Centers of Excellence in Interventional Cardiology and Radiology

INTERVENTIONAL CARDIOLOGY

Percutaneous Mitral Ballon Valvuloplasty (PMBV)

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Only 24 hours hospitalization

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Generalities

Valvuloplasty is performed, in certain circumstances, to open a stenotic (stiff) heart valve.

Valves of the heart

The heart is a pump made of muscle tissue. The heart has four pumping chambers: two upper chambers, called atria, and two lower chambers, called ventricles. The right atrium pumps blood into the right ventricle, which then pumps the blood into the lungs where carbon dioxide is given off and oxygen is taken into the blood.

From the lungs, the blood flows back into the left atrium, is pumped into the left ventricle, and then is pumped through the aorta out to the rest of the body and the coronary arteries. When the atria are pumping, the ventricles are relaxed in order to receive the blood from the atria. Once the atria have pumped their entire blood load into the ventricles, they relax while the ventricles pump the blood out to the lungs and to the rest of the body.

In order to keep the blood flowing forward during its journey through the heart, there are valves between each of the heart’s pumping chambers:

Tricuspid valve – located between the right atrium and the right ventricle

Pulmonary (or pulmonic) valve – located between the right ventricle and the pulmonary artery

Mitral valve – located between the left atrium and the left ventricle

Aortic valve – located between the left ventricle and the aorta

If the heart valves become damaged or diseased, they may not function properly. Conditions that may cause dysfunction of heart valves are valvular stenosis and valvular insufficiency (regurgitation). When one (or more) valve(s) becomes stenotic (stiff), the heart muscle must work harder to pump the blood through the valve.

Mitral stenosis

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Rheumatic mitral valve disease, manifested by commissural leaflet fusion, is the most common cause of mitral stenosis, usually decades after the acute illness.

Nonrheumatic mitral stenosis is unusual, although calcific stenosis is now seen with increasing frequency in hemodialysis patients. Other rare causes of mitral stenosis include carcinoid syndrome, eosinophilic endomyocardial fibroelastosis, and congenital mitral stenosis

Commissural fusion of the mitral valve leaflets leads to obstruction of blood flow from the left atrium to the left ventricle. This obstruction, in turn, leads to chronically elevated pulmonary arterial pressures and symptoms of heart failure, especially with exercise or other conditions associated with tachycardia.

Symptoms

Mitral stenosis may cause the following symptoms:

The first complaints with mitral stenosis are usually of dyspnea on exertion (breathing difficulties)

Women with mitral stenosis frequently present during pregnancy when cardiac output and circulating intravascular volume increase.

Dizziness

Chest pain

Palpitations

Edema (swelling) of the feet, ankles, or abdomen

Rapid weight gain due to fluid retention.

Diagnosis

Early symptoms may be very subtle, and a history of rheumatic fever is often difficult to elicit.

Patients are sometimes initially diagnosed with upper respiratory illness before re-evaluation prompts consideration for cardiovascular disease.

Your doctor will do a complete cardiac exam. Physical examination may demonstrate a diastolic rumble or an opening snap.

An EKG is a simple, painless test that records the heart’s electrical activity. An EKG shows how fast your heart is beating and its rhythm (steady or irregular). Atrial fibrillation often occurs in mitral stenosis as a result of left atrial dilatation and chronically elevated left atrial wall stress.

Transthoracic Echocardiography the diagnostic test of choice, is usually necessary and sufficient to confirm the diagnosis of mitral stenosis; it shows the size and shape of your heart and how well your heart chambers and valves are working. In some cases, your doctor may indicate a transesophageal echocardiography (TEE), for a proper diagnostic, wich uses sound waves to take pictures of your heart through the esophagus. The esophagus is the passage leading from your mouth to your stomach. During this test, the transducer is attached to the end of a flexible tube. The tube is guided down your throat and into your esophagus. You’ll likely be given medicine to help you relax during the procedure. TEE is used to detect blood clots that may be forming in the atria because of AF. Prior to proceeding with PMBV, all patients should be evaluated by transesophageal echocardiogram (TEE) with specific focus on the left atrial appendage to exclude thrombus.

A chest X-ray rarely shows pulmonary edema unless precipitated by an exacerbating illness; however, in advanced mitral stenosis, Kerley B lines from chronically elevated pulmonary venous pressures are sometimes visualized.

Coronary arteriography should be performed in selected patients prior to PMBV (in patients older than 35 years older than 35 years with coronary risk factors and women who are postmenopausal). Patients with chest pain, evidence of ischemia, decreased LV function, or a history of coronary artery disease should also undergo preprocedural coronary arteriography.

Indications

Symptoms in mild to moderate mitral stenosis can be improved with medical therapy. Beta-blockers and calcium channel blockers help to control heart rate and increase diastolic filling time. Diuretics can help with heart failure symptoms.

Severe symptomatic mitral stenosis should be treated with percutaneous mitral balloon valvuloplasty (PMBV) or surgically.

Surgical commissurotomy has been compared with percutaneous valvuloplasty in several randomized trials and outcomes are consistently better with percutaneous valvuloplasty in patients who are good candidates. Surgical commissurotomy should, however, be considered in patients with severe subvalvular or calcific mitral valve disease.

Valvuloplasty is performed in certain situations in order to open a heart valve that has become stiff. Not all conditions in which a heart valve becomes stiff are treatable with valvuloplasty. There may be other reasons for your doctor to recommend a valvuloplasty.

PMBV is indicated for patients with:

severe mitral stenosis (MVA < 1.5 cm2), favorable valve morphology and absence of contraindications such as left atrial thrombus or significant mitral regurgitation.

asymptomatic patients with severe mitral stenosis, pulmonary hypertension (systolic pulmonary pressure >50 mm Hg at rest or >60 mm Hg with exercise) and favorable valve morphology should also be considered for PMBV.

patients with calcific mitral stenosis who are at high risk for surgical commissurotomy should be considered for PMBV when advanced heart failure and severe mitral stenosis are present. Similar patients who are at lower risk for surgical commissurotomy may also be considered for PMBV.

symptomatic patients with milder stenosis and pulmonary hypertension may be considered for PMBV.

asymptomatic patients with severe mitral stenosis with new atrial fibrillation may also be considered for PMBV.

palliative treatment may be considered in patients who are not suitable candidates for surgery even when valve morphology is not ideal.

Though limited, experience with balloon valvuloplasty for congenital mitral stenosis suggests little benefit from a potentially dangerous procedure. Surgery is usually preferable in these patients who often have associated complex anatomy. These patients should, therefore, be evaluated by a multidisciplinary team at an experienced center.

Contraindication

The presence of left atrial thrombus is an absolute contraindication to PMBV because of the high risk for systemic embolism. If left atrial thrombus is found, the patient should be treated with systemic anticoagulation for 3-6 months and undergo repeat TEE to confirm resolution of thrombus prior to PMBV. Patients with left atrial thrombus requiring more urgent therapy should be considered for surgical mitral valve replacement with ligation of the left atrial appendage.

Moderate to severe mitral regurgitation is also a contraindication to PMBV because of the risk of worsening regurgitation as a result of the procedure.

Severe concomitant aortic valve disease, severe organic tricuspid stenosis, and severe functional tricuspid regurgitation with an enlarged annulus are also contraindications to PMBV.

Severe concomitant coronary artery disease requiring bypass surgery is a contraindication to PMBV. These patients should be considered for a combined coronary artery bypass and surgical mitral valve procedure.

Unfavorable valve morphology is a relative contraindication to PMBV, although in selected patients, especially in those who are high surgical risk or in cases of palliation, PMBV can be considered.

Procedure

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Prior to proceeding with PMBV, all patients should be evaluated by transesophageal echocardiogram (TEE) with specific focus on the left atrial appendage to exclude thrombus

The procedure may be done under local anaesthesia in a catherisation laboratory. You will receive a sedative medication in your IV before the procedure to help you relax.

TEE-guided PMBV usually requires intubation prior to the procedure and comanagement with an anesthesia team.

The hair at the catheter insertion site (groin area) is clipped off. You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure.

Then, after local asepsy and proper anticoagulation, a small inguinal incision is made. Once the local anesthetic has taken effect, a sheath, or introducer, will be inserted into the blood vessel. This is a plastic tube through which the catheter will be inserted into the blood vessel and advanced into the heart. The valvuloplasty catheter will be inserted through the sheath into the blood vessel. The doctor will advance the catheter through the vein (antergrade approach) or artery (retrograde approach) across the heart valve. Fluoroscopy (a special type of X-ray that will be displayed on a TV monitor) may be used to assist in advancing the catheter to the heart. Once the catheter is in place, contrast dye will be injected through the catheter into the valve in order to look at the area.

You may feel some effects when the contrast dye is injected into the IV line. These effects include a flushing sensation, a salty or metallic taste in the mouth, or a brief headache. These effects usually last for a few moments.

You should notify the doctor if you feel any breathing difficulties, sweating, numbness, itching, chills, nausea and/or vomiting, or heart palpitations.

Once the balloon is in place and has been inflated, you may notice some dizziness or even brief chest discomfort. This should subside when the balloon is deflated.

The balloon may be inflated and deflated several times in order open the valve.

Once it has been determined that the valve is opened sufficiently, the catheter will be removed. The catheter insertion site may be closed with a closure device that uses collagen to seal the opening in the artery, by the use of sutures, or by applying manual pressure over the area to keep the blood vessel from bleeding. Your doctor will determine which method is appropriate for your condition.

Your doctor may decide not to remove the sheath, or introducer, from the insertion site for approximately four to six hours, in order to allow the effects of blood-thinning medication given during the procedure to wear off. You will need to lie flat during this time. If you become uncomfortable in this position, your nurse may give you medication to make you more comfortable.

Is it painful?

No, is not a painfull procedure, because it is done under local or general anaesthesia. You may feel some stinging at the site for a few seconds after the local anesthetic is injected.

How long does it take?

The procedure usually lasts about an 1-2 hours.

Risks

The complications are reduced by the proper preparation and the continuous surveillance of the patient. Potential complications:

allergic reactions to administered substances, including renal disfunction

reactions to anesthetic compounds

arteriovenous fistulas at the catheter insertion site

blood clot or damage to the blood vessel at the insertion site

minor bleeding at the vascular puncture site, haematoma

significant blood loss that may require blood transfusion

fever

headache, migraine

infection at the catheter insertion site

cardiac dysrhythmias or arrhythmias (abnormal heart rhythms)

gaseous embolism

stroke – the risk of transient ischemic attack and or cerebrovascular accident is minimized with routine preprocedural TEE to exclude left atrial thrombus.

new or worsening valve regurgitation (leakage)

rupture of the valve, requiring open-heart surgery

the risk of death with PMBV is less than 1%. This risk is higher in elderly or severely ill patients and those in shock at the time of the procedure.

the risk of cardiac perforation is approximately 1%

an iatrogenic atrial septal defect is almost always present immediately after PMBV by antegrade approach. This small puncture, however, almost always closes spontaneously within weeks. Less than 2% of patients have a persistent shunt.

Up to 20% of patients will develop recurrent symptomatic mitral stenosis

Before procedure

The preoperative assessment will establish if the interventional treatment is the best option for you.

Tell your doctor yf you’re pregnant.

Prior to the intervention, your doctor must be prevented about any history of allergic reactions. Blood tests are taken including hemoglobin level, coagulation, renal function, and other specific tests.

Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure. You will be asked to sign a consent form that gives permission to do the procedure.

Notify your doctor if you are sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).

Based on your medical condition, your doctor may give you other specific preparation instructions.

After procedure

You will be taken back to the recovery area on a trolley and be able to sit up. You will be given pain medication for incisional pain. The nurses will carry out routine observations, such as taking your pulse and blood pressure, to make sure that there are no untoward effects. They will also look at the skin entry point to make sure there is no bleeding from it. If the insertion was in the groin, you will not be allowed to bend your leg for several hours.

You will generally stay in bed for a few hours, until you have recovered when you will be allowed home.

You will be encouraged to drink water and other fluids to help flush the contrast dye from your body.

Since the procedure is minimally invasive, the postprocedural recovery is usually very fast. You will most likely spend the night in the hospital after your procedure. Depending on your condition and the results of your procedure, your stay may be longer. You will receive detailed instructions for your discharge and recovery period.

Once at home, you should monitor the insertion site for bleeding, unusual pain, swelling, and abnormal discoloration or temperature change at or near the injection site. A small bruise is normal. If you notice a constant or large amount of blood at the site that cannot be contained with a small dressing, notify your doctor.

It will be important to keep the insertion site clean and dry. Your doctor will give you specific bathing instructions.

You may be advised not to participate in any strenuous activities. Your doctor will instruct you about when you can return to work and resume normal activities.

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The severity of mitral stenosis and/or mitral regurgitation should be assessed by echocardiography after PMBV and patients should maintain regular follow-up with a cardiologist. Participation in sports and exercise should be based on the degree of residual mitral stenosis, mitral regurgitation, and/or left ventricular dysfunction.

Up to 20% of patients will develop recurrent symptomatic mitral stenosis. Repeat PMBV can be considered in these patients.

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