Percutaneous mitral commissurotomy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Joanna J. Wykrzykowska, M.D.

Percutaneous Mitral Commissurotomy

Patient selection

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

Technique

1. Transvenous transeptal technique is most commonly used with the Inoue balloon system
2. 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
3. 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
4. The latter is necessary to monitor for puncture into adjacent structures such as aorta
5. 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
6. Mullins sheath is exchanged for a solid-core coiled 0.025 inch guidewire over which a 14 Fr dilator is placed
7. 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

Outcomes

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

Complications

1. Usually less than 5% with low mortality
2. Failure to puncture the interatrial septum is the most common reason for aborted procedure
3. Most common complication is development of severe mitral regurgitation

References

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