Percutaneous Mitral Valvuloplasty Using Echocardiographic Intercommissural Diameter as Reference for Balloon Sizing: A Randomized Controlled Trial

Abstract

Background: Percutaneous balloon mitral valvuloplasty is the preferred therapeutic strategy in patients with mitral stenosis, but it has shortcomings in a subset of patients. Hypothesis: A new method of balloon sizing through echocardiographic measurement of the intercommissural diameter would be safe and effective and lead to better outcomes. Methods: Eighty-six mitral-stenosis patients were randomly assigned to undergo balloon mitral valvuloplasty either with height-based balloon reference sizing (HBRS group, n = 43) or with balloons sized by the echocardiographic measurement of intercommissural diameter (EBRS group, n = 43). Postprocedural mitral valve area (MVA) and severity of mitral regurgitation (MR) were assessed via echocardiography and ventriculography. Intention-to-treat approach was applied for the statistical analysis. Results: Baseline characteristics were not different between the groups. The mean of the estimated balloon reference sizes was significantly higher in the HBRS patients than in the EBRS group (26.4 ± 0.92 mm, 95% confidence interval [CI]: 26.2-26.6 vs 24.5 ± 1.03 mm, 95% CI: 24.2-24.7, respectively; P = 0.006). Final MVAs were significantly larger in the EBRS group (1.5 ± 0.2 cm 2 , 95% CI: 1.46-1.59 vs 1.4 ± 0.2 cm 2 , 95% CI: 1.35-1.47, respectively; P = 0.01). The occurrence of new or aggravated MR was significantly lower in the EBRS group as assessed both by echocardiography (P = 0.04) and ventriculography (P = 0.05). Mitral regurgitation was aggravated in 13 (29.3%) patients in the HBRS group and in 5 (11.5%) patients in the EBRS group. Conclusions: Percutaneous balloon mitral valvuloplasty via the Inoue technique using balloons sized by the echocardiographic measurement of the maximal commissural diameter is an effective and safe method that might lead to an acceptable increase in the MVA and significant decrease in the rate and severity of iatrogenic MR.

Percutaneous Mitral Valvuloplasty in a Patient With a Previous Transcatheter Aortic Valve Implantation

“…The mitral ring was intensively calcified, with severe mitral stenosis. A 0.8 cm 2 valve area was estimated, without significant regurgitation [1]. There was severe tricuspid regurgitation with an important pulmonary hypertension.…”

Percutaneous Balloon Mitral Valvuloplasty

“…Finally, inflation of the waist portion of the balloon separates commissures [22]. Several balloon sizes are available (24,26,28, and 30 mm in diameter), and each can be inflated in a 4-mm diameter zone. The reference balloon size (RS) is calculated based on the height of the patient (patient's height in cm rounded to the nearest 0, divided by 10, and 10 added to the ratio) or the newly introduced method of inter-commissural diameter [23][24][25].…”

“…Several balloon sizes are available (24,26,28, and 30 mm in diameter), and each can be inflated in a 4-mm diameter zone. The reference balloon size (RS) is calculated based on the height of the patient (patient's height in cm rounded to the nearest 0, divided by 10, and 10 added to the ratio) or the newly introduced method of inter-commissural diameter [23][24][25]. In patients with pliable valves, an RS-matched balloon is selected but in patients with pre-existing MR, severe commissural calcification, significant subvalvular involvement, or very severe MS (MVA ≤ 0.5 cm 2 ), as well as in patients with special situations where they do not need very large valve areas or in patients whose complications are more common and difficult to manage (i.e., old patients, pregnancy, etc.…”

Modern views on treatment of critical mitral stenosis

“…Prior to the advent of BMV, most patients with symptomatic mitral stenosis underwent surgical mitral commissurotomy, either open or closed. The closed mitral commissurotomy was first described by Harken and Bailey in the late 1940s [13]. Subsequently, after the development of cardiopulmonary bypass, the open surgical commissurotomy replaced the closed technique in most countries in the late 1960s and early 1970s [14].…”