Percutaneous Mitral Balloon Valvuloplasty

Prepared by : Hamza Duygu, MDAtaturk Training and Research Hospital, Department of Cardiology, İzmir, Turkey

Turkish & Hellenic CongressJune 30, 2012

Seçkin Pehlivanoğlu, MD

Başkent University, İstanbul Hospital

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Presenter’s Disclosure

• I do not have any (potential conflict of) interest for this special subject

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Background:

• Rheumatic heart disease is a chronic manifestation of rheumatic carditis, which occurs in 60% to 90% of cases of rheumatic fever.

• Although all of the cardiac valves may be involved by this rheumatic process, the mitral valve is involved most prominently.

Mitral stenosis

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Mitral valve apparatus

Mitral stenosis

Percutaneous Mitral Balloon Valvuloplasty :Choice of Treatment in Mitral Stenosis

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Etiology :

• Primarily a result of rheumatic fever~ 99% of MV’s @ surgery show rheumatic damage results inscarring & fusion of valve apparatus

• Rarely congenital

• Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease

• Two-thirds of all patients with MS are female.

Mitral stenosis

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Mitral Stenosis: Clinical pathophysiology

Right Heart Failure:Hepatic Congestion

JVDTricuspid Regurgitation

RA Enlargement

↑↑↑↑ Pulmonary HTNPulmonary Congestion

Atrial FibLA Thrombi

LA Enlargement

↑↑↑↑ LA Pressure

RV Pressure OverloadRVH

RV Failure LV Filling

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Mitral Stenosis: Mitral Stenosis: Complications

• Atrial dysrrhythmias

• Systemic embolization (10-25%)– Risk of embolization is related to, age, presence of atrial fibrillation,

previous embolic events

• Congestive heart failure

• Pulmonary infarcts (result of severe CHF)

• Hemoptysis– Massive: 20 to ruptured bronchial veins (pulmonary HTN)– Streaking/pink froth: pulmonary edema, or infection

• Endocarditis

• Pulmonary infections

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Mitral Stenosis: Mitral Stenosis: Diagnosis Diagnosis (TTE)

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Mitral Stenosis: Mitral Stenosis: Diagnosis Diagnosis (TTE)

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Mitral Stenosis: Mitral Stenosis: Diagnosis Diagnosis ((3D ECHO)

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Mitral Stenosis: Pathophysiology / Clinical stages

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Percutaneous Mitral Commissurotomy (PMC)

Percutaneous, Inoue, 1984 Surgical, Harken, 1948

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CRITERIA FORPERCUTANEOUS MITRAL BALLOON VALVULOPLASTY

• Significant symptoms

• Isolated mitral stenosis

• No (or trivial) mitral regurgitation

• Mobile, non-calcified valve/subvalve apparatus on echo

• Left atrium free of thrombus

* local expertise and availability in the fields of valvuloplasty and surgery

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• severity of MS (MVA, gradients)

• pulmonary artery pressure

• MR

• concomitant valve disease

• left atrial diameter

• valve morphology (Wilkins score)

Patient selection for PMC: TTE

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Wilkins’ scoring system

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• to exclude-LA/LAA thrombus-moderate or severe MR

• if TTE provides suboptimal information

• guidance for transseptal puncture (for inexperienced interventionalist or MBV during pregnancy)

Patient selection for PMC: TEE

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PMC: Procedural success

Overall: 80-95%

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PMC: Complications

Technical failure 1.0-15%

Procedural mortality 0-3%

Severe MR 2-10%

ASD 5-10%

Emergency surgery <1%

Haemopericardium 0-2%

Stroke 0.5-3.0%

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Circulation 2002;105:1465-71.

PMC: Predictors of procedural success

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PMC: Immediate outcomes

• The immediate results of percutaneous mitral valvotomy are similar to those of surgical mitral commissurotomy

– Mean MVA doubles (from 1.0 cm2 to 2.0 cm2) – 50% to 60% reduction in transmitral gradient. – Overall, 80% to 95% procedural success (MVA >1.5 cm2 and a decrease in LA

pressure to <18 mm Hg).

• Most common acute complications – severe MR 2% to 10% – residual ASD

• Large ASD (>1.5:1 L->R shunt) in <12% with the double balloon technique and <5% with the Inoue balloon technique.

• Smaller ASD detected by TEE in larger numbers of patients.

• Less frequent complications – perforation of LV (0.5% - 4.0%)– embolic events (0.5% - 3%)– MI (0.3% - 0.5%).

• Mortality – 1% to 2% – < 1% with increasing experience in selected patients.

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Long-term results: Event-free survival after PMC(Balloon Valvuloplasty Registry who were stratified by baseline echocardiographic

morphology score)

8 to 12

> 12

P < 0.0001

<8

• Percutaneous BMV is the procedure of choice in patients who have symptomatic, hemodynamically severe stenosis with an echocardiographic score of 8 or less and without left atrial thrombus

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Long-term results: Percutaneous valvuloplasty of MS

• Survival rate 60 % - 90 % over 3-7 yrs

• Restenosis rate 40% after 7 yrs.

• Randomized trials comparing percutaneous approach with both closed and open surgical commissurotomy consisted mainly of younger patients with favorable morphology.

– No significant difference in acute hemodynamic results or complication rate.– No difference in clinical improvement or exercise time in early follow-up– More favorable hemodynamics and symptomatic results with percutaneous

approach than closed commissurotomy and equivalent results with open commissurotomy.

• MR stable or decreases slightly.

• ASD likely to close later in majority of cases.

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PMC: Restenosis

Catheter Cardiovasc Interv 2007;69:40–46

-85% at 5 yrs,

-70% at 10 yrs,

-44% at 15 yrs

Freedom from RS:

-a low echo score -post procedural MVA ≥2.0 cm2

Predictors:

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• In centers with skilled, experienced operators, PMC with the Inoue balloon is an effective technique, providing sustained clinical improvement in over 80% of well selected patients

• Event-free survival after 10 years is over 70%

• The immediate and long-term outcome of patients undergoing PMC is multi-factorial

• The use of echocardiography in conjuction with other clinical and morphological predictors of PMC outcome allows identification ofpatients who will obtain the best outcome from PMC

PMC: Conclusions

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Thank you for your attention!

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