically significant [[mitral stenosis]] based on pulmonary artery systolic pressure greater than 60 mm Hg, pulmonary artery wedge pressure of 25 mm Hg or more, or mean [[mitral valve]] gradient greater than 15 mm Hg during exercise.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
 
|-
 
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Percutaneous mitral balloon valvotomy]] may be considered as an alternative to surgery for patients with moderate or severe [[mitral stenosis]] who have a nonpliable calcified valve and are in NYHA functional class III-IV.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
*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]] thickening
*[[Subvalvar thickening]]
*[[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.
 
* 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]]===
* 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>
*More than moderate [[mitral regurgitation]]
*Massive or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe  organic [[tricuspid stenosis]] or severe functional [[tricuspid regurgitation]]  with enlarged annulus
* Severe 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.<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 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.<ref name="pmid11447412">{{cite journal |vauthors=Aviles RJ, Nishimura RA, Pellikka PA, Andreen KM, Holmes DR |title=Utility of stress Doppler echocardiography in patients undergoing percutaneous mitral balloon valvotomy |journal=J Am Soc Echocardiogr |volume=14 |issue=7 |pages=676–81 |date=July 2001 |pmid=11447412 |doi=10.1067/mje.2001.112585 |url=}}</ref>
 
====Complications====
* [[Cerebral accident]] (0.5-1%)
*  [[Mitral regurgitation]] requiring [[surgery]] (1.6-3%)<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>
* [[Mortality]] (0-0.5%)<ref name="pmid17253604">{{cite journal |vauthors=Fawzy ME |title=Percutaneous mitral balloon valvotomy |journal=Catheter Cardiovasc Interv |volume=69 |issue=2 |pages=313–21 |date=February 2007 |pmid=17253604 |doi=10.1002/ccd.21008 |url=}}</ref>


==References==
==References==

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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