Assessment of mitral valve for PTMC
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Transcript of Assessment of mitral valve for PTMC
ASSESSMENT OF MITRAL VALVE FOR PTMC
Dr Satyam Rajvanshi
HISTORY
• Early in the development of percutaneous mitral and aortic balloon dilation, the technique was considered to be experimental, unproven, and even dangerous.
• However, many invasive cardiologists had similarly been sceptical when they heard of the Swiss physician Greuntzig's proposal of balloon dilation of coronary arteries.
Circulation Vol 82, No 2, August 1990
• The surprising success of balloon angioplasty (1982) made cardiologists receptive to the possibility that balloons could effectively treat valvular stenosis.
Circulation Vol 82, No 2, August 1990
• Case Series & case reports published from 1985-1988 after Inoue’s publication; Also Double balloon technique
• Because it was experimental, patients who were poor candidates for surgical valve replacement were those initially chosen for mitral balloon dilation – ELDERLY, SEVERELY DEFORMED VALVE, HEAVY VALVULAR CALCIFICATION
• Even in these patients, balloon dilation was suprisingly successful at times
• The impressive results of surgical commissurotomy relied in part on surgeons' "almost mystical ability to select (surgical) candidates”
Circulation Vol 82, No 2, August 1990
• Which valves might respond to balloon dilation seemed to cardiologists an unanswered question??
Br Heart J 1988;60:299-308
Circulation Vol 79 No 3, March 1989
Circulation Vol 82 No 3, August 1990
Predictive variables
• Factors assessed to predict optimal or suboptimal outcome
• Suboptimal – Any 1 or more• Final valve area < 1 cm2 / <1.5 cm2 in later studies• post-dilatation mean left atrial pressure > 10 mmHg• Change in area < 25% of the initial valve area in those
with a mitral valve area > 1 cm2 before procedure
Variables assessed in early studies
• Clinical– Age, Sex, Baseline Rhythm, NYHA class
• Echocardiographic– Structural features of MV and subvalvular
apparatus– MVA (Planimety)– LA size– Grade of MR
• Hemodynamic– MVA– TransMitral PG– CO– PVR– LVEDP
• Technical– Balloon used– Effective dilating area of balloon– Number of inflations
RESULTS
• Clinical– Age, Sex, Baseline Rhythm, NYHA class
• Echocardiographic– Structural features of MV and subvalvular
apparatus– LA size– MVA (Planimety) – Grade of MR
Surprisingly, more severe stenosis or smaller baseline valve area did not predict Suboptimal outcome; smaller MVA as likely as larger MVA to give suboptimal results
Age, AF, NYHA class - weak predictors
• Hemodynamic– MVA– TransMitral PG– CO– PVR– LVEDP
• Technical– Balloon used– Number of inflations– Effective balloon dilatation area (EBDA)
Flouroscopic Calcium alsoWeak predictor
• Strongest & best predictor of immediate hemodynamic optimal result
MITRAL VALVE STRUCTURE
SCORE
Most patients with a total echocardiographic score > 11 had a suboptimal result
Those with a score < 9 had an optimal result
The score failed to predict outcome in those with scores of 9 to 11
• Why 8?
• The sensitivity of the total echo score for predicting a "good" outcome - calculated for each score value - proportion of all patients with a "good" outcome who had scores equal to or less than that score value
• The specificity was the proportion of all patients with a suboptimal outcome who had a total echo score above that score value
Echo score relevance
• Higher EBDA and Sinus Rhythm are significant favourable predictors
• Baseline AF rhythm also independently predicts restenosis
• Upto 50% pts – MR grade increased by 1+; 50% of these – MR decreased by 1 grade in follow-up; 30% pts - MR grade increased by >1+
Score ≤8 ≥8
Immediate optimal result 88% 44%
NYHA class improvement 90% 56%
Re-stenosis at 2 yrs by Echo
<10% 70%
EVALUATION OF PATIENT
INDICATION
• SYMPTOMATIC NYHA II or more• MVA < 1.5 cm2 in a normal sized adult (or < 1 cm2 / m2) • Favourable valve morphology
• Reasonable (IIa) in– symptomatic patients in whom surgery carries high
risk for adverse events or outcomes, even when valve morphology is not ideal,• restenosis after a previous BMV or previous
commissurotomy who are unsuitable candidates for surgery because of very high risk – very old, frail patients; associated severe ischemic heart disease; pulmonary, renal, or neoplastic disease; • women of childbearing age in whom mitral valve
replacement is undesirable; • Pregnant women with MS.
CONTRAINDICATIONS
• MR > 2+
• Left atrial thrombus• Severe commisural calcification (Bicommisural
heavy – Grade 4 calcification)
IF INDICATED
• ECG • CHEST RADIOGRAPH• ECHOCARDIOGRAPHY
ECG
• LAE• RAE• RVH• Atrial arrhythmias
• P wave duration and P wave dispersion correlate with MS severity
Pacing Clin Electrophysiol 2008;31:1620-4
• RAD & RBBB presence correlates with MS severity
Cardiology 2006; 105:219-22
• Acute hemodynamic changes following BMV produce corresponding changes in ECG, mainly in P wave and QRS axis
Indian Heart J 1998;50:179-82
RADIOGRAPHY
CHEST RADIOGRAPHY
• LAE• Calcification• PVH• PAH
VENTRICULOGRAPHY
• MV doming and calcification
• MR severity
• Subvalvular disease (Atkins)Mitral-subvalvular distance (ES)/AoV-Apex distance (ED)<0.2 – Severe subvalvular disease
End-systole End-diastole
ECHOCARDIOGRAPHY
Parameters assessed
• Severity of MS• Pliability of valve (suitability)• MR• LA thrombus• IAS • Other ass. Valvular ds• PAH
M-mode
• DE amplitude more than 18 mm – pliable valve
• EF slope less than 20 mm/sec – Severe MS
MS severity by planimetry
• PSAX• MAX opening in mid diastole• Plane perpendicular to orifice• Lowest gain setting• Open commissures included• Avg 3 cycles in SR, 5-10 in AF
• Limitation– Gain– Calcification– Commissure– Plane
MV separation index < 0.8> 1.1
Valve mobility
• Wilkins grading 1-4• Reid grading 0-2 -- Extent of doming
Valve thickening
• < 4 mm normal• 5-8 mm – MILD• >8 mm – MARKED
• Valve thickness/post Aortic wall thickness<1.5 – Normal <2 – Mild 2-5 – Moderate >5 – Marked /Severe
Valve calcification
SubValve thickening
• PLAX• A4C/A2C
IAS
LA thombus
Scoring
• Wilkins• Reid (Br Heart J 1977;39:1088-92)
• Lung-Cormier (Antunes MJ, Acquired Heart valve ds, 1995)
• Padial (JACC 1996;27:1225-31)
• Massachusetts General Hospital (MGH)• Ain Shams (Echocardiography 2009; 26:119-27)
• RT3DE
Wilkins Score
Reid Score
Lung and Cormier score
Padial Score
• Significant MR post BMV– Uneven MV thickening– Severe subvalvular ds– Commisural calcification
Cutoff 10
Ain Shams
• Calcification– Leaflet margin – 2– Leaflet Body – 4– Commisure – 6
• Subvalvular thickening– Less than half - 4– More than half - 4– Full length - 6 Cutoff - 4
RT3DE
• Preprocedural MRDoes not predict success directlyBenefit of using larger balloon only in
absence of significant MR
• TEELA and LAA clotUnderestimates subvalvular ds
Scoring system problems
• Subjective, Semiquantitative• Echo diff of nodular fibrosis from calcium• Subvalve ds underestimation• Non inclusion of commisural calcium• Uneven distribution of pathology
• Combination of scores solves some of these problems
TAKE HOME MESSAGE
• BMV is feasible, safe, and successful, provided that proper assessment has been done pre-procedure
• Check Indications & Contraindications• Echo scoring – Combine scores, include
commisural calcium score• TEE to rule out LA clot esp in patients with AF• Periprocedural monitoring and follow-up is
essential