Pitfalls and tips in inoue balloon mitral commissurotomy

Changes in platelet, coagulation, and fibrinolytic activities in mitral stenosis after percutaneous mitral valvotomy: role of hemodynamic changes and systemic inflammation

Markers of platelet activity (P-selectin), fibrinolysis (d-dimer), thrombin activity (prothrombin fragments 1, 2 [PF1,2] and thrombin-antithrombin III complex [TAT]), and inflammation (interleukin 1β [IL-1β]) were measured in 65 patients with mitral stenosis (MS) before and 2 weeks after percutaneous mitral valvotomy (PMV) and in 23 controls. All markers were significantly higher than the control and significantly decreased after PMV. P-selectin change correlated with the changes in left atrial diameter (LAD), pulmonary artery systolic pressure (PASP), and IL-1β. d-Dimer change had similar correlations, LAD, PASP, and IL-1β. The PF1,2 change correlated with the change in IL-1β. The TAT change correlated with the changes in LAD. The IL-1β change correlated with the changes in PASP. In conclusion, MS is associated with heightened inflammatory, platelet, thrombin, and fibrinolytic activities that decrease after PMV. Altered hemodynamics and reduced inflammatory activity might have a possible role in these changes.

Modified technique of Joseph balloon mitral valvuloplasty

Joseph balloon mitral valvuloplasty is a single balloon procedure for severe symptomatic mitral stenosis. We present a case where difficulty was encountered in advancing the balloon catheter across the mitral valve by standard technique. As the left atrium was grossly dilated, every time the balloon was tracked over the 0.035" extra support wire placed in left ventricle, the wire prolapsed into left atrium. A modified method wherein the balloon was maneuvered into left ventricle with the support of 14F long introducer sheath is presented. This step is useful to complete balloon mitral valvuloplasty successfully in subset of patients with giant left atrium.

Percutaneous mitral valvuloplasty using echocardiographic intercommissural diameter as reference for balloon sizing: a randomized controlled trial

BACKGROUND

Percutaneous balloon mitral valvuloplasty is the preferred therapeutic strategy in patients with mitral stenosis, but it has shortcomings in a subset of patients.

HYPOTHESIS

A new method of balloon sizing through echocardiographic measurement of the intercommissural diameter would be safe and effective and lead to better outcomes.

METHODS

Eighty-six mitral-stenosis patients were randomly assigned to undergo balloon mitral valvuloplasty either with height-based balloon reference sizing (HBRS group, n = 43) or with balloons sized by the echocardiographic measurement of intercommissural diameter (EBRS group, n = 43). Postprocedural mitral valve area (MVA) and severity of mitral regurgitation (MR) were assessed via echocardiography and ventriculography. Intention-to-treat approach was applied for the statistical analysis.

RESULTS

Baseline characteristics were not different between the groups. The mean of the estimated balloon reference sizes was significantly higher in the HBRS patients than in the EBRS group (26.4 ± 0.92 mm, 95% confidence interval [CI]: 26.2-26.6 vs 24.5 ± 1.03 mm, 95% CI: 24.2-24.7, respectively; P = 0.006). Final MVAs were significantly larger in the EBRS group (1.5 ± 0.2 cm(2), 95% CI: 1.46-1.59 vs 1.4 ± 0.2 cm(2), 95% CI: 1.35-1.47, respectively; P = 0.01). The occurrence of new or aggravated MR was significantly lower in the EBRS group as assessed both by echocardiography (P = 0.04) and ventriculography (P = 0.05). Mitral regurgitation was aggravated in 13 (29.3%) patients in the HBRS group and in 5 (11.5%) patients in the EBRS group.

CONCLUSIONS

Percutaneous balloon mitral valvuloplasty via the Inoue technique using balloons sized by the echocardiographic measurement of the maximal commissural diameter is an effective and safe method that might lead to an acceptable increase in the MVA and significant decrease in the rate and severity of iatrogenic MR.

New Scores for the Assessment of Mitral Stenosis Using Real-Time Three-Dimensional Echocardiography

Nonsurgical management of patients with symptomatic mitral valve stenosis has been established as the therapeutic modality of choice for two decades. Catheter-based balloon dilation of the stenotic valvular area has been shown, at least, as effective as surgical interventions. Unfavorable results of catheter-based interventions are largely due to unfavorable morphology of the valve apparatus, particularly leaflets calcification and subvalvular apparatus involvement. A mitral valve score has been proposed in Boston, MA, about two decades ago, based on morphologic assessment of mitral valve apparatus by two-dimensional (2D) echocardiography to predict successful balloon dilation of the mitral valve. Several other scores have been developed in the following years in order to more successfully predict balloon dilatation outcome. However, all those scores were based on 2D echocardiography, which is limited by ability to distinguish calcification and subvalvular involvement. The introduction of new matrix-based ultrasound probe has allowed 3D echocardiography (3DE) to provide more detailed morphologic analysis of mitral valve apparatus including calcification and subvalvular involvement. Recently, a new 3DE scoring system has been proposed by our group, which represents an important leap into refinement of the use of echocardiography guiding mitral valve interventions.

Percutaneous mitral balloon valvuloplasty

Almost all mitral stenosis (MS) is rheumatic in etiology. The patient with MS who is symptomatic despite medical therapy should undergo percutaneous mitral balloon valvuloplasty or mitral valvular surgery (commissurotomy or replacement). The choice of procedure is determined by patient preference and the echocardiographic morphologic features of the valvular and subvalvular apparati. With balloon valvuloplasty, the rate of success is > 90%. At institutions where operators are experienced with balloon valvuloplasty and open surgical commissurotomy, their acute and long-term results are comparable. Balloon valvuloplasty occasionally is associated with complications, including death in 0 to 1%, moderate or severe valvular regurgitation in 3 to 5%, and systemic embolization in 1 to 3%.

Percutaneous transvenous mitral commissurotomy versus surgical commissurotomy in the treatment of mitral stenosis

There is no doubt that percutaneous transvenous mitral commissurotomy (PTMC) in experienced centers is associated with a low risk of major complications and yields excellent immediate and long-term outcome. Although previous observational studies on both PTMC and surgical commissurotomy have indicated similar outcome between the two treatment strategies in terms of valve area improvement and risk of major complication (death, thromboembolism and significant resultant mitral regurgitation), it was not until recently that several prospective randomized trials comparing the two procedures and involving > 470 patients with favorable valve characteristics (pliable, noncalcified valve with mild subvalvular disease and no or mild mitral regurgitation), have confirmed that PTMC is indeed just as, if not more, effective as surgical commissurotomy. The late restenosis rate at up to 3-year follow-up appears comparable. Furthermore, PTMC has other additional benefits. It is nontraumatic, may be repeated without additional risk, and has been shown to be an extremely useful and efficacious palliative tool in those with end-stage mitral stenosis or with unfavorable valve anatomy who refuse surgery, and in certain subset of patients at high surgical risk because of medical comorbidities.

Echocardiographic assessment of mitral valve morphology after Percutaneous Transvenous Mitral Commissurotomy (PTMC)

AIMS

PTMC produces significant changes in mitral valve morphology as improvement in leaflets mobility. The determinants of such improvement have not been assessed before.

METHODS AND RESULTS

The study included 291 symptomatic patients with mitral stenosis undergoing PTMC. Post-PTMC subvalvular splitting area was a determinant of post-PTMC excursion in both the anterior (B 0.16, 95% CI 0.03 to 0.30, p < 0.05) and the posterior (B 0.12, 95% CI 0.01 to 0.24, p < 0.05) leaflets. Another determinant was the post-PTMC transmitral pressure gradient for anterior (B -0.02, 95% CI -0.04 to -0.005, p < 0.01) and posterior (B -0.01, 95% CI -0.04 to -0.005, p < 0.05) leaflets excursion. The relationship between post-PTMC MVA and leaflet excursion was non-linear "S curve". There was a steep increase of both anterior (p, 0.02) and posterior (p, 0.03) leaflets excursion with increased MVA till the MVA reached a value of about 1.5 cm2; after which both linear and S curves became nearly parallel.

CONCLUSION

The improvement in leaflets excursion after PTMC is determined by several morphologic and hemodynamic changes produced in the valve. The increase in MVA improves mobility within limit; after which any further increase in MVA is not associated by a significant improvement in mobility in both leaflets.

A new simplified method for calculating mean mitral pressure gradient

BACKGROUND

Mean mitral valve pressure gradient (MVPG) is one of the key measures of the severity of mitral stenosis. The method for calculating MVPG, however, is complex and time consuming. The purpose of this study is to establish a new simple method for calculating MVPG.

METHODS

Hemodynamic data were analyzed in 105 patients who underwent percutaneous balloon mitral valvuloplasty (PBMV). A new simplified method for calculating mitral pressure gradient was proposed, i.e., mean MVPG = MLAP - LVEDP/2, where MLAP is mean left atrial pressure, and LVEDP is left ventricular end-diastolic pressure.

RESULTS

MVPGs derived from the standard and the new method were 13.28 +/- 7.42 mm Hg and 13.50 +/- 7.93 mm Hg, respectively, and there was no significant difference between the values of these two methods (P = 0.065). The MVPG derived from the new simplified method correlated closely with that calculated by the standard approach (r = 0.975, P < 0.001). Moreover, there was no significant difference between mitral valve areas (MVA) derived from the standard and the new approach either before or after PBMV in the 38 patients in whom cardiac output was measured.

CONCLUSION

We conclude that mitral pressure gradient can be calculated reliably with our new simplified method.

Neuro-embolic protection during percutaneous balloon mitral valvuloplasty

This report describes the management of a patient with severe symptomatic mitral stenosis and a large mobile thrombus extending from the left atrial appendage that was resistant to warfarin therapy. Percutaneous balloon mitral valvuloplasty was performed with cerebral protection using bilateral internal carotid artery filters to minimize the risk of embolic stroke.

Transjugular approach to balloon mitral valvuloplasty helps overcome impediments caused by anatomical alterations

Ten patients who had anatomic alterations that cause impediments to successful completion of conventional transfemoral balloon mitral valvuloplasty (BMV) underwent transjugular BMV. They included six patients in whom conventional BMV could not be completed due to cardiac anatomic distortion; two patients with dextrocardia (one with visceroatrial situs solitus and the other with situs inversus); two patients with venous abnormalities (one with azygous continuation of the inferior vena cava and the other with bilateral iliac/femoral vein occlusion). Transjugular BMV was successful in all 10 patients (mean mitral valve area increasing from 0.68 +/- 0.17 to 1.92 +/- 0.40 cm(2); range, 1.56-2.76 cm(2)); it was quick (mean total fluoroscopy time, 10.5 +/- 2.7 min; range, 7.3-15.2 min); and it was safe (no major or minor complications except one patient who developed severe mitral regurgitation that only required medical therapy). The jugular approach to BMV overcomes many of the technical problems caused by anatomic changes that are encountered in transfemoral BMV and complements the latter approach.

Comparison of early results of percutaneous metallic mitral commissurotome with Inoue balloon technique in patients with high mitral echocardiographic scores

We compared the safety, efficacy, and cost of the newly introduced percutaneous metallic commissurotome (PMC) with the results of Inoue balloon mitral valvuloplasty (BMV) in 80 patients with mitral stenosis (MS). The mean increase in mitral valve area (MVA) was 0.95 +/- 0.19 to 1.7 +/- 0.35 cm(2) for PMC and 0.97 +/- 0.15 to 1.81 +/- 0.36 cm(2) for BMV (P = NS). The Wilkins echocardiographic scores before dilatation did not correlate with any difference in MVA after dilatation. Bilateral commissural splitting was significantly more common with PMC than with BMV (30/39 patients, 76.9%, vs. 21/40 patients, 52.5%; P = 0.02). Postprocedural severe mitral regurgitation occurred in 1/39 (2.6%) in the PMC group and in 4/41 (9.8%) in the BMV group. Because the PMC device is resterilizable, we estimated the cost to be one-fourth the cost of BMV with the Inoue balloon. The estimated device cost ratio of PMC to BMV for each patient was 1 to 4.25. The early results of PMC on the MVA are comparable to BMV. However, PMC had better results not only in patients with high echocardiographic scores, but the PMC device splits commissural calcification better than BMV.

Successful inoue balloon mitral commissurotomy in double-orifice mitral stenosis

We report a rare case of stenotic double-orifice mitral valve of incomplete bridge type in a 40-year-old male. The fibrous bridge tissue between the leaflets was successfully split with a 24-mm Inoue balloon catheter using the stepwise dilation technique. Cathet. Cardiovasc. Intervent. 49:200-203, 2000.

Complications of Inoue balloon mitral commissurotomy: impact of operator experience and evolving technique

BACKGROUND

There have been no single-center studies that have systematically addressed the acute outcome of Inoue balloon mitral commissurotomy (BMC) performed in a large series of patients. Accordingly, this study sought to examine the impact of operator experience and continuing technical modifications on the success and complication rates of BMC.

METHODS

BMC was performed in 799 patients: 469 patients with pliable mitral valves (group 1) and 330 patients with calcified valves and/or severe subvalvular disease (group 2). Acute complications were examined and compared between groups before and after modifications in BMC techniques. Major modifications included the use of a height-derived balloon sizing method for the selection of an appropriate balloon catheter, a cautionary stepwise dilation technique, and avoidance of traction on the interatrial septum during balloon inflations.

RESULTS

Technical failures were encountered in 4 (0.5%) patients in our early experience. One patient sustained cardiac perforation and tamponade and was the only case requiring emergency surgery. There were no deaths. Systemic embolic events were observed in 11 (1.4%), all among the first 353 patients before the routine use of pre-BMC transesophageal echocardiography. Severe postprocedure angiographic (>/=3+) mitral regurgitation occurred in 4% of patients, 2% in group 1 versus 9% in group 2 (P =.0001). With increased operator experience and technical modifications, this complication was significantly reduced from 5% (7 of 150 patients) to 0% in the last 316 patients in group 1 (P =.0001) and from 11% (26 of 228 patients) to 3% (3 of 101 patients) in group 2 (P =.031). The incidence of significant interatrial shunting (pulmonary-to-systemic flow ratio >/=1.3) was also significantly reduced from 12% to 6% (P =.0034).

CONCLUSION

Incremental operator experience and ongoing technical refinements in BMC techniques have resulted in a 100% technical success rate and a significant diminution in complications in patients with a wide spectrum of stenotic mitral valve morphologic features.

String-plucking as a mechanism of chordal rupture during balloon mitral valvuloplasty using inoue balloon catheter

Percutaneous transvenous mitral commissurotomy using the Inoue technique was performed in a 59-year-old female with mitral stenosis and a severely calcified mitral leaflets. Although not entrapped in the subvalvular apparatus, the balloon catheter was deviated away from the mitral orifice-apex axis of the left ventricle during the inflation of the proximal balloon, which plucked and severed the chordae tendineae of the posterior mitral leaflet and resulted in severe mitral regurgitation.

Popping-out of an inoue balloon catheter: a rare sign of a severe subvalvular mitral lesion

Percutaneous transvenous mitral commissurotomy using the Inoue technique was performed in a patient with a severe subvalvular lesion. Although not entrapped or impeded by the subvalvular lesion, the distal balloon was levered upwards and the procedure ended up with the balloon catheter popping-out during the late phase of inflation.

Long-term (36-63 month) clinical and echocardiographic follow-up after Inoue balloon mitral commissurotomy

Although Inoue balloon mitral commissurotomy (BMC) offers excellent short-term results, there remains a paucity of data on its long-term (> or =3 yr) outcome. We therefore analyzed the outcome of 68 consecutive patients who had regular long-term clinical and serial echocardiographic follow-up of > or =3 yr after successful BMC. The procedure provided significant improvements in transmitral valve gradient (13+/-6 mmHg before to 5+/-2 mmHg after BMC, P = 0.0001), left atrial pressure (21+/-6 mmHg before to 14+/-5 mmHg after BMC, P = 0.0001), and mitral valve area (0.8+/-0.2 cm2 before to 1.7+/-0.4 cm2 after BMC, P = 0.0001) without incurring > grade 2+ angiographic mitral regurgitation. At a mean follow-up of 44+/-9 mos (range, 36-63 mo), functional benefits were maintained in 91% of patients. Serial echocardiographic evaluations performed in 97% of patients revealed a restenosis rate of 15% (defined as a loss of >50% initial gain in valve area or a valve area of <1.5 cm2). No strokes or deaths were encountered. Of the 15 clinical, echocardiographic, and procedural variables analyzed in a multivariate model, only the presence of chronic atrial fibrillation was an independent correlate of restenosis (P < 0.05). It was clearly more common in patients with than those without restenosis (100% with vs. 57%, respectively, P = 0.009). In conclusion, our study shows that BMC confers maintained long-term functional benefits and a low anatomic restenosis rate 23 yr after BMC.

Comparative evaluation of transthoracic and transesophageal echocardiography in detection of left atrial thrombus before percutaneous transvenous mitral commissurotomy. Do all patients need transesophageal examination?

We postulated that the sensitivity of transthoracic echocardiography in detection of left atrial cavity or appendage thrombi is better in south-east asian patients with rheumatic mitral stenosis. This was considering that these patients are generally younger, have lesser body weight and thinner chest walls resulting in better transthoracic echogenecity than their western counterparts. We prospectively performed transthoracic and transoesophageal echocardiography in 150 consecutive Indian patients (mean age 28.8+/-7.2 years; 78 men) being evaluated for percutaneous transvenous mitral commissurotomy. The overall sensitivity of transthoracic echocardiography was 74% (95% C.I. 59-88%). This was significantly higher than the pooled estimate from five western reports which evaluated similar patients (overall sensitivity 12%; 95% C.I. 0-25%; P<0.0001). The sensitivity rose to 83% when patients with poor echogenecity were excluded. Amongst patients with good echogenecity (81% patients) the diagnosis of left atrial thrombi was correctly made or suspected on transthoracic examination in all patients subsequently shown to have thrombi on transoesophageal echocardiography. Significant savings in cost may be safely achieved by limiting transoesophageal echocardiography to patients in whom left atrial cavity or appendage is not adequately visualized on transthoracic examination due to poor echogenecity, or in whom there are shadows suggestive but not diagnostic of thrombi.

Transjugular approach to transseptal balloon mitral valvuloplasty

The feasibility of a transjugular approach to septal puncture and Inoue-balloon mitral valvuloplasty (BMV) was studied in 20 patients with severe mitral stenosis and varying degrees of anatomic atrial distortion. Left atrial entry by transjugular septal puncture was achieved without difficulty and BMV completed in all patients. In all of 16 patients who had high septal punctures, crossing the mitral valve with the Inoue-balloon was consistently simple and quick. In one patient, septal dilation after very high septal puncture led to a tear extending to the atrial free wall, resulting in cardiac tamponade requiring surgery. Another patient developed severe mitral regurgitation after BMV and required mitral valve replacement. Excellent results were obtained in 16 patients. The transjugular approach simplifies BMV procedure significantly in patients with distorted atrial anatomy and allows rapid patient mobilization. Its safety and efficacy need to be established in larger studies.

Immediate and long-term results of percutaneous Inoue balloon mitral commissurotomy with use of a simple height-derived balloon sizing method for the stepwise dilation technique

OBJECTIVE

To assess the short- and long-term efficacy of Inoue balloon percutaneous transvenous mitral commissurotomy (PTMC) with use of our simple balloon sizing method based on patient height.

DESIGN

Data from 105 consecutive patients with symptomatic mitral stenosis who underwent 107 PTMC procedures between October 1991 and April 1995 at our hospital were analyzed.

RESULTS

All PTMC procedures were successfully completed with no instances of cardiac perforation, systemic embolism, severe mitral regurgitation (grade 3 or more angiographically), or death. The mean mitral valve area increased from 0.8 +/- 0.2 cm2 to 1.7 +/- 0.4 cm2 (P = 0.0001), as assessed echocardiographically. Optimal results -- defined as an improvement in valve area of 50% or more or a final valve area of 1.5 cm2 or more without significant mitral regurgitation (an increase in mitral regurgitation of two or more grades or a final regurgitation of grade 3 or more) -- were obtained in 96% of patients. At a mean follow-up interval of 20 months, symptomatic benefit was maintained in 97% of patients. Echocardiographic evidence of restenosis (loss of more than 50% initial gain in valve area, a valve area of less than 1.5 cm2, or both) was noted in 9.8%.

CONCLUSION

Inoue balloon PTMC with use of our simple balloon sizing method yielded excellent short- and long-term results in terms of mitral valve enlargement and sustained symptomatic benefit without the creation of severe mitral regurgitation.

Percutaneous Inoue-balloon valvuloplasty in patients with mitral stenosis and associated moderate mitral regurgitation

The present study compares the outcome of percutaneous Inoue-balloon mitral valvuloplasty performed in 21 patients with (group A) and 83 patients without (group B) preexisting moderate mitral regurgitation, using our height-derived balloon-sizing method. All procedures were successfully completed without untoward complications. The immediate increments in mitral valve area measured by echocardiographic methods and optimal valvuloplasty results were significantly higher in group B compared with group A (0.9 cm2 vs. 0.7 cm2, P = 0.01, and 99% vs. 90%, P = 0.007, respectively). No patients in either group sustained a final grade > or = 3/4 angiographic mitral regurgitation. A mild increase in mitral regurgitation was encountered more commonly in group B than in group A patients (22% vs. 0%, P = 0.03). At a mean follow-up of 19-20 months, the substantial majority of patients (> or = 90%) in both groups continued to experience maintained symptomatic benefits. In conclusion, our preliminary data seem to indicate that percutaneous Inoue-balloon mitral valvuloplasty using our height-derived balloon-sizing method in the stepwise dilatation approach in selected patients with significant mitral stenosis and concomitant moderate mitral regurgitation is associated with a low risk of developing severe mitral regurgitation, with effective mitral valve enlargement, and with sustained midterm symptomatic benefits.