Percutaneous mitral balloon commissurotomy
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)
- 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. [1]
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): | |
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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[3] |
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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[3] |
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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.
- 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.[4][5]
- 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.
- The new onset of atrial fibrillation (AF) may indicate proceeding with PMBC in the asymptomatic patient with a favorable valve morphology as follow:[6]
- 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[7]
- 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.[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
- Cerebral accident (0.5-1%)
- Mitral regurgitation requiring surgery (1.6-3%)[5]
- Mortality (0-0.5%)[10]
References
- ↑ 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). - ↑ 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). - ↑ 3.0 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). - ↑ 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.
- ↑ 5.0 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.
- ↑ 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). - ↑ 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.
- ↑ Inoue K, Feldman T (1993). "Percutaneous transvenous mitral commissurotomy using the Inoue balloon catheter". Cathet Cardiovasc Diagn. 28 (2): 119–25. PMID 8448794.
- ↑ 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.
- ↑ Fawzy ME (February 2007). "Percutaneous mitral balloon valvotomy". Catheter Cardiovasc Interv. 69 (2): 313–21. doi:10.1002/ccd.21008. PMID 17253604.