What is the Procedure of Percutaneous Balloon Mitral Valvuloplasty?

GURGAON, India - Nov. 19, 2018 - PRLog -- Before the advent of PBMV, most patients with symptomatic MS were treated with surgical mitral commissurotomy which was either open or closed. After the development of cardiopulmonary bypass, the open surgical commissurotomy replaced the closed technique in 1982, Kanji Inoue, a Japanese cardiac surgeon, first developed the idea that a degenerated mitral valve could be inflated using a balloon made of strong yet pliant natural rubber. Today, Inoue's single balloon technique has become the most popular method for performing PBMV. Pathological studies have disclosed that the main mechanism of successful PBMV is a fracture of the commissures. In comparison to surgical mitral commissurotomy, PBMV has shown equal or even better success rates and comparable restenosis rates. Randomized trials comparing PBMV to closed commissurotomy have shown that PBMV is superior to closed commissurotomy, providing a larger valve area and better technique as well.

The transseptal technique is the most common technique used to perform percutaneous balloon mitral valvuloplasty. This technique consists of advancing a catheter over the wire across the interatrial septum after transseptal puncture which enlarges the opening and then advancing one large balloon (Inoue balloon) or two smaller balloons (double-balloon technique) across the mitral orifice and inflating them within the orifice. Although acute and short-term outcomes differ little between both these techniques, the complications such as death, left ventricular perforation, and stroke appears to be less common with the Inoue balloon, that is, the single balloon. The multiple advantages of the Inoue balloon, include a low profile of the device, the elimination of the stiff guidewire which minimizes the risk of LV perforation, easy manoeuvrability, and the stepwise dilation (gradual increase of balloon size on sequential inflations).

Patient's undergoing PBMV are usually admitted on the day of the procedure with instructions to fast from midnight; they have their anticoagulation with warfarin withheld for three days, aiming for an international normalized ratio of 1.7 on procedure day. Transesophageal (TEE) echo should be performed before PBMV for patients with atrial fibrillation or prior history of systemic embolism or very obese patient where the left atrium was not properly visualized. In most of the cases, TEE is used to assist the proceduralist and the patient will be anaesthetized and right heart catheterization is performed to obtain full pre-procedure hemodynamics and a left ventriculogram can be performed to assess the baseline MR.

Once the transseptal puncture is performed, then heparin is administered aiming for an activated clotting time and the LA pressure is measured to calculate the transmitral gradient. Using the transseptal sheath stainless steel spring coil guidewire is introduced into the LA. And it is over this wire the tapered dilator is used to dilate the femoral vein and the interatrial septum, and is then removed.

Based on the patient's height, the required size of the IBC is chosen and the IBC's inner tube is then flushed with heparinized saline. Dilute contrast is used to flush the balloon through the vent tube, which outflows through the main tube and the main vent stopcocks are then closed. A syringe is filled with dilute contrast and slowly injected into the balloon through the main stopcock.

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Once the balloon is fully dilated, the supplied calliper is used to measure the waist and the balloon is fully sucked down. The same step is then repeated using the maximal diameter on the syringe. The balloon stretching tube is then flushed with heparinized saline which is then used to stretch the balloon to allow crossing the intra-artrial septum. It is inserted into the catheter inner tube and the two hubs are locked together metal to metal. These hubs are then pushed toward the W-connector where its plastic hub is locked to the metal hub. This assembly is then inserted over the wire and partially into the LA. As it nears the LA wall the tip is made elastic by unlocking the balloon and stretching tube and withdrawing 2 to 3 cm and unlocking metal to metal. Once the entire balloon has crossed the septum the inner tube is unlocked and pulled back from the W-connector also unlocking metal to plastic. The guidewire and balloon stretching tube are then removed together.

The balloon is then partially inflated the distal balloon so that it will move forward and across the MV. The distal balloon is then inflated fully and pulled back and forth a few times to ensure it is not lodged into the chordae. It is then that it is pulled against the MV gently, and the proximal balloon is inflated quickly to perform valvuloplasty. The balloon is then deflated and pulled back into the LA. The result of valvuloplasty is then checked and the IBC is removed.

PBMV is a safe procedure with high success rate, especially if the patients chosen have optimal valve morphology as determined by echo score.

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