Percutaneous mitral valvuloplasty (MPV) dilates a stenotic valve using a balloon catheter.
Mitral stenosis (MS) is a condition whose incidence is still high in developing countries where rheumatic fever is prominent.
Untreated, it is a disease that is progressive causes limiting symptoms (dyspnea, fatigue) and severe complications (systemic embolism, pulmonary hypertension, heart failure, pulmonary embolism).
The development of percutaneous mitral balloon valvuloplasty (PBMV) by Inoue in 1984 and Lock in 1985 has opened new horizons in treating this pathology.
Selection of patients for VMP
The echocardiogram is the actual test to carry out the indication, not only because it provides us with information on the severity of the MS but also provides us with information on the morphology and valvular and subvalvular involvement, degree of calcification, presence of mitral insufficiency, lesions associated valves, degree of pulmonary hypertension and presence of thrombus in LA.
In the indication of PMV, specific evaluations must be taken into account:
1) functional grade, 2) hemodynamic evaluation (transmitral gradient and mitral area), and 3) echocardiographic evaluation to determine the degree of MS (mild if ≥1.5 cm2; moderate 1.0-1.5 cm2; severe <1.0 cm2), presence and degree of mitral regurgitation (MR), and mitral anatomy.
There are two classifications to assess the anatomy: the French classification (flexible, rigid, and/or fibrocalcific) and the Wilkins Score, which gives values from 1 to 4 for flexibility, thickening, calcification, and subvalvular involvement, with a total score of 4 to 4. 16.
A score <8 and a flexible valve are the most favorable; score 9-10 and fibrous valves are less fortunate, and score ≥11 and fibrocalcific valves are the least indicated for PMV.
It would be indicated in:
- Patients with moderate or severe MS have symptoms that do not improve with medical treatment.
- In asymptomatic patients in situations such as MS and severe pulmonary hypertension; women with severe or moderate-severe MS who wish to become pregnant; significant left atrial enlargement leading to loss of sinus rhythm; Severe MS in patients who are going to undergo substantial surgery that a situation of pulmonary edema could complicate.
- In patients with mild MS but with disabling symptoms that do not subside with medical treatment1.
Evaluates the extent of the valvular and subvalvular compromise, determining the probability of a successful result of PBMV, assigns a value from 0 to 4 to each of the following four elements:
- Degree of motility of the mitral valves
- The severity of valve thickening
- The seriousness of leaflet calcification
- Thickening and calcification of the subvalvular apparatus
Initially, the transseptal puncture is performed to reach the left atrium (see video 1) from the right atrium. Next, a long guide (wire) is advanced that is located in the left atrium (see video 2), and that will help us advance the Inoue balloon (valvuloplasty balloon).
The Inoue balloon in the left atrium is advanced to the left ventricle through the mitral valve. Once the Inoue balloon is located in the left ventricle, progressive inflation is performed so that the most distal balloon is inflated first, which will serve to anchor the balloon in the valve when it is removed.
Once the first balloon is anchored to the valve, we complete the balloon inflation in an hourglass shape (see video 3) with the mitral valve in the center of the balloon (notch).