Tools
Catheter Management of Mitral Stenosis
Introduction
Mitral stenosis is a progressive valvular disorder that results in left atrial (LA) enlargement, atrial fibrillation, and heart failure.[1] Despite advances in modern medicine, rheumatic heart disease remains the most common cause of mitral stenosis, especially in low- and middle-income countries.[2] Rheumatic mitral stenosis usually presents in patients aged between 20 and 40 years, about 10 to 15 years after the onset of rheumatic fever. In the United States, mitral stenosis secondary to rheumatic heart disease most commonly presents in the immigrant population and those with limited access to healthcare facilities.[3] Calcific degenerative mitral valve stenosis is another cause of mitral stenosis, but it is far less common and typically seen in older adults.[4] Patients with symptomatic mitral stenosis usually present with symptoms of heart failure, atrial fibrillation, or thromboembolism. Risk factors for rheumatic mitral stenosis include a history of rheumatic fever and a previously untreated streptococcus infection.[5] Some data suggest that patients with chronic kidney diseases and dialysis are at increased risk for calcific, degenerative mitral stenosis.[6]
The key physical examination findings in hemodynamically significant mitral stenosis may include irregular pulse (due to atrial fibrillation), prominent a wave in the jugular venous examination, tapping apex beat, signs of pulmonary hypertension/right-heart failure, an opening snap, and the classic low-pitched, middiastolic rumbling murmur with presystolic accentuation.[7] A chest radiograph may show the prominence of the pulmonary arteries, the straightening of the left heart border, the LA, and signs of pulmonary edema.[8] The electrocardiogram may show atrial fibrillation or evidence of LA enlargement and right ventricular hypertrophy.[9] The 2-dimensional and Doppler echocardiogram is the best imaging modality for diagnosing mitral stenosis and assessing its severity and hemodynamic consequences.[10]
Medical therapy is used as an initial symptomatic treatment for severe mitral stenosis; however, it does not improve the long-term outcomes of the disease.[11] As assessed by echocardiography, percutaneous mitral balloon commissurotomy (PMBC) is recommended as the first-line treatment for rheumatic mitral stenosis in patients with suitable mitral valve anatomy. Meanwhile, surgical mitral valve repair/replacement is limited to patients whose valves are unsuitable.[12][13] Valves designed for transcatheter aortic valve replacement have been used in a percutaneous transcatheter mitral valve replacement technique to treat degenerative mitral stenosis.[14] PMBC treats mitral stenosis by splitting the fusion of the mitral valve commissures, and it is most effective in rheumatic mitral stenosis and certain forms of congenital mitral stenosis.[15] This activity will provide a detailed description of the mitral valve, the pathology of mitral stenosis, and possible options for catheter management, including indications, contraindications, complications, and the clinical significance of catheter management.
Anatomy and Physiology
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Anatomy and Physiology
The mitral valve is between the LA and the left ventricle (LV). The mitral valve apparatus is a complex anatomical structure consisting of a mitral annulus, mitral valve leaflets, chordae tendineae, and papillary muscles.[16] The mitral valve is a bicuspid atrioventricular valve comprising a large anterior and a small posterior leaflet, also known as cusps. Both leaflets are divided into 3 scallops for descriptive purposes.[17] Both the leaflets of the mitral valve meet each other at the commissures. A healthy mitral valve permits blood to flow from the LA to the LV, but not in the opposite direction. A common pathology of the mitral valve is stenosis or narrowing of the mitral valve orifice.
Rheumatic mitral stenosis occurs as a result of a chronic inflammatory process. This condition is characterized by the thickening of the edges of the mitral valve leaflets, resulting in commissural fusion and a reduction in the mitral valve opening during diastole.[18] PMBC works by splitting the fused commissures. The normal mitral valve orifice area is 4 to 6 cm2; hemodynamic consequences start when the mitral orifice area is reduced to 2 cm2. Severe mitral stenosis is characterized by a planimetered mitral valve area of less than 1.5 cm² and a diastolic pressure half-time of greater than 150 ms. Very severe mitral stenosis is characterized by a mitral valve area smaller than 1.0 cm² and a diastolic pressure half-time of greater than 220 ms.[19] Patients with severe or very severe mitral stenosis are candidates for PMBC.
The Manjunath classification categorizes LA and left atrial appendage (LAA) thrombi based on their location and appearance on transesophageal echocardiography. The classification includes: type Ia (thrombus confined to the LAA), type Ib (LAA thrombus protruding into the LA cavity), type IIa (LA roof thrombus above the fossa ovalis), type IIb (LA roof thrombus extending below the fossa ovalis), type III (layered thrombus on the interatrial septum), type IV (mobile thrombus attached to the LA free wall, roof, or septum), and type V (ball-valve thrombus). This classification helps guide management decisions, particularly in patients with mitral stenosis undergoing balloon mitral valvuloplasty. Certain types of thrombi (eg, Ia, Ib, and IIa) are amenable to BMV using modified techniques, while others may require alternative treatment strategies.[20]
Indications
The contemporary clinical practice guidelines recommend PMBC in patients with rheumatic mitral stenosis who meet the following criteria:
- Symptomatic individuals with severe rheumatic mitral stenosis with valve morphology suitable for PMBC and who do not have LA thrombus or moderate to severe mitral regurgitation (MR) qualify for PMBC as class I (level of evidence: A).
- Severely symptomatic individuals with severe mitral stenosis, having valve morphology not suitable for PMBC but are not candidates for mitral valve surgery, qualify for PMBC as class IIb (level of evidence: B).
- Asymptomatic individuals with severe rheumatic mitral stenosis, having valve morphology suitable for PMBC, who do not have LA thrombus or moderate to severe MR, qualify for PMBC as class IIa (level of evidence: B) if their pulmonary artery systolic pressure is >50 mm Hg.
- Asymptomatic individuals with severe rheumatic mitral stenosis having valve morphology suitable for PMBC and do not have LA thrombus or moderate to severe MR qualify for PMBC as class IIb (level of evidence: C) if they develop new-onset atrial fibrillation.
- Severely symptomatic individuals with moderate rheumatic mitral stenosis, having valve morphology suitable for PMBC, and do not have LA thrombus or moderate to severe MR, qualify for PMBC as class IIb (level of evidence: C) if found to have hemodynamically significant mitral stenosis based on pulmonary artery wedge pressure of >25 mm Hg or mean mitral valve gradient of >15 mm Hg on exercise.
- Asymptomatic women with severe rheumatic mitral stenosis, who are considering pregnancy, have valve morphology suitable for PMBC, and do not have LA thrombus or moderate to severe MR, qualify for PMBC before pregnancy as class IIa (level of evidence: C).[19][21]
Contraindications
According to the American College of Cardiology and the European Society of Cardiology, PMBC is contraindicated in patients with LA thrombus. However, in clinical practice, certain types of thrombi—such as type Ia, Ib, and IIa—may be considered suitable for balloon mitral valvotomy using modified techniques. Other contraindications include: a heavily calcified mitral valve with morphology unfavorable for PMBC; moderate to severe MR (3+ or 4+); active infective endocarditis; acute thromboembolic stroke; mitral annular calcification; subvalvular fibrosis; and other valvular abnormalities requiring surgical correction. Mitral valve surgery is recommended for patients with symptomatic severe mitral stenosis who have a contraindication to percutaneous balloon mitral valvuloplasty.[15][22]
Equipment
PMBC is an invasive procedure performed in the cardiac catheterization laboratory under general anesthesia and requires special equipment.[23][24] This equipment includes:
- Echocardiographic machine with transesophageal probe
- Invasive hemodynamic monitoring system
- Vascular access sheaths
- Supporting sheath for transseptal puncture
- Transseptal puncture needle
- Inoue balloon
Personnel
PMBC requires a multidisciplinary team.[25] The key to a successful procedure is having a trained interventional or structural heart disease cardiologist with special expertise in percutaneous transcatheter procedures. A transesophageal echocardiogram (TEE) serves as a critical imaging modality for perioperative assessment of the mitral valve and evaluation of procedural success during percutaneous balloon mitral commissurotomy, making the involvement of a cardiologist with advanced echocardiographic expertise an essential component of the interprofessional team.[26] Other personnel include a cardiac surgeon, cardiac anesthesia specialist, cardiac nurse, and a cardiac catheterization laboratory technician.[27]
Preparation
Preprocedural Assessment
Preprocedural assessment of the mitral valve is the most crucial step in PMBC, as it determines the procedure's success and long-term outcomes.[25] Every patient undergoing PMBC shall have a comprehensive echocardiographic examination, and the morphology of the mitral valve shall be assessed. In addition to the valve morphology, the long-term outcomes of the procedure depend on clinical hemodynamics and the immediate results of the procedure.[28]
Multiple echocardiographic scoring systems have been developed to assess the suitability of the mitral valve for PMBC and predict the outcomes of the procedure. The Wilkin score was 1 of the first scoring systems proposed to predict the results of PMBC, and it is the most commonly used scoring system in the contemporary era.[29] The 4 echocardiographic variables, including leaflet mobility, leaflet thickening, leaflet calcification, and thickening of the subvalvular apparatus, are used to calculate the Wilkin score. The sum of the grades of the variables mentioned above gives a maximum score of 16.[30]
A score of 8 or less predicts a more favorable outcome than those with a higher score. However, a score above 8 does not exclude a patient from having a balloon mitral commissurotomy. Although commissural calcification or fusion is not included in the Wilkin scoring system, it is another crucial predictor for poor outcomes after balloon mitral commissurotomy.[31] Combining the Wilkin score with another scoring system can be used in select patients to predict the procedure's outcomes and choose the most effective treatment strategy for each patient.[32] In addition to evaluating valve morphology, a TEE is done in every patient before PMBC to assess the degree of MR and LAA thrombus. LA thrombus is most commonly found in the LAA, and a TEE has a higher sensitivity than a transthoracic echocardiography for evaluating LAA thrombus.[33]
Preparation for the Procedure
On the day of the surgery, patients receive instructions to fast for at least 6 to 8 hours before the procedure. Anticoagulation therapy is held before the procedure. At least 2 peripheral venous lines are required to administer drugs, and electrocardiographic leads are placed to monitor rhythm. Patients are selectively intubated, and the procedure is performed under general anesthesia. Before performing the PBMV, a right heart catheterization is performed to assess pressures inside the heart, as part of invasive cardiac hemodynamics.[34]
Technique or Treatment
PMBC
The guidelines recommend performing PMBC in a comprehensive heart valve center with backup support from cardiac surgery.[35] The procedure is performed under general anesthesia and TEE guidance. As with any percutaneous transcatheter procedure, vascular access is obtained to initiate the procedure.[36] Most operators use a femoral approach for this procedure. Upon obtaining vascular access, a transseptal puncture is performed to facilitate access to the LA.[37] Weight-based heparin is infused after obtaining access to the LA to keep activated clotting time above 300 seconds (300-350 seconds).[38] Care is made to avoid introducing any air bubbles into the heart. Arterial access can be obtained to monitor the invasive hemodynamics and perform left heart catheterization. After a transseptal puncture, the hemodynamics of the LA are assessed, and transmitral pressure gradients are calculated.
If the measurements meet the criteria to continue the procedure, then a guide wire is advanced into the LA. The femoral vein and interatrial septum are both dilated to ease the delivery of the Inoue balloon-tipped catheter. Once dilated, the balloon-tipped catheter is threaded over the guide wire in the LA and positioned at the site of the mitral valve. The tip of the balloon is dilated first, then the rest of the balloon is dilated to open the narrowed orifice of the mitral valve. This procedure is typically monitored using TEE and fluoroscopy.[39] After confirming the position of the balloon, rapid inflation and deflation of the balloon are performed to perform a commissurotomy.[15] Balloon commissurotomy works similarly to surgical commissurotomy, resulting in the opening of the mitral valve through the separation of fused commissures.[36]
Following commissurotomy, direct measurement of transmitral gradients is performed, along with an echocardiographic assessment of the transmitral gradients. The mitral valve area is then calculated using planimetry. MR is also assessed with a TEE. If there is still significant stenosis with mild-to-moderate MR, the procedure is then repeated 1 mm below the maximal diameter. Once optimal results are obtained, the LA hemodynamics are repeated to calculate a new postprocedure residual transmitral gradient, and the postoperative planimetered mitral valve area is measured.[40]
A right heart catheterization is then obtained to assess the right side of the heart hemodynamics, along with a left ventriculogram to evaluate MR severity. Guidelines recommend obtaining an echocardiogram a few days after PMBC, as the pressure half-time calculation for the mitral valve area may be inaccurate due to postprocedure compliance changes in both the atrium and ventricle. An assessment of MR and an atrial septal defect should also be performed. A yearly clinic review and echocardiographic evaluation are required. Anticoagulation should be continued in patients with paroxysmal or chronic atrial fibrillation. If mitral stenosis recurs, PBMV can be repeated. At that time, if there are significant valvular anomalies, surgical mitral valve replacement would be recommended.[41]
Complications
The complications of PMBC depend on the operator's expertise and patient selection. Vascular access site complications are the most common complications in PMBC, which are compatible with a right heart catheterization. The common vascular access-related complications include hematoma, retroperitoneal bleeding, arteriovenous fistulae, and pseudoaneurysm.[42] The complications specific to PMBC are rare and may include: thromboembolic events (0%-4%), cardiac tamponade (0%-2%), MR (1%-9%), and procedure-related mortality is less than 0.5%.[25] The interatrial septal defect after transseptal puncture usually results in a trace intracardiac shunt, and the hemodynamically significant shunt is very rare.[43][44]
Clinical Significance
The primary advantages of PMBC are its lower cost and the avoidance of a thoracotomy and cardiopulmonary bypass. One study revealed that the pathophysiology of mitral stenosis results in a decrease in coronary flow reserve. Therapy with PMBC significantly improves coronary flow reserve, leading to improved cardiac output from both the right and left chambers.[45][46] Proper patient selection and appropriate balloon sizing during the procedure can help improve outcomes and prevent PMBC complications.[47] PMBC immediately relieves mitral valve obstruction and improves hemodynamics, with good long-term outcomes in appropriately selected patients. However, reintervention is required in more than one-third of the patients due to the progressive reduction of the mitral valve area over 5 to 10 years.[48]
Enhancing Healthcare Team Outcomes
Effective catheter management of mitral stenosis requires clinicians to integrate advanced procedural skills with evidence-based strategies for patient selection, periprocedural care, and postprocedural monitoring. Physicians and advanced practitioners must be proficient in interpreting echocardiographic findings, recognizing hemodynamic instability, and coordinating anticoagulation strategies. Nurses play a vital role in patient education, procedural preparation, and hemodynamic monitoring, while pharmacists ensure safe and effective medication management, particularly with anticoagulation and adjunctive therapies. Each professional must apply critical thinking and clinical judgment to anticipate complications, intervene early, and support recovery. Percutaneous transcatheter mitral valve procedures are complex procedures that require evaluation from multiple specialties to determine the best procedural approach for optimal outcome.[49]
Interprofessional communication and structured care coordination are essential to optimizing outcomes. Seamless collaboration between cardiologists, interventionalists, anesthesiologists, nurses, and pharmacists fosters shared decision-making and minimizes errors. Strategies such as multidisciplinary valve team discussions, standardized communication tools, and protocol-driven follow-up care enhance patient safety and continuity of care. By working together in a coordinated manner, the care team not only improves technical success and reduces complications but also strengthens patient trust, satisfaction, and long-term outcomes.
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