Percutaneous Mitral Valvuloplasty Research Articles

Percutaneous Mitral Balloon Valvuloplasty in a Patient with Situs Inversus with Dextrocardia: A Case Report

Situs inversus with dextrocardia is a rare congenital disorder. There is a rare coincidence of rheumatic severe mitral stenosis in a patient with situs inversus and dextrocardia. Most of these patients undergo surgery due to technical difficulty, here we report a case of a 41-year-old male managed successfully with percutaneous intervention. Percutaneous mitral balloon valvuloplasty (PMBV) is feasible in these rare group patient with some additional modifications of the standard Accura balloon technique. Procedure should be carried out under Transthoracic echocardiography (TEE) guidance with surgical team standby in case emergency need of surgery. Despite all the precautions, careful watch on these patients has to be kept during immediate post procedure phase for at least 12 hours for any untoward complication.

“Unveiling the Complexity: Coexistence of Rheumatic Heart Disease and Pulmonary Arteriovenous Malformation - A Unique Case Report”

Abstract Background The coexistence of Rheumatic Heart Disease (RHD) and Pulmonary Arteriovenous Malformation (PAVM) is a rare clinical scenario that poses diagnostic and therapeutic challenges. This case report explores the clinical presentation, diagnostic journey, and multidisciplinary management of a patient presenting with both conditions. Case Summary A 47-year-old female with a history of RHD presented with symptoms of dyspnoea on exertion and cyanosis, suggestive of both cardiac and pulmonary involvement. Subsequent investigations involving imaging, echocardiography, and invasive pulmonary angiography, revealed the co-existence of RHD and multiple PAVM in patient’s left lower lobe of lung. The patient underwent a tailored treatment plan, initially involving percutaneous mitral balloon valvuloplasty for RHD, followed by a staged procedure of transcatheter PAVM closure with Amplatzer™ Vascular Plug II performed one month later. Her saturation normalized following intervention. The patient's progress was monitored closely, with adjustments made to the treatment plan based on evolving clinical scenarios. Patient remained well in short term follow up. Discussion This case highlights the complexity of managing patients having two diverse conditions RHD and PAVM coexisting together, thus emphasizing the importance of a multidisciplinary approach. The unique intersection of cardiac and pulmonary pathologies necessitates careful consideration of diagnostic nuances and tailored treatment strategies. Lessons learned from this case offer valuable insights for clinicians encountering similar scenarios and underscore the significance of individualized, patient-centred care in optimizing outcomes for those with dual pathologies.

Optimizing Percutaneous Mitral Valvuloplasty for Rheumatic Mitral Stenosis - Clinical Significance of Changes in Mitral Valve Area.

Percutaneous mitral valvuloplasty (PMV) is a standard treatment for severe rheumatic mitral stenosis (RMS). However, the prognostic significance of the change in mitral valve area (∆MVA) during PMV is not fully understood.Methods and Results: This study analyzed data from the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, which included 3,140 patients with severe RMS. We focused on patients with severe RMS undergoing their first PMV. Changes in echocardiographic parameters, including MVA quantified before and after PMV, and composite outcomes, including mitral valve reintervention, heart failure admission, stroke, and all-cause death, were evaluated. An optimal result was defined as a postprocedural MVA ≥1.5 cm2without mitral regurgitation greater than Grade II. Of the 308 patients included in the study, those with optimal results and ∆MVA >0.5 cm² had a better prognosis (log-rank P<0.001). Patients who achieved optimal results but with ∆MVA ≤0.5 cm² had a greater risk of composite outcomes than those with optimal outcomes and ∆MVA >0.5 cm² (nested Cox regression analysis, hazard ratio 2.27; 95% confidence interval 1.09-4.73; P=0.028). Achieving an increase in ∆MVA of >0.5 cm2was found to be correlated with improved outcomes. This suggests that, in addition to achieving traditional optimal results, targeting an increase in ∆MVA of >0.5 cm2could be a beneficial objective in PMV treatment for RMS.

Multimodality imaging in PMV: comparison between cardiac computed tomography and echocardiography from multicenter mitral stenosis registry (MASTER registry)

Abstract Background The Wilkins score is a grading system that, from the past to the present, provides vital hints in patients with rheumatic mitral stenosis (MS). However even if the score is modest, complications may occur after percutaneous mitral valvuloplasty (PMV)1. Also Wilkins score alone does not reflect the development of various multi-modality imaging related to mitral stenosis. The purpose of this study was to evaluate the variability between echocardiography and cardiac computed tomography (CT) in measuring the score, and to examine the immediate PMV outcome related to the score measured by each modalities. Methods From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry of 3,140 patients with at least moderate MS, we included 96 rheumatic MS patients (age 56.4±11.5 years, 78 women) who underwent PMV and had remeasurable images between January 2010 and December 2022. We analyzed the discrepancies between the Wilkins score determined by echocardiography (transthoracic echocardiography or transesophageal echo in certain individuals) and the score determined by cardiac CT as a whole or among each parameter. Furthermore, the frequency of composite outcomes with high scores was compared between modalities. A composite outcome was defined as a case in which the outcome following PMV was not optimal (post PMV mitral valve area (MVA) less than 1.5 cm2 or mitral regurgitation (MR) with grade II-III or higher occurred). Results The average Wilkins score obtained by echocardiography was less than that measured by CT. (7.2±1.3 vs. 8.0±2.4) CT displayed higher score values than echocardiography, particularly for thickness (n= 47, 41.7%) and sub-valvular thickness (n= 40, 41.7%). Echo evaluated the presence of calcium, but CT showed no calcium in many cases. (n=19, 19.4% vs. n=38, 39.6%). Based on the previously commonly used Wilkins score of 9 points, when evaluated by echocardiography, there wasn't a significant difference except for the post MVA (1.6±0.2 vs. 1.5±0.2 cm2, p value = 0.015) between less than and more than 9 points. Yet, in 40 patients with a CT-evaluated Wilkins score of 9 or higher, the post MVA was substantially smaller (1.6±0.1 vs. 1.5±0.3 cm2, p = 0.019) than in those without, and MDPG remained elevated even after the procedure. (4.0±1.4 vs. 4.9 ± 1.9 mmHg, p = 0.017) In addition, there were more cases where the MVA remained less than 1.5 cm2 after the procedure (n=10, 17.9% vs. n=22, 55.0%, p&amp;lt;0.001). For this reason, the composite outcome found to be highly likely to occur. Even when the Wilkins score evaluated by echo was low, the composite outcome ratio was similarly high if the CT score was high. Conclusions The average value of the Wilkins score measured by echocardiography was lower than that measured by CT, mainly due to differences in leaflet thickness and sub-valvular thickness evaluation. Cases with a high Wilkins score evaluated by CT were more likely to have suboptimal MVA or significant MR after PMV.Wilkins score measured by each modalitieComposite event rate by Wilkins score

Impact of procedural success definitions on long-term outcomes in patients with rheumatic mitral stenosis treated with percutaneous mitral valvuloplasty

Abstract Background Three different definitions of PBMV success have been reported in the literature. It is uncertain which definitions should be used in practice or clinical studies since there have been no comparative studies on the impact of these definitions on long-term outcomes after PBMV. Purpose We assessed the impact of the three PBMV success definitions on long-term outcomes in rheumatic MS patients treated with PBMV. Methods This was a retrospective study on consecutive severe rheumatic MS patients treated with PBMV in tertiary-care university hospital center between January 2003 and October 2020. Patients with in-hospital complications (death, emergency surgery or stroke) were excluded. Definition A was post-PBMV mitral valve area (MVA) ≥ 1.5 cm2 or ≥ 50% increase in MVA and mitral regurgitation less than 3+. Definition B was MVA ≥ 1.5 cm2 and MR ≤ 2+, and definition C was ≥ 50% increase in MVA or area of ≥ 1.5 cm2, with no more than 1 grade increment in MR severity. The patients were grouped according to success or no success according to each success definition. Cox regression analyses were performed to assess the associations between PBMV success and the composite outcome of all-cause death, mitral surgery or re-PBMV at long-term. Net reclassification improvement (NRI) was used to compare the impact of the success definitions. Results Of 589 patients included in the study, 83.2% were women with a mean age of 41.6 years and median Wilkin score of 8. The mean follow-up time was 5.5 years. The PBMV success rates according to the A, B and C definitions were 81.15%, 60.27% and 74.87%, respectively. Patients with PBMV success according to the A or B definitions had significantly lower risk of the composite outcome than those without success (success vs no success, definition A – HR 0.64, [95% CI 0.46-0.87], p 0.005, definition B – HR 0.71, [95% CI 0.53-0.94], p 0.016). Patients with PBMV success according to definition C had a similar risk of the composite outcome as those without success (HR 0.78, [95% CI 0.57-1.05], p 0.10). Patients with PBMV success according to definition A had a significantly lower risk of all-cause death than their counterparts (adjusted HR 0.57, [95% CI 0.38 - 0.86], p 0.006). The risk of death in patients with PBMV success according to the B or C definitions were similar to those without success. The c-indexes and 95% CIs for the composite outcomes of definitions A, B and C were 0.56 [0.52-0.60], 0.57 [0.52-0.61], and 0.54 [0.50-0.58], respectively. The A definitions discriminated the composite outcome better than the C definition (NRI – A vs. C 38.07%, [95% CI 13.18%-84.86%). The discriminative ability of the B definition was similar to the C definition (NRI - B vs. C 24.38%,[95% CI 11.37%-78.87%]). Conclusions The PBMV success rate varied among the different success definitions. The impact of success definitions A and B on long-term outcomes seemed to be better than the C definition.Characteristics of study patientsKaplan-Meier cumulative event

Abstract 14880: Optimizing Percutaneous Mitral Valvuloplasty for Rheumatic Mitral Stenosis: Clinical Significance of Mitral Valve Area Changes

Introduction: Percutaneous mitral valvuloplasty (PMV) is an established treatment for severe rheumatic mitral stenosis (RMS). However, there is limited data on the clinical significance of mitral valve area change (ΔMVA) during PMV on prognosis. Hypothesis: The prognosis improves with greater post-procedure ΔMVA. Methods: Data from the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, which included 3,140 patients with at least moderate RMS were analyzed. Out of those, patients with severe RMS (MVA &lt; 1.5 cm 2 ) who underwent their first PMV were included for analysis. Changes in echocardiographic parameters before and after PMV were calculated, and composite outcomes including all-cause death, heart failure admission, stroke, and mitral valve re-intervention were evaluated. Results: A total of 295 patients were included, and during the median follow-up of 91.1 months, composite outcomes occurred in 76 patients (16.5% in optimal and ΔMVA &gt; 0.5 cm2 group vs. 27.7% in optimal but ΔMVA ≤ 0.5 cm2 group vs. 35.7% in suboptimal group, respectively). Patients who achieved optimal results with ΔMVA &gt; 0.5 cm 2 had a better prognosis compared to other groups. (log-rank p=0.002). The group with optimal result but ΔMVA ≤ 0.5 cm2 had a higher risk for composite outcomes compared to the group with ΔMVA &gt; 0.5 cm2 (Hazard’s Ratio: 2.29, 95% confidence interval: 1.11-4.72, p=0.024). Conclusions: Achieving a significant increase in ΔMVA of at least 0.5 cm 2 can improve prognosis, and this could be recommended as an additional objective during PMV, in addition to the traditional optimal targets.

Abstract 16711: Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement versus Percutaneous Mitral Valvuloplasty

Introduction: Mitral stenosis (MS) severity is determined by mitral valve area (MVA); the threshold for severe MS was raised from MVA of 1.0 cm 2 to 1.5 cm 2 in recent guidelines. Hypothesis: This study aimed to compare the clinical outcomes, according to percutaneous mitral valvuloplasty (PMV) versus mitral valve replacement (MVR) treatment strategy, of severe MS patients with the updated criteria for the subgroups categorized by MVA of 1.0 cm 2 and 1.5 cm 2 . Methods: From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry of 3,140 patients, we included severe MS patients who underwent PMV or MVR between January 2000 and December 2021 except previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm 2 &lt;mva≤1.5 cm2 and MVA≤1.0 cm 2 , respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo-intervention. Results: Among 442 patients (mean 56.5±11.9 years, women 77.1%), the MVR group (n=260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n=182). During a mean follow-up of 6.9±5.2 years with inverse probability weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (p=0.010). In subgroup analysis of MS-MS and VS-MS patients, primary outcomes did not differ. However, the MVR group in VS-MS patients showed better secondary outcomes (p=0.012) (Figure). Conclusions: PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, due to increased early redo-intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

Abstract 13502: Obesity Paradox in Severe Rheumatic Mitral Stenosis: A Prospective Analysis Using a Machine Learning-Based Approach

Background: The obesity paradox posits that obese patients have better prognosis in cardiovascular diseases. Scarce data exists on the obesity paradox in rheumatic mitral stenosis (RMS) Hypothesis: Obesity is associated with a favorable prognosis in severe RMS Methods: Patients with severe RMS referred to a tertiary center from 2011 to 2022 were prospectively included. Patients with previous valve interventions were excluded; clinical and echocardiographic data were collected at baseline. Severe RMS was defined as a mitral valve area ≤ 1.5 cm2 by planimetry and patients were divided into 2 groups: (1) BMI ≥ 30 kg/m 2 ; (2) BMI &lt; 30 kg/m 2 . A combined outcome of percutaneous mitral valvuloplasty, mitral replacement and cardiovascular death was set. Logistic regression adjusted for confounders and gradient boosted decision-tree analysis were used Results: A total of 315 patients (82.2% female, mean age 53.3 years) were included. Over a median follow up of 30 months, 87% of patients had the outcome. MVA was higher in group 1 (p&lt;0.001) while left atrial volume index (LAVi) and net atrioventricular compliance were lower (p=0.008 both). Overall, BMI was not a good independent predictor of outcome (OR 0.98, 95% CI: 0.91-1.06, p=0.50) and occurrence of outcome was similar between groups (p=0.481). In both groups, mean importance of BMI in determining the outcome was similar (17.7 ± 6.1% and 17.0 ± 2.6% respectively) Conclusion: Obese patients had higher MVA and lower LAVi. However, our data suggests that BMI was not a significant independent predictor of poorer prognosis and its importance was not different between the groups. These findings challenge the obesity paradox in severe RMS

Sleep Quality in patients with rheumatic mitral stenosis and the effect of percutaneous mitral balloon valvuloplasty on Sleep Quality

Background: Impaired sleep quality is common in patients with heart disease. However, data on the effects of mitral stenosis severity and percutaneous mitral balloon valvuloplasty on sleep quality are scarce.&#x0D; Materials and methods: 205 patients included in the study were divided into two groups as severe and non-severe (mild to moderate MS) rheumatic MS. 123 patients with mild to moderate MS and 82 patients with severe MS were analyzed. 82 patients with severe rheumatic MS who underwent percutaneous mitral balloon valvuloplasty were prospectively enrolled. Sleep quality was prospectively investigated immediately before and approximately six months after the percutaneous mitral balloon valvuloplasty procedure. The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality.&#x0D; Results: The PSQI score was considerably higher in patients with severe MS compared to mild to moderate MS (3.7 ± 2.0 vs. 7.7 ± 2.9, p

Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement vs Percutaneous Mitral Valvuloplasty

BackgroundThis study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm2). MethodsFrom the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm2 < MVA ≤ 1.5 cm2 and MVA ≤ 1.0 cm2, respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention. ResultsAmong 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012). ConclusionsPMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

Assessment of the left atrial volume and function following percutaneous mitral balloon valvuloplasty: Insights into acute and late impact of atrial fibrillation on atrial remodeling

BackgroundRheumatic mitral stenosis (MS) leads to LA remodeling with disordered electrical activation that may revert with valve intervention. This study aimed to assess the acute and late impact of percutaneous mitral balloon valvuloplasty (PMBV) on LA volume and function in patients with atrial fibrillation (AF) compared with sinus rhythm. MethodsA total of 167 patients with severe MS undergoing PMBV were prospectively enrolled. LA volumes and function were measured by three-dimensional echocardiography (3DE) pre PMBV, within 24 to 48 h after PMBV, and at 1 year. ResultsMean age was 43.5 ± 11.8 years old, and 142 (85%) patients were women. At baseline, 46 patients (27.5%) were in permanent AF, and 62 (37.1%) classified as New York Heart Association functional class III or IV. In sinus rhythm population, LA volumes decreased immediately after PMBV and continue to decrease at 1-year follow-up. LA emptying fraction increased from 23.6 ± 10.4% to 33.8 ± 11.9% acutely after the procedure (p < 0.001), and to 37.2 ± 13.2% at 1-year follow-up (p = 0.028). Patients with AF only had a significant decrease in LA minimum volume immediately after PMBV, with no significant changes in maximum volume either immediately or at follow-up. In these patients, LA emptying fraction increased immediately after the procedure from 15.8 ± 9.9% to 22.8 ± 9.8 (p = 0.001) with no evidence for additional improvement at the 1-year follow-up. Age, and post-procedural mean gradient were identified as the most significant factors associated with the absolute changes in LA function between baseline and the 1-year follow-up. ConclusionsIn patients with severe MS, the impact of PMBV on LA volume and function varies according to cardiac rhythm. In patients in sinus rhythm, the procedure leads to improvement of LA volumes and function both acutely and at 1-year follow-up. Patients with AF had a lesser improvement in LA function immediately after the procedure, without further improvement over time despite adequate relief of valve obstruction.

Fluoroscopy versus Transthoracic Echocardiography for Detection of Mitral Valve Calcification in Patients Undergoing Percutaneous Mitral Balloon Valvuloplasty

Objectives: Rheumatic heart disease remains a significant problem in developing countries, with mitral stenosis (MS) being a frequent manifestation. The objective of this study was to compare transthoracic echocardiographic (TTE) findings of mitral valve calcification with fluoroscopy. Methodology: This cross-sectional study was conducted at the department of adult cardiology, National Institute of Cardiovascular Diseases (NICVD) Karachi. All patients were candidates for percutaneous mitral balloon valvuloplasty (PMBV), aged between 15 to 65 years of either gender. Patients who underwent TTE were subjected to fluoroscopy before PMBV. The Kappa coefficient was calculated to assess the agreement between the two modalities. An appropriate t-test or Mann-Whitney U test was applied, and a p-value ≤ 0.05 was taken as the criterion for statistical significance. Results: A total of 160 patients were included in this study with a mean age of 34.01± 12.32 years, 119 (74.4%) were between 18 to 40 years of age, and 108 (67.5%) were female. Calcification was observed in 40.6% (65) on echocardiography and 50.6% (81) of the patients on fluoroscopy. A substantial agreement was observed between the two modalities with a Kappa coefficient of 0.75 for the detection of calcification. Conclusion: No significant difference was observed in the detection of calcification on echocardiography and fluoroscopy, along with a substantial agreement between the two modalities for the detection of calcification. Echocardiography can be a less invasive alternative to fluoroscopy for the detection of calcification before PMBV.

Modern views on treatment of critical mitral stenosis

Mitral stenosis - narrowing of the left atrioventricular orifice due to fusion of the leaflets of the bicuspid valve, changes in subvalvular structures and fibrous degeneration of the valve ring. This creates obstacles to the flow of blood from the left atrium and is accompanied by a decrease in stroke volume and cardiac output. Mitral stenosis leads to pulmonary hypertension syndrome. This review provides an update on rheumatic mitral stenosis, its possible causes, clinical picture diagnosis and modern treatment options in the evolving world. The latest therapeutic approaches, including lifestyle changes, medical, surgical, and transcatheter valvular interventions including percutaneous transcatheter mitral valvuloplasty will be discussed.

Systemic Immune Inflammation-Index and CANLPH Score in Patients with Mitral Stenosis Undergoing Balloon Valvuloplasty

Objective: to evaluate CANLPH score and systemic immune inflammation index (SII) in patients with symptomatic rheumatic mitral stenosis (MS) undergoing percutaneous mitral balloon valvuloplasty (PMBV). Methods: 62 patients who underwent PMBV in our clinic between 2018 and 2021 were included retrospectively. The patients were divided into 2 groups according to echo score. The CANLPH score was calculated from the cut-off values of C-reactive protein to albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR) and platelet to hemoglobin ratio (PHR), determined with the Youden index and SII by the formula platelet x neutrophil/lymphocyte. P &lt;0.05 was considered statistically significant. Results: The mean age of the patients was 44.5±10.4 years (40 female, 64.5%). The mean values of SII and CANLPH scores were higher in the Echo score &gt;8 group (p &lt;0.001, both). The mean mitral gradient before and after PMBV was 12.6±5.7mm Hg and 5.0±2.4 mm Hg, and the mean valve area was 1.12±0.27 cm2 and 1.85±0.29 cm2. A statistically significant and negative correlation was observed between the gradient decrease after the procedure and the CANLPH score and SII (r=-0.426, p=0.001 and r=-0.418, p=0.001, respectively). In receiver operating characteristic (ROC) curve analysis, it was concluded that the ability of CANPLH score to predict the higher Echo scores was noninferior to SII with an area under curve (AUC:0.820 (0.701-0.906) and AUC:0.786 (0.664-0.880), z statistics 0.576 and p=0.564. Conclusion: SII and CANLPH scores are correlated with Echo score. A significant negative relationship was found with both biomarkers and gradient decrease after the PMBV.

Anesthetic Management of Pericardial Tamponade During Percutaneous Mitral Balloon Valvuloplasty - A Case Report

Percutaneous mitral balloon valvuloplasty (PMV) is the treatment of choice for symptomatic mitral valve stenosis. Most common complication of this procedure is pericardial tamponade. Early diagnosis and immediate management are essential and lifesaving as it determines the clinical outcome. Hereby a case report of successful management of pericardial tamponade following PMV in a middle-aged female patient with severe rheumatic mitral stenosis by multidisciplinary team approach with a focus on Anesthesia care and management.

Three-dimensional Echocardiography during Percutaneous Mitral Balloon Valvuloplasty

Percutaneous mitral balloon valvuloplasty (PMBV) has been frequently used as an alternative to open or closed surgical mitral commissurotomy for the treatment of selected patients with symptomatic rheumatic mitral stenosis. PMBV has been proven a safe and effective method, often performed under fluoroscopic guidance. With the advent of three-dimensional echocardiography (3DE), interventional cardiologists have been able to successfully perform complex procedures such as paravalvular leak closure, transcatheter edge-to-edge repair of the mitral valve (MV) using MitraClip, etc. With the expertise derived from these procedures, 3DE has received considerable interests in many other procedures, including PMBV. Pre-, intra-, and postprocedural assessments of the mitral valve (MV) area; commissural splitting; the presence, degree, and location of mitral regurgitation; and other procedure-related complications can be more accurately and readily made using 3DE. In addition, real-time 3D transesophageal echocardiography has been proven to be more accurate than two-dimensional (2D) techniques in identifying specific MV abnormalities associated with complex diseases. Moreover, real-time 3DE offers the advantage of shorter fluoroscopy and radiation times throughout PMBV. This article reviews the use of 3DE during PMBV in light of the most recent literature and based on expertise and discusses the pros and cons of 3DE, with emphasis on its superiority to conventional 2D echocardiography.

Shockwave Lithotripsy for Calcific Mitral Valve Stenosis: A Promising Technology

Shockwave Lithotripsy for Calcific Mitral Valve Stenosis: A Promising Technology

Pitfalls of percutaneous mitral balloon valvuloplasty.

Pitfalls of percutaneous mitral balloon valvuloplasty.

Lithotripsy-Assisted Transcatheter Mitral Valve Replacement for Severe Mitral Annular and Valve Calcification

<h2>Abstract</h2><h3>Background</h3> Transcatheter mitral valve replacement (TMVR) is evolving; however, limitations include severe calcification of the mitral valve leaflets and mitral annular calcification (MAC), which may be associated with incomplete valve expansion. Shockwave intravascular lithotripsy (IVL)–assisted percutaneous mitral valvuloplasty to treat calcific mitral stenosis has been reported. We describe the first human use of IVL-assisted transseptal TMVR with the Intrepid valve to treat a severely calcified mitral valve in a patient with severe stenosis and regurgitation. <h3>Methods</h3> An 83-year-old man with rheumatic heart disease and severe MAC (MAC score, 10; calcium volume score, 7756 cm³) presented with combined mitral stenosis and regurgitation (valve area, 1.5 cm²; 3+ mitral regurgitation [MR]) and medically refractory heart failure symptoms and was enrolled into the APOLLO (Transcatheter Mitral Valve Replacement With the Medtronic Intrepid TMVR System in Patients With Severe Symptomatic Mitral Regurgitation) trial of Intrepid valve TMVR. Transseptal implantation of a 48-mm Intrepid valve was facilitated by Shockwave IVL delivered via two 8.0 × 60–mm M5+ balloons placed across the mitral annulus before implantation. Cerebral embolic protection during IVL and valve implant was provided by a Sentinel device and left subclavian balloon occlusion. <h3>Results</h3> Despite initial postimplant valve frame deformation and moderate central MR, postdilation achieved valve frame expansion and reduced MR. Echocardiography and computed tomography performed before hospital discharge and at 30 days show progressive valve frame expansion in the anteroposterior dimension, increased valve area, and resolution of MR. <h3>Conclusions</h3> Intravascular lithotripsy of severe MAC before self-expanding TMVR may enhance annular compliance, mitigate fibroelastic recoil, and minimize TMVR valve frame deformation. Although promising, further study is required before IVL is considered a routine adjunct for TMVR in severe MAC.

History of PTMC at National Institute of Cardiovascular Diseases Karachi.

Rheumatic mitral stenosis (MS) incidence and severity rates have decreased in the developed world, but the condition is still very common in many nations. Since its invention, percutaneous mitral balloon valvuloplasty has transformed the therapy of mitral stenosis, shown promising short- and long-term outcomes, and taken the role of surgical mitral commissurotomy as the preferred method of managing rheumatic mitral stenosis in suitable patients. The morphologic characteristics of the valve leaflets and sub valvular structures can be used to predict the possibility of hemodynamic benefit and the danger of complications with balloon valvuloplasty. The results will be less than ideal if the valves are hard, thickened, and extensively calcified. We presented the retrospective data of approximately 500 patients from March 2001 to June 2006 in this paper.