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| __NOTOC__
| | #Redirect [[Percutaneous mitral balloon commissurotomy]] |
| {{SI}}
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| {{CMG}}; Joanna J. Wykrzykowska, M.D.
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| ==Percutaneous Mitral Commissurotomy==
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| ====Patient selection====
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| #Mitral stenosis due to rheumatic disease is becoming less common in the US but is very prevalent worldwide
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| #Symptoms of shortness of breath and valve area or less than 1.5 cm2 are indications for commissurotomy
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| #Unlike with the surgical approach, elevated pulmonary pressures or depressued LV function are not contraindications
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| #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
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| #Contraindications include presence of left atrial appendage clot, moderate to severe mitral regurgitation or other indications for open heart surgery
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| ====Technique====
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| #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
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| #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
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| #The latter is necessary to monitor for puncture into adjacent structures such as aorta
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| #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
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| #Mullins sheath is exchanged for a solid-core coiled 0.025 inch guidewire over which a 14 Fr dilator is placed
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| #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 commisural splitting
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| ====Outcomes====
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| #Results of the commisurotomy should be assessed with hemodynamics and echocardiography
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| #If second inflation is needed mitral regurgitation should be assessed
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| #In general increasing valve area to greater than 1 cm2/m2 is an acceptable result
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| #Usually the valve area doubles and the pulmonary pressures degrease immediately
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| #5 year survival is in the 90% range
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| ====Complications====
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| #Usually less than 5% with low mortality
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| #Failure to puncture the interatrial septum is the most common reason for aborted procedure
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| #Most common complication is development of severe mitral regurgitation
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| ==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>==
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| ===Rheumatic 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>===
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| {|class="wikitable"
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| |-
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Percutaneous or surgical MV commissurotomy is indicated when anatomically possible for treatment of severe [[Mitral stenosis|MS]], when clinically indicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |}
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| ==Sources==
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| *2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease <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>
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| ==References==
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| {{reflist|2}}
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| {{Electrocardiography}}
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| {{Circulatory system pathology}}
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| [[Category:Cardiology]]
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| [[Category:Valvular heart disease]]
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| [[Category:Cardiac surgery]]
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| [[Category:Surgery]]
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