Percutaneous mitral balloon valvotomy for mitral stenosis
DR RAMESHWAR BISHNOI
CYGNUS SUPERSPECIALITY HOSPITAL
INTRODUCTION: Mitral stenosis (MS) is a common valvular disease in developing countries. Most common etiology in these countries are rheumatic . Untreated progressive disease can lead to significant symptoms (eg, dyspnea and fatigue) and serious complications (eg, pulmonary edema, systemic embolism, and pulmonary hypertension). Symptoms usually appearing 10 to 20 years after the episode of acute rheumatic fever.
Medical therapy can relieve symptoms but it does not affect the obstruction to flow. Earlier surgical commissurotomy and open valvuloplasty were the only methods by which MS corrected for many years . Percutaneous mitral balloon valvotomy (PMBV) by Inoue in 1984 and Lock in 1985 for the treatment of selected patients with MS has revolutionized the treatment of this disorder.
Patients to be selected for percutaneous mitral balloon valvotomy (PMBV) on the basis of hemodynamic and echocardiographic criteria
When intervention is warranted, the 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines generally recommended that PMBV is preferred over 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 .
Echocardiography — Echocardiography is an essential screening procedure in patients who appear to be candidates for PMBV [1,2-4].
Valvular anatomy — The extent of valvular and subvalvular deformity should be evaluated and the likelihood of a successful result after PMBV should be assessed by the Wilkins score, which is calculated from the sum of grades of 0 to 4 for each of the four factors :
- The degree of leaflet rigidity(mobility)
- The severity of leaflet thickening
- The amount of leaflet calcification
- The extent of subvalvular thickening
The maximum score is 16; higher scores indicate more severe anatomic disease and a lower likelihood of a successful balloon valvotomy with durability.
TECHNIQUE — During cardiac catheterization, a transseptal puncture is used to gain access to the mitral valve from the left atrium. A deflated balloon is advanced from the venous circulation to the right atrium, across the interatrial septum to the left atrium, and across the stenotic mitral valve. Inflation and rapid deflation of the balloon opens the stenotic valve via separation of the fused commissures .
In addition to direct measurement of the transmitral pressure gradient, transthoracic echocardiography with measurement of mitral valve area and assessment of mitral regurgitant severity after each balloon dilation is the standard approach for monitoring percutaneous mitral balloon valvotomy (PMBV)
The procedure is stopped when an adequate valve area has been achieved or if there is a significant increase in mitral regurgitant severity.
Preference for PMBV — The salutary long-term results, lower costs, and the avoidance of thoracotomy make percutaneous mitral balloon valvotomy (PMBV) the treatment of choice in patients with mitral stenosis (MS) who have the following features :
- Severe MS
- Pliable, noncalcified mitral valves
- Symptoms (or, if asymptomatic, very severe MS)
- The absence of left atrial thrombus
- The absence of moderate to severe mitral regurgitation
Case history-27 yr old female patient admitted with complaint of shortness of breath despite of medical therapy.On examination she was having diastolic murmur at mitral area. Her echocardiography showed severe mitral valve stenosis(Image 1) and LA enlargement with no evidence of thrombus in LA/LAA.Her ECG was having sinus rhythm. Patient’s echocardiographic Wilkins score for PTMC was favourable .
Sizing of balloon according to patient height was 25mm(24-26mm).After septal puncture LA wire passed (image 1) and over the LA wire PTMC balloon crossed septum .This PTMC balloon with the help of Shaper passed in left ventricle. After inflation of distal part ,balloon put across mitral valve and complete inflation done (Image 3).Significant resolution of hemodynamic parameters occurred post procedure as well as mitral valve area increased by >50% of baseline. Patient is symptomatically better on follow up