Percutaneous balloon mitral valvuloplasty

Interventional Echocardiography of the MV: What the Interventionalist Wants to Know

The past 2 decades have seen a proliferation of transcatheter mitral valve (MV) therapies, which are less invasive and distinct from surgical MV repair or replacement. The commonly used MV transcatheter therapies include (1) percutaneous mitral balloon commissurotomy (PMBC) for rheumatic mitral stenosis; (2) edge-to-edge repair with the MitraClip for mitral regurgitation; (3) valve-in-valve implantation in bioprosthetic MV, native MV, or mitral ring; and (4) closure of paravalvular leaks (PVLs). This article will focus on the use of echocardiography in the diagnosis, patient selection, procedural guidance, and postprocedural follow-up for PMBC, with notes on the role of transesophageal echocardiography in transcatheter interventions for prosthetic valve degeneration and PVL closure.

Mitral valvuloplasty with the Inoue balloon tracked over an arteriovenous wire

Mitral stenosis is associated with significant morbidity and mortality. Percutaneous balloon mitral valvuloplasty is a standard treatment option for severe mitral stenosis, and in some patients may be the only feasible option. In patients with suitable valve anatomy and morphology, and with requisite physician expertise the procedure has a high success rate and good long-term outcomes. Nonetheless, even in appropriately selected patients the procedure can pose significant technical challenges. The transeptal antegrade approach using the Inoue Balloon system may be associated with difficulty and rarely with failure to cross the stenotic mitral valve. We report a case of initial Inoue balloon failure to cross followed by successful Inoue mitral valvuloplasty tracked over an arteriovenous wire loop.

Initial experience of using intracardiac echocardiography (ICE) for guiding balloon mitral valvuloplasty (BMV)

BACKGROUND AND AIMS

BMV is an established treatment for rheumatic mitral valve stenosis. The procedure is historically guided by fluoroscopy, and the role of intracardiac echocardiogram (ICE) guidance is not well defined. We report our initial experience of using ICE to guide BMV procedures.

METHODS

During BMV procedure, ICE catheter was inserted into the right atrium from the right femoral vein, and the septal puncture was monitored by ICE, as well as positioning of the balloon in the mitral valve. Comparisons were made between ICE, transthoracic echocardiography (TTE), and catheterization derived hemodynamic measurements (cath).

RESULTS

Seventeen patients with mitral stenosis underwent the procedure. The mean age was 44.4 ± 21 years. The mean MV area increased from 0.9 ± 0.1 cm(2) to 1.7 ± 0.2 cm(2), P < 0.0001 and the mean gradient decreased from 12.6 ± 5.8 mmHg to 4.9 ± 1.8 mmHg, P < 0.001. Atrial septum puncture and guidance of the balloon into the MV apparatus were obtained in all patients under ICE guidance. Severe MR developed in one patient and was readily detected by ICE. ICE derived gradient measurements were comparable to those obtained by TTE, and cath.

CONCLUSION

ICE guidance of BMV is feasible, and useful in monitoring safe septal puncture, optimizing balloon positioning, and in detecting complications. The hemodynamic measurements obtained were comparable to those obtained by TTE, and cath.

Percutaneous Balloon Mitral Valvuloplasty During Pregnancy

Although on the decline in industrialized nations, rheumatic mitral stenosis is still the most commonly encountered valvular lesion in pregnancy. Treatment of pregnant women with mitral stenosis is complicated by the risk that traditional drug and interventional therapies pose to the fetus. The goal of medical therapy in these patients is to reduce heart rate and left atrial pressure, as the dramatic increase in cardiac output associated with pregnancy can more than double the transmitral gradient. In the setting of the symptomatic pregnant patient with severe mitral stenosis who is not responding to, or cannot tolerate, medical therapy, percutaneous balloon valvuloplasty may be indicated.

Percutaneous transmitral commissurotomy in juvenile mitral stenosis—comparison of long term results of Inoue balloon technique and metallic commissurotomy

OBJECTIVES

To compare the immediate and long term results of percutaneous mitral valvotomy using metallic commissurotome and Inoue balloon in juvenile mitral stenosis.

BACKGROUND

Inoue balloon technique for mitral commissurotomy (IBMC) is well established and carried out worldwide in the treatment of juvenile mitral stenosis. Percutaneous mitral metallic commissurotomy (PMMC) is reported to be a cheaper and effective alternative to balloon mitral commissurotomy.

METHODS

Thirty-three patients aged less than 20 years, who underwent PMMC, were compared with 33 age and sex matched control patients who underwent IBMC. Success of valvotomy, procedure related complications, and follow-up events of the two techniques were compared.

RESULTS

Basal echocardiographic and hemodynamic data were similar in both groups. Procedural success was similar in both groups, 31/33. Complications like cardiac tamponade and mitral regurgitation (requiring or not requiring mitral valve replacement) were similar in both groups. On follow-up of more than 3 years, both groups had comparable hemodynamic parameters and restenosis rates.

CONCLUSIONS

Both IBMC and PMMC are successful in providing relief from severe juvenile mitral stenosis in terms of gain in valve area and reduction in transmitral gradient. Both techniques have similar procedural success and complication rates. The long term follow-up results are comparable at follow-up of more than 3 years.

Long-term outcome of patients undergoing balloon mitral valvotomy in pregnancy

The outcome of 36 patients (mean age 25.8 +/- 4.3 years) who underwent balloon mitral valvuloplasty during pregnancy is described in this report. The procedure was successful in 35 patients (97.2%), with no maternal mortality, and all patients subsequently had symptomatic improvement and uneventful deliveries. The children had normal growth and development at a follow up of 2.8 +/- 3.3 years. Thus, in patients with symptomatic severe mitral stenosis, balloon mitral valvuloplasty is feasible, safe, and effective with good long-term outcomes for both the mother and the fetus.

Comparison of percutaneous transmitral commissurotomy with Inoue balloon technique and metallic commissurotomy: immediate and short-term follow-up results of a randomized study

BACKGROUND

The Inoue balloon technique for mitral commissurotomy is well established and carried out worldwide. Metallic commissurotomy is reported to be a cheaper and effective alternative to balloon mitral commissurotomy.

METHODS

One hundred patients were randomized into 2 groups to undergo percutaneous transmitral commissurotomy (PTMC) by means of the Inoue balloon technique (IBMC, n = 49) or metallic commissurotomy (PMMC, n = 51). Patients were crossed over to the other technique when the initial technique was a failure. Success of valvotomy, procedure-related complications, and follow-up events of the 2 techniques were compared.

RESULTS

Basal echocardiographic and hemodynamic data were similar in both groups. Procedural success was similar in both groups: 45 of 49 procedures (91.8%) in the IBMC group, compared with 46 of 51 procedures (90.18%) in the PMMC group (P = 1.0). Crossover was also comparable, with 1 occurring in the IBMC group, compared with 3 in the PMMC group. Complications such as cardiac tamponade and mitral regurgitation (requiring or not requiring mitral valve replacement) were similar in both groups, with 3 complications in the IBMC group, compared with 4 complications in the PMMC group (P =.29). After a follow-up period of approximately 4 months, both groups had similar event rates and comparable hemodynamic parameters (P = not significant).

CONCLUSIONS

Both IBMC and PMMC are successful means of providing relief from severe mitral stenosis with a gain in valve area and reduction in transmitral gradient. Both techniques have similar procedural success, complication rates, and follow-up events.

Percutaneous transvenous mitral commissurotomy: immediate and long-term follow-up results

Percutaneous transvenous mitral commissurotomy has emerged as an effective nonsurgical technique for the treatment of patients with symptomatic mitral stenosis. This report highlights the immediate and long-term follow-up results of this procedure in an unselected cohort of patients with rheumatic mitral stenosis from a single center. It was performed in a total of 4,850 patients using double balloon in 320 (6.6%), flow-guided Inoue balloon technique in 4,374 (90.2%), and metallic valvulotome in 156 (3.2%) patients. Their age range was 6.5-72 years (mean, 27.2 +/- 11.2 years) and 1,552 (32%) patients were under 20 years of age. Atrial fibrillation was present in 702 (14.5%) patients. No patient was rejected on the basis of echocardiographic score using the Wilkins criteria. Echocardiographic score of > or = 8 was present in 1,632 (33.6%) patients, of which 103 (2.1%) had densely calcified (Wilkins score 4+) valve. A detailed clinical and echocardiographic (two-dimensional, continuous-wave Doppler and color-flow imaging) assessment was done at every 3 months for the first year and at 6-month interval thereafter. The procedure was technically successful in 4,838 (99.8%) patients but optimal result was achieved in 4,408 (90.9%) patients with an increase in mitral valve area (MVA) from 0.7 +/- 0.2 to 1.9 +/- 0.3 cm(2) (P < 0.001) and a reduction in mean transmitral gradient from 29.5 +/- 7.0 to 5.9 +/- 2.1 mm Hg (P < 0.001). The mean left atrial pressure decreased from 32.1 +/- 9.8 to 13.1 +/- 6.2 mm Hg (P < 0.001). Although there was no statistically significant difference in the MVA achieved between de novo and restenosed valves (1.9 +/- 0.3 and 1.8 +/- 0.2 cm(2), respectively; P > 0.05), or between noncalcific and calcific valves (2.0 +/- 0.3 and 1.8 +/- 0.2 cm(2), respectively; P > 0.05), on the whole MVA obtained after percutaneous transvenous mitral commissurotomy was less in restenosed and calcific valves. Ten (0.20%) patients had cardiac tamponade during the procedure. Mitral regurgitation appeared or worsened in 2,038 (42%) patients, of which 68 (1.4%) developed severe mitral regurgitation. Urgent mitral valve replacement was carried out in 52 (1.1%) of these patients. Data of 3,500 patients followed over a period of 94 +/- 41 months (range, 12-166 months) revealed MVA of 1.7 +/- 0.3 cm(2). Elective mitral valve replacement was done in 34 (0.97%) patients. Mitral restenosis was seen in 168 (4.8%) patients, of which 133 (3.8%) were having recurrence of class III or more symptoms. Thus, percutaneous transvenous mitral commissurotomy is an effective and safe procedure with gratifying results in high percentage of patients. The benefits are sustained in a majority of these patients on long-term follow-up. It should be considered as the treatment of choice in patients with rheumatic mitral stenosis of all age groups.

Conduction disturbances related to percutaneous balloon mitral valvuloplasty

During the performance of 280 consecutive percutaneous balloon mitral valvuloplasty operations, two cases of conduction disturbances were reported (0.7%). These rare complications are transient and due to the mechanical pressure of the balloon on the conduction system.

Utility of three-dimensional echocardiography during balloon mitral valvuloplasty

OBJECTIVES

We investigated the role of three-dimensional echocardiography in assessing mitral valve anatomy in greater detail in patients immediately before and after balloon mitral valvuloplasty (BMV).

BACKGROUND

Three-dimensional echocardiography is a recently developed, evolving imaging technique that allows visualization of intracardiac structures from any perspective.

METHODS

We studied 19 patients undergoing BMV using transesophageal echocardiography (TEE) (Chicago, Illinois) to image the mitral valve. The TEE was interfaced to a TomTec three-dimensional workstation that allows electrocardiographic and respiratory cycle gated image acquisition. The acquired images are digitized, and after postprocessing a three-dimensional image is reconstructed. The mitral valve was viewed "en-face" as if looking up from the left ventricle.

RESULTS

The mean mitral valve area (by pressure half-time from the Doppler of the two-dimensional echocardiogram) increased after BMV from 0.86+/-0.06 cm2 to 2.07+/-0.10 cm2, p < 0.0001. This was similar to the mitral valve areas obtained by planimetry from the three-dimensional images. The three-dimensional reconstructions showed a complete commissural split in 10 patients and partial splitting in 9 patients. In three of the eight patients who had an increase in the amount of mitral regurgitation secondary to BMV, the three-dimensional reconstructions were able to detect tears within the valve leaflet. One leaflet tear actually extended up to the mitral valve annulus and was associated with the only case of severe mitral regurgitation.

CONCLUSIONS

The three-dimensional echocardiographic reconstruction enabled visualization of the mitral valve so that commissural splitting and leaflet tears not seen on the two-dimensional echocardiogram became visible.