Page 733 - Read Online

Page 2 of 24 Palacios Mini-invasive Surg 2020;4:73 I http://dx.doi.org/10.20517/2574-1225.2020.72

likely to develop significant mitral regurgitation post-PMV. This score takes into account the distribution (even or
uneven) of leaflet thickening and calcification, the degree and symmetry of commissural disease, and the severity
of subvalvular disease. The transvenous transseptal approach is the most widely used PMV technique. The two
major techniques of PMV are the double-balloon technique and the Inoue technique which are equally effective
techniques of PMV. Encouraging results of PMV have been reported in special mitral stenosis population cohorts
including pregnant women, patients with previous surgical commissurotomy, patients with atrial fibrillation,
patients with pulmonary hypertension, elderly patients, patients with calcific mitral stenosis, and patients with
associated aortic regurgitation. To summarize, PMV is the preferred form of therapy for relief of mitral stenosis
for a selected group of patients with symptomatic mitral stenosis and suitable valve anatomy for valvuloplasty.
Patients with Echo-Sc ≤ 8 have the best results, particularly if they are young, are in normal sinus rhythm, have
no pulmonary hypertension, and have no evidence of calcification of the mitral valve under fluoroscopy. The
immediate and long-term results of PMV in this group of patients are similar to those reported after surgical mitral
commissurotomy. Patients with Echo-Sc > 8 have only a 50% chance to obtain a successful hemodynamic result
with PMV, and the long-term follow-up results are worse than those from patients with Echo-Sc ≤ 8. In patients
with Echo-Sc ≥ 12, it is unlikely that PMV could produce good immediate or long-term results and they preferably
should undergo mitral valve replacement. However, PMV could be considered in these patients if they are high-risk
or unqualified surgical candidates.

Keywords: Mitral stenosis, mitral balloon valvuloplasty, rheumatic mitral stenosis

INTRODUCTION
Mitral stenosis is more often caused by rheumatic heart disease. Other causes of mitral stenosis include
[1-3]
severe calcification of the mitral annulus and congenital defects of the mitral valve . Until the early
1980s, surgery was the only possible treatment for severe mitral stenosis; then, a new alternative appeared,
[4]
percutaneous mitral balloon valvuloplasty (PMV). Since its introduction in 1982 by Inoue et al. , PMV
has been used successfully as an alternative to open or closed surgical mitral commissurotomy for the
[4-8]
treatment of patients with symptomatic rheumatic mitral stenosis . In 1986, we performed the first
percutaneous mitral balloon valvuloplasty in the United States in a 70-year-old man with end-stage mitral
[5]
stenosis . What have we learned about this technique over the subsequent 34 years? In this chapter, I
report an analysis of the immediate and long-term results of PMV.

PATIENT SELECTION FOR PMV
Clinical evaluation of patients with mitral stenosis is the first step of the decision to intervene. Excellent
results with PMV are seen in individuals with a crisp opening snap, a Wilkin’s echocardiographic score
≤ 8, and no calcium in the commissures. The existence of an opening snap confirms the mitral valve’s
mobility and pliability. As the mitral valve becomes severely calcified and immobilized, the opening snap
disappears and the first heart sound amplitude decreases. Appropriate patient selection is an essential
step when predicting the immediate results of PMV. Candidates for PMV require precise assessment of
mitral valve morphology [7,9-12] . The assessment of the anatomy of the mitral valve is critical and it aims
to eliminate contraindications and define prognostic considerations. Table 1 shows current American
Heart Association/ American College of Cardiology, and European guidelines for the use of PMV [13,14] .
The presence of a left atrial thrombus is the main contraindication for the technique and requires the
performance of transesophageal echocardiography before the procedure [Table 1].

As shown in Tables 2 and 3, PMV is a safe procedure that produces good immediate hemodynamic
outcome, low complication rate, and clinical improvement in the majority of patients with mitral
stenosis [8,9,15-17] . The immediate and long-term results appear to be similar to those of surgical mitral