Yokoi, Masashi Iwabuchi, Hitoshi Yasumoto and Hideyuki Nosaka

Masakiyo Nobuyoshi, Takeshi Arita, Shin-ichi Shirai, Naoya Hamasaki, Hiroyoshi

Percutaneous Balloon Mitral Valvuloplasty : A Review
ISSN: 1524-4539
Copyright 2008 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online
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Percutaneous Balloon Mitral Valvuloplasty
A Review
Masakiyo Nobuyoshi, MD; Takeshi Arita, MD; Shin-ichi Shirai, MD; Naoya Hamasaki, MD;
Hiroyoshi Yokoi, MD; Masashi Iwabuchi, MD; Hitoshi Yasumoto, MD; Hideyuki Nosaka, MD
S
everal diseases have been acknowledged as pathological
causes for mitral valve stenosis (MS), of which rheumatic
heart disease is the most prevalent. Rheumatic heart disease is
a chronic manifestation of rheumatic carditis, which occurs in
60% to 90% of cases of rheumatic fever. Rheumatic fever is
a late sequela to Group A -hemolytic streptococcal infection
of the throat. The initial rheumatic fever results only in an
edematous inflammatory process, leading to the fibrinoid
necrosis of the connective tissue and cellular reactions. The
initial valvulitis results in verruciform deposition of fibrin
along the closing portion of the leaflets. Although all of the
cardiac valves may be involved by this rheumatic process, the
mitral valve is involved most prominently. The endocardial
lesion most often leaves permanent sequela resulting in
valvular regurgitation, stenosis, or both. Stenosis of this valve
occurs from leaflet thickening, commissural fusion, and
chordal shortening/fusion due to the above described patho-
logical process.
Rheumatic Heart Valve Disease Is Still
Epidemic in Asia
The decrease of the incidence of rheumatic heart disease in
developed countries had already begun in 1910, and it is now
below 1.0 per 100 000. On the other hand, the occurrence rate
of rheumatic heart disease in developing countries remains
substantial. Because the decline in the prevalence of rheu-
matic fever in industrialized nations started even before the
era of penicillin and thus was related to improved living
standards, the continued prevalence of rheumatic heart dis-
ease in undeveloped or developing countries is related not
only to the limited availability of penicillin but to their
socioeconomic status (ie, overpopulation, overcrowding, pov-
erty, and poor access to medical care).
According to the annual report by the World Heart Feder-
ation, an estimated 12 million people are currently affected by
rheumatic fever and rheumatic heart disease worldwide, and
high incidence rates are reported in the Southern Pacific
Islands. Several studies were conducted on the prevalence of
rheumatic heart disease, reporting 0.14/1000 in Japan,
1
1.86/
1000 in China,
2
0.5/1000 in Korea,
3
4.54/1000 in India,
4
and
1.3/1000 in Bangladesh.
5
In rapidly evolving Asian countries, awareness of rheu-
matic heart disease has prevailed along with the widespread
use of transthoracic echocardiography. Furthermore, de-
mands for adequate medical therapies are expanding in
tandem with explosive socioeconomic growth that may con-
tribute to expanding use of percutaneous balloon mitral
valvuloplasty (PBMV).
Percutaneous Balloon Mitral Valvuloplasty:
The Concept
Before the advent of PBMV, most patients with symptomatic
MS were treated with surgical mitral commissurotomy, either
open or closed. Closed mitral commissurotomy was first
described by Harken and Bailey in the late 1940s.
6
Subse-
quently, after the development of cardiopulmonary bypass,
the open surgical commissurotomy replaced the closed tech-
nique in most countries in the late 1960s and early 1970s. In
1982, Kanji Inoue, a Japanese cardiac surgeon, first devel-
oped the idea that a degenerated mitral valve could be inflated
using a balloon made of strong yet pliant natural rubber.
7
This
concept was similar to the already abandoned closed surgical
technique at that time. At first, this unique technique was
largely limited to the Far East Asia, whereas in most of the
other countries traditional cylindrically shaped balloons,
which were initially developed for pulmonic valvuloplasty,
were utilized for mitral valvuloplasty. Lock et al
8
in India first
reported the use of such a cylindrical balloon for mitral
valvuloplasty. Subsequently, the idea of a double-balloon
technique was introduced from Saudi Arabia
9
as a potential
alternative method for balloon commissurotomy. The double-
balloon technique requires that 2 guidewires be positioned in
the left ventricular apex, through which 2 floating balloon
catheters are then advanced across the mitral valve orifice.
Although the double-balloon technique is surely effective, it is
more technically demanding and thus often requires a longer
procedure time, which may lead to inadvertent complications.
The guidewire positioned in the left ventricular apex sometimes
induces perforation of the apex, leading to cardiac tamponade. In
fact, PBMV using a single Inoue balloon yields equivalent
efficacy when compared with the double-balloon technique and
with lower procedural risks.
10
Today, therefore, Inoues single-
From Kokura Memorial Hospital (M.N., T.A., S.S., H. Yokoi, M.I. H. Yasumoto, H.N.) and Hamasaki Cardiology Clinic (N.H.), Kitakyushu, Japan.
Correspondence to Masakiyo Nobuyoshi, MD, Department of Cardiology, Kokura Memorial Hospital, 11, Kifune-cho, Kokura-kitaku, Kitakyushu,
Japan. E-mail kmhptca@kokura-heart.com
(Circulation. 2009;119:e211-e219.)
2009 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.108.792952
e211
Heart Disease in Asia
by guest on January 8, 2012 http://circ.ahajournals.org/ Downloaded from
balloon technique has become the most popular method for
performing PBMV in most parts of the world.
The mechanism of PBMV is the same as the already
abandoned closed mitral commissurotomy.
11
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
better
12,13
success rates and comparable restenosis rates.
13
Randomized trials comparing PBMV to closed commissurot-
omy have shown that PBMV is superior to closed commis-
surotomy, providing a larger valve area and better long-term
durability.
14
Echocardiography Plays a Major Role in
Patient Selection for PBMV
Indications for PBMV
The management of symptomatic and severe MS is described
comprehensively in recent guidelines published jointly by the
American Heart Association (AHA) and the American Col-
lege of Cardiology (ACC)
15
and in guidelines published by
the European Society of Cardiology (ESC)
16
(Figure 1).
In the case of moderate or severe MS, one has to assess the
anatomy of the mitral valve meticulously with regard to the
feasibility and safety of PBMV. As shown in Table 1, the
most widely used echocardiographic parameter is the Wilkins
score, which takes into consideration the anatomy of the
leaflet, the commissures, and the subvalvular apparatus.
17
The
scoring system assigns a point value from 1 to 4 for each of
(1) valve calcification, (2) leaflet mobility, (3) leaflet thick-
ening, and (4) subvalvular apparatus degeneration. A mitral
valve with a score 8 to 9 with no more than moderate mitral
regurgitation is deemed the best candidate for PBMV. In
patients with a score 9 to 10, especially with more than
moderate mitral regurgitation, surgical therapy should be
advised except in cases with serious comorbidities.
A simpler echocardiographic classification for the stenotic
mitral valve is the Iung and Cormier score
18
(Table 2). This
score is unique for taking the length of the chordae into
consideration.
A limitation of both scoring systems is the lack of
information on the location of valve abnormalities in relation
to the commissures, which may influence the results of
PBMV.
19,20
As PBMV theoretically helps resolve MS by
splitting the commissures, a valve with a bilateral commis-
sural fusion could benefit more fully. Conversely, a valve
without any commissural fusion, in which rigid leaflets or
Figure 1. ACC/AHA guidelines in 2007
advocate earlier use of PBMV for symp-
tomatic patients with MS in cases where
the valve morphology is adequate. H&P
indicates history and physical; CXR, chest
x-ray; ECHO, echocardiogram; MVA,
mitral valve area; PASP, pulmonary artery
systolic pressure; PAWP, pulmonary
artery wedge pressure; MVG, mitral valve
gradient; and PH, pulmonary hyperten-
sion. Adapted from Bonow et al
15
with
permission from the American Heart
Association. Copyright 2006 by the Amer-
ican College of Cardiology Foundation
and the American Heart Association, Inc.
Table 1. Wilkins Score
Grade Mobility Thickening Calcification Subvalvular Thickening
1 Highly mobile with only leaflet
tips restricted
Leaflets near normal in
thickness (45 mm)
A single area of increased
echo brightness
Minimal thickening just below the mitral
leaflets
2 Leaflet mid portions and base
portions have normal mobility
Midleaflets normal, considerable
thickening of margins (58 mm)
Scattered areas of brightness
confined to leaflet margins
Thickening of chordal structures extending
to one of the chordal length
3 Valve continues to move
forward in diastole, mainly
from the base
Thickening extending through
the entire leaflets (58 mm)
Brightness extending into the
mid portions of the leaflets
Thickening extended to distal third of the
chords
4 No or minimal forward
movement of the leaflets in
diastole
Considerable thickening of all
leaflet tissue (810 mm)
Extensive brightness
throughout much of the
leaflet tissue
Extensive thickening and shortening of all
chordal structures extending down to the
papillary muscle
Adapted from Wilkins et al
17
with permission from BMJ Publishing Group Ltd. Copyright 1988 BMJ Publishing Group Ltd and British Cardiovascular Society.
e212 Circulation March 3, 2009
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annulus gives rise to orifice stenosis, may not benefit from
commissurotomy because the leaflets or subvalvular appara-
tus could fracture. In addition, the presence of severe or
bilateral calcification on the commissures could predict poor
outcome due to worsening mitral regurgitation postprocedur-
ally
21
or a suboptimal increase in the valve area.
22,23
Which-
ever scoring system is adopted, the success of PBMV requires
that the pliability of the leaflet and the degree of degeneration
and calcification of the commissures, subvalvular apparatus,
annulus, and the leaflets be meticulously assessed.
To detect thrombus in the left atrium or left atrial append-
age, transesophageal echocardiography should be performed
before performing PBMV. At our institute, we never perform
PBMV if we find thrombus in the left atrium or left atrial
appendage. Although some investigators have insisted that
PBMV can be safely performed even when thrombus is
present in the left atrial appendage,
24
this therapeutic ap-
proach should be seriously discouraged. If thrombus is found,
PBMV should be postponed and the patient should be started
on warfarin with the prothrombin timeinternational normal-
ized ratio controlled at a relatively higher level for 3 to 6
months, after which transesophageal echocardiography should
be repeated to confirm the disappearance of the clot. If the
thrombus has disappeared, PBMV can then be safely performed,
or if the thrombus remains, surgical intervention on the mitral
valve along with removal of the thrombus should be
recommended.
Controversies about indications for PBMV exist in cases
with (1) asymptomatic moderate (mitral valve area 1.0 to 1.5
cm
2
) to severe (mitral valve area 1.0 cm
2
) MS, (2) symp-
tomatic mild (mitral valve area 1.5 cm
2
), and (3) symptom-
atic severe MS with unfavorable anatomic characteristics.
In asymptomatic moderate to severe MS, both guidelines
advocated that early use of PBMV be considered for patients
with high risk of embolism (ESC: paroxysmal atrial fibrilla-
tion [Class IIa], history of embolism [Class IIa], evidence of
atrial spontaneous contrast echo [Class IIa]; AHA/ACC: new
onset of paroxysmal atrial fibrillation [Class IIb] or hemody-
namic decompensation; ESC: high pulmonary artery systolic
pressure [Class IIa], need for major surgery [Class IIa], and
pregnancy [Class IIa]; and AHA/ACC: pulmonary hyperten-
sion at rest [Class I] or during exercise [class I] and poor
exercise tolerance [Class I] when patients have favorable
clinical/anatomic characteristics). If patients complain of
dyspnea on exertion that is out of proportion to the degree of
MS, the ACC/AHA guideline recommends use of exercise
Doppler echocardiography
25
to reveal occult hemodynam-
ically significant MS.
The prognostic significance of such hemodynamic com-
promise at exercise, however, remains unclear, and therefore
application of PBMV for asymptomatic mild MS should be
carefully reviewed in each case. The ACC/AHA guidelines
recommend use of PBMV in these scenarios (Class IIb). On
the other hand, mitral valve area 1.5 cm
2
is considered one
of the contraindications to PBMV according to the ESC
guidelines.
Although the underlying mitral valve morphology is the
factor of greatest importance in determining outcome after
the therapy, PBMV can be offered as the initial treatment
(ESC: Class IIa, AHA/ACC: Class IIa) for selected patients
with unfavorable anatomic characteristics but no unfavorable
clinical characteristics (ESC: Class IIa; the ESC defines
unfavorable clinical characteristics as absence of several
factors: old age, New York Heart Association [NYHA] class
IV, severe pulmonary hypertension, atrial fibrillation and
history of commissurotomy) or have high surgical risk (AHA:
Class IIa).
Contraindications to PBMV are summarized in Table 3. In
addition to these, a MS with no commissural fusion should be
considered as a relative contraindication, as previously de-
scribed. PBMV should be considered first-line therapy in
most cases of severe MS without obvious contraindications.
2
Selection of Appropriate Balloon Size
Selection of the appropriate balloon size is one of the most
critical factors for accomplishing this procedure (ie, for
releasing the stenotic mitral orifice without causing extensive
damage to the commissures, leaflets, and subvalvular appa-
ratus leading to excessive mitral regurgitation). For selecting
the appropriate balloon size, some researchers have advo-
cated methods to select balloon size with the patients
height
26
or body surface area
27
as a reference. A simple
equation to obtain the reference size (height [cm]/1010) has
been proposed.
28
The obvious point should be made, how-
ever, that the relationship of ones height to the diameter of
the mitral valve orifice is not necessarily linear. Furthermore,
the operator must remember that annular calcification will
affect the size of the mitral valve orifice regardless of the
patients physical constitution. To avoid undesired extensive
injury to the mitral valve apparatus, we select the balloon size
by directly measuring the mitral annular diameter using
2-dimensional echocardiography. The mitral annular diame-
ter can be measured on the apical 4- or 2-chamber view
during mid- to end-systole. Measuring mitral annular diam-
Table 2. Iung and Cormier Score
Group Mitral Valve Anatomy
1 Pliable noncalcified anterior mitral leaflet and mild subvalvular
disease
2 Pliable noncalcified anterior mitral leaflet and severe
subvalvular disease
3 Calcification of mitral valve of any extent, as assessed by
fluoroscopy, whatever the state of the subvalvular apparatus
Adapted from Iung et al
18
with permission from the American Heart
Association. Copyright 1996 American Heart Association.
Table 3. Contraindications to PBMV
Persistent left atrial or left atrial appendage thrombus
More than moderate mitral regurgitation
Massive or bicommissural calcification
Severe concomitant aortic valve disease
Severe organic tricuspid stenosis or severe functional regurgitation with
enlarged annulus
Severe concomitant coronary artery disease requiring bypass surgery
Nobuyoshi et al Mitral Valvuloplasty e213
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eter at different planes gives different values owing to the
noncircular, nonplanar shape of the annulus. Theoretically, a
diameter close to the distance between 2 commissures (prob-
ably annular diameter on the apical 2-chamber view) could
serve as the reference size for the Inoue balloon. However,
the minimal mitral annular diameter should be adopted to
avoid the risk of tearing the leaflets. Figure 2 shows an
example in which the diameter of the mitral valve orifice was
measured at 22.8 mm. In this case, we chose a 22-mm balloon
catheter, and initially we inflated the balloon to 20 mm, 2 to
3 mm smaller than the maximal balloon size.
The PBMV Procedure
The Inoue Balloon catheter (Toray, Tokyo, Japan) is a 12F
polyvinylchloride tube with a coaxial lumina. The balloon
section is stiffened and slenderized when stretched by the
insertion of a metal tube. The balloon size is pressure
dependent and consists of 3 portions with slightly different
compliance. As pressure is gradually added, the distal portion
of the balloon inflates first, followed by the proximal portion.
The unique part of the Inoue balloon is its middle waist
portion that has the least pressure compliance, with which
fixation of the balloon catheter is facilitated and the degen-
erated fused commissure(s) can be dilated substantially.
The procedure is always performed via a femoral approach
with a 9F sheath in the vein and a 5F sheath in the artery, with
the patient under light sedation. After bolus administration of
1000 U heparin, right heart catheterization is performed.
Right atriography is then performed to determine the septal
puncture site for the Brockenbrough needle. Transseptal
catheterization is performed via a standard Brockenbrough
procedure using anteroposterior views. While slowly with-
drawing the Brockenbrough catheter from superior vena cava
into the interatrial septum, the operator advances the Brock-
enbrough needle beyond the interatrial septum when the tip of
the catheter falls into the fossa ovalis. Computed tomography
or transesophageal echocardiography can be useful in identi-
fying the anatomic location of the interatrial septum relative
to the right atrium. Transesophageal or intracardiac echocar-
diography can be used not only as guidance for the Brock-
enbrough procedure but also as a monitor to early detect
serious complications (ie, perforation and tamponade).
After advancing the Brockenbrough needle, a coiled-tip
guidewire is placed into the left atrium through the Brocken-
brough sheath. Then, we administer 9000 U of heparin to
reduce the risk of a thromboembolic event during the manip-
ulation of catheters and wires in the left atrium. Anticoagu-
lation time is monitored during the procedures to maintain
appropriate levels of anticoagulation.
In the next step, the Inoue balloon catheter is advanced
over the coiled-tip wire. A system for accomplishing PBMV
consists of the following devices
29
: Inoue balloon catheter,
metallic stiffening cannula (18 gauge, 80 cm in length) for
stretching and stiffening the Inoue balloon catheter, guide-
wire for PBMV (0.028 inches in diameter, 180 cm in length),
dilator (14F polyethylene tube with a thinner tip 70 cm in
length) for dilating the puncture site of the femoral vein and
atrial septum, and a stylet (wire with J-shaped tip, 0.038
inches in diameter, 80 cm in length) for directing the Inoue
balloon toward the mitral orifice. Once the balloon catheter
has crossed the interatrial septum, the catheter should be
placed in the left atrium so that the catheter forms a loop with
the tip facing toward the mitral valve orifice. The tip of the
balloon is inflated with 1 to 2 mL of contrast media, allowing
blood flow to direct the balloon tip into the left ventricle. If
advancement of the Inoue balloon proves difficult, the stylet
is inserted in the balloon catheter, and the balloon catheter
with stylet are moved together toward the mitral valve orifice.
With the right anterior oblique view, which helps identify the
proper line between the base and the apex, the deflated Inoue
balloon catheter is advanced until the tip of the catheter has
crossed the mitral valve into the left ventricle.
Once the balloon catheter has been inserted into the left
ventricle, the distal portion of the balloon is inflated with
contrast media using a specially graduated syringe. The
catheter is then pulled until resistance is felt. During inflation
of the balloon, the appearance of a deformed distal balloon
may suggest entrapment in the subvalvular apparatus. In this
situation, further inflation should not be performed and the
balloon should be repositioned to a location that is more
proximal to the mitral orifice to avoid trauma to the subval-
vular apparatus.
The Inoue balloon has a much less compliant portion in its
waist that assists in the secure dilatation of the mitral valve
orifice. Figure 3 shows the typical step-by-step appearance of
the Inoue balloon catheter. Before placing the Inoue balloon
catheter, we routinely select the balloon size by which valve
orifice is finally dilated, as previously described.
After each dilatation, the operator should obtain the left
atrial pressure through the middle port of the Inoue catheter
and the left ventricular pressure through the pig-tail catheter
simultaneously. If the pressure gradient between the left atrial
pressure and the simultaneously obtained left ventricular
pressure does not decrease, the balloon size is increased in
1-mm increments until the pressure gradient decreases or
substantial worsening of mitral regurgitation occurs. In addi-
tion, 2-dimensional echocardiographic observations are per-
formed after each dilatation. To assess mitral valve orifice
area after each dilatation, planimetry of the valve orifice with
2-dimensional echocardiography should be adopted rather
than the pressure half-time method on continuous Doppler
Figure 2. Measurement of mitral valve annular diameter.
e214 Circulation March 3, 2009
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waveform, because pressure half-timederived orifice area
might be inaccurate in this acute setting.
30
If 1 of the 3 following events is encountereddecrease in
the pressure gradient between the left atrium and the left
ventricle, occurrence of significant mitral regurgitation, or
substantial splitting of the commissurefurther dilatation is
not performed unless critical complications might otherwise
ensue.
31
Immediate Results of PBMV
The binary end point of immediate procedural success is most
often a final valve area 1.50 cm
2
without moderate or severe
mitral regurgitation. After PBMV, mitral valve area approx-
imately doubles in most successful cases. Mitral valve anat-
omy as assessed by 2-dimensional echocardiography is a
strong predictor of the immediate results of PBMV. The
previously described Wilkins score has a discriminant cut-off
point at 8 according to analyses of the immediate results of
PBMV. Whatever echo scoring system is used, older age,
smaller valve area, previous commissurotomy, or baseline
mitral regurgitation should be considered as potential predic-
tors for poor immediate outcome with a similar predictive
strength as valve calcification.
18
In clinical practice, young
patients (50 years old) with favorable valve anatomy have
usually showed particularly good immediate results.
3234
Post-PBMV Complications
Most of the adverse complications relevant to this procedure
occur during the procedure
32
(ie, during the process of
interatrial septum puncture, manipulation of the Inoue bal-
loon catheter in the left atrium, and commissurotomy of the
mitral valve by Inoue balloon catheter). Major complications
with regard to the Brockenbrough puncture are related to
penetration of the Brockenbrough needle into the adjacent
structure (ie, ascending aorta and the postatrium pericardial
space). The most common serious complication is hemoperi-
cardium, with an incidence of 0% to 2.0%.
35
When hemo-
pericardium or rupture into the space surrounding the aortic
root occurs, protamine sulfate should be administered to
promote spontaneous hemostasis unless urgent surgical inter-
vention is necessary.
Although relatively rare, unintended perforation by the tip
of the Inoue catheter or guidewires while being manipulated
in the cardiac chambers might happen in the left atrial
appendage, the pulmonary veins, or the left ventricular apex
because of the vulnerability of these structures. Detachment
of undetected microthrombi in the left atrium or left atrial
appendage by the catheter or guidewire tip also could occur.
To avoid these mechanical complications, gentle manipula-
tion of the guidewires and catheters should be required, and
the Inoue catheter should be formed using the stylet, with the
tip of the catheter properly directed toward the mitral valve
orifice.
An increase of mitral regurgitation is another possible
complication after commissurotomy; however, in most cases,
the degree of mitral regurgitation slightly increases after
PBMV without requiring surgical intervention. The mecha-
nism of the increase or new appearance of mitral regurgita-
Figure 3. Manipulation of the Inoue bal-
loon catheter. A, Advanced deep into the
left ventricle. B, Pulled with the distal por-
tion inated. C, Ination of the proximal
portion followed by ination of the middle
waist portion of the balloon. D, Properly
inated middle portion of the balloon
securely dilates commissural.
Nobuyoshi et al Mitral Valvuloplasty e215
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tion is reported to be excessive tearing of the commissures(s)
or the posterior/anterior leaflet at noncommissural part,
incomplete closure of a calcified leaflet, localized rupture
of the subvalvular apparatus, and shortened chordate
tendineae after splitting of the commissure(s). Severe
mitral regurgitation is relatively rare, with a frequency
ranging from 1.4% to 9.4%.
33,36
Puncture by the Brockenbrough needle and by advanc-
ing the 9F catheter at the interatrial septum creates an
iatrogenic left-to-right shunt at the interatrial level persist-
ing for more than several months and, in some cases, years.
These shunts, with a frequency of 10% to 90% dependent
on the methods used for their detection, are usually small
and restrictive and almost never become hemodynamically
significant (Qp/Qs 1.5).
Long-Term Results
Most patients with initial procedural success report signifi-
cant functional improvement. When immediate results are
suboptimal, the patients functional status does not improve
or improves only transiently. Because the mechanism and
background of MS may affect the long-term results of
PBMV, analysis should be conducted in 2 different categories
of the population: (1) in young patients with favorable valve
anatomy who are the homogenous population mainly encoun-
tered in developing countries; and (2) in older patients with
less-favorable valve anatomy, who are a much more heterog-
enous group and who are seen in Western countries.
The best results of PBMV are observed in young patients
who have MS with favorable anatomic characteristics (ie,
pliable noncalcified valves and moderate impairment of the
subvalvular apparatus). Published series from India and
Tunisia have clearly demonstrated the safety and efficacy of
PBMV in such patients.
37,38
After PBMV, at least 90% of
patients are alive without intervention on the mitral valve and
with few or no symptoms 5 to 7 years after the procedure.
37,38
Randomized trials conducted in these young populations
show that 3- and 7-year results of PBMV are as good as those
obtained with open-heart commissurotomy
39
and better than
those with closed-heart commissurotomy.
37
Fawzy et al
40,41
reported an event-free survival rate of 79%
at 10 years and 43% at 15 years in relatively younger patients
(mean age 3111 years) and were significantly higher for
patients with optimal valve anatomy (88% at 10 years, 66% at
15 years). They found that favorable valve anatomy, age, and
postprocedural mitral valve area were predictors of event-free
survival.
42
Iung et al
43
reported an event-free survival (survival with
freedom from repeat PMBV, mitral valve replacement, car-
diac death, high NYHA class) rate of 61% at 10 years in
1000 patients (mean age 4914 years) with successful
PBMV. Although favorable long-term prognosis largely de-
pends on immediate procedural success, the prediction of late
prognosis includes multiple factors including old age, unfa-
vorable valve anatomy, high NYHA class, atrial fibrillation,
low valve area after PBMV, high gradient after PBMV, and
grade 2 mitral regurgitation after PBMV.
43,44
Suboptimal immediate results lead to relatively early in-
tervention, which explains the presence of an early drop of
event-free survival after the procedure. Conversely, some
patients experience late functional deterioration many years
after the procedure, which is likely related to mitral resteno-
sis.
45
Post-PBMV mitral restenosis is defined as a valve area
1.5 cm
2
or a 50% loss of the initial gain in valve area.
46
Reportedly, the freedom from restenosis rates were 85% at 5
years, 70% at 10 years, and 44% at 15 years and were
significantly higher (ie, 92% at 5 years, 85% at 10 years, and
65% at 15 years) for patients with optimal morphology.
40,41
Repeat PBMV should be proposed as first-line therapy if
patients had symptoms related to MS and showed only mild
mitral regurgitation based on the observational evidence that
the mechanism of mitral restenosis is primarily commissural
refusion.
47
In patients with incomplete commissural fusion,
repeat PBMV might end in suboptimal results.
48
In cases
without any commissural fusion, mitral restenosis could be
due to a rigid valve or subvalvular apparatus, and therefore
repeat PBMV should be considered as contraindicated.
The presence and degree of post-PBMV mitral regurgita-
tion play a part in long-term prognosis. When severe mitral
regurgitation occurs after PBMV, the patients prognosis is
relatively poor and surgical treatment is required at some
point. The mechanism of post-PBMV mitral regurgitation is
reported to be closely related to long-term prognosis.
49
Although most mild but significant cases of mitral regurgi-
tation are caused by commissural split, the causes of new
appearance of severe mitral regurgitation are chordal rupture
or leaflet laceration. Kim et al reported that patients with
commissural mitral regurgitation had a significantly lower
rate of mitral valve replacement than patients with noncom-
missural mitral regurgitation.
49
PBMV for Special Patient Populations
A number of special patient subgroups are important to
consider.
Postsurgical or Balloon Commissurotomy
PBMV can safely be performed for most patients after
commissurotomy, either surgical or percutaneous. Two major
mechanisms are responsible for valvular restenosis: commis-
sural refusion and progression of subvalvular thickening/
degeneration. Turgeman et al reported that patients with
mitral restenosis caused by symmetrical commissural refu-
sion obtain better results from repeat procedures compared
with patients with restenosis in whom the pathological
mechanism of restenosis is mainly subvalvular and commis-
sures are not bilaterally fused but rather unilaterally or bilaterally
split.
48
With regard to the long-term prognosis of patients treated
with repeat PBMV or with surgical replacement in cases of
mitral restenosis after PBMV, several reports have supported
safety and favorable outcome for repeat PBMV.
50,51
How-
ever, the most recent study demonstrated a more favorable
outcome for mitral valve replacement, especially in patients
followed up for 9 years.
52
One report
47
compared repeat PBMV for postintervention
restenosis with initial PBMV for de novo MS relative to
immediate results and long-term results. No significant dif-
ferences were found between repeat and initial PBMV rela-
e216 Circulation March 3, 2009
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tive to good immediate results (postprocedural MVA 1.5
cm
2
, mitral regurgitation 2/4) and freedom from restenosis
rates at 10 years follow-up (93% versus 96%, and 58%
versus 68%, respectively). Ten-year event-free survival rates
were slightly higher for patients who underwent initial
PBMV for de novo MS (54% versus 80%).
Pregnant Patients
Pregnancy can become a hemodynamic burden even in
normal subjects by increasing the intravascular volume by
30% to 50% over nonpregnant levels. This hemodynamic
change might result in an increase in the transmitral gradient
and left atrial pressure, which may lead to acute pulmonary
flash edema. Maternal mortality for patients with MS who are
in NYHA class 1 and 2 is 0.4% and significantly higher
(6.8%) for those in NYHA class 3 and 4, particularly during
labor and delivery.
53
Surgical commissurotomy is indeed
effective for most of these patients but is reported to have
maternal mortality between 1.7% and 3.1% and fetal mortal-
ity ranging from 5% to 33%.
53,54
PBMV should be performed
by experienced operators with abdominal and pelvic shield-
ing and with minimum radiation exposure and should be
avoided during the first trimester. With these precautions,
PBMV can be safely performed. Esteves et al
55
reported
optimal immediate and long-term results in pregnant patients
who underwent PBMV during the second trimester of their
pregnancy.
Children and Adolescents
Characteristically, MS evolves through several fairly well-
defined clinical stages. Specifically, a latent period has been
identified of 10 to 20 years before symptons appear. In
tropical and subtropical regions, however, progression may
be more rapid.
56
Tight MS was not a common lesion in
children in Western countries even when rheumatic fever was
rampant.
57
Furthermore, it has been stated that only 50% of
patients with premature MS show Aschoff bodies at surgery
or autopsy.
57
Questions on whether juvenile MS is a true
variant of rheumatic MS remain to be answered. Several
researchers have reported similar
58
or even better
59,60
success
rates for PBMV in children with MS. Severe congenital MS
is a rare mitral valve deformity with several anatomic
subtypes: typical, supramitral mitral ring, parachute mitral
valve, and double-orifice mitral valve. Although most pa-
tients with congenital MS can safely be treated by PBMV,
higher rates of postprocedural exacerbation of mitral regur-
gitation due to tearing of the leaflet or subvalvular apparatus
have been reported.
61,62
Atrial Fibrillation/Thrombotic Formation
Atrial fibrillation occurs commonly in MS, affecting almost
40% of all patients. Atrial fibrillation in rheumatic MS is
different in pathophysiology from atrial fibrillation in non-
rheumatic disease. ACC/AHA guidelines suggest that PBMV
can be a therapeutic option for patients with asymptomatic
MS and with newer occurrence of atrial arrhythmias.
15
Admittedly, after successfully relief of an obstructed mitral
valve orifice, left atrial function improves, as evidenced by
the reduced size of left atrial volume,
63
improved left append-
age flow velocity,
64
and decreased intensity of spontaneous
contrast echo.
65
However, no large trials have shown an
antiarrhythmic effect of PBMV.
66
One promising study has
shown that successful PBMV was strongly associated with a
decreased thromboembolic risk in patients with MS and atrial
fibrillation.
67
Further studies are required to show beneficial
effects of PBMV besides hemodynamic improvement.
Conclusion
Although the incidence of rheumatic fever and the prevalence
of rheumatic heart disease as a sequela are decreasing in most
Asian countries, a small but substantial occurrence of rheu-
matic MS exists and will continue to exist in Asia. The need
for adequate understanding of indications, PBMV proce-
dures, and assessment of results cannot be overemphasized.
Disclosures
None.
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KEY WORDS: balloon valvuloplasty

echocardioagraphy

mitral valve

mitral valve stenosis

rheumatic heart disease
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