From the Guidelines
Percutaneous Balloon Mitral Commissurotomy (PBMC) is contraindicated in patients with left atrial thrombus, more than mild mitral regurgitation, severe or bicommissural calcification, and severe concomitant aortic valve disease or severe combined tricuspid stenosis and regurgitation, as stated in the 2012 guidelines on the management of valvular heart disease 1.
Contraindications for PBMC
The following are considered contraindications for PBMC:
- Left atrial thrombus
- More than mild mitral regurgitation
- Severe or bicommissural calcification
- Absence of commissural fusion
- Severe concomitant aortic valve disease, or severe combined tricuspid stenosis and regurgitation
- Concomitant coronary artery disease requiring bypass surgery These contraindications are based on the potential risks and complications associated with the procedure, including the risk of embolic events, worsening regurgitation, and poor outcomes in patients with heavily calcified valves.
Rationale for Contraindications
The contraindications for PBMC are based on the mechanism of the procedure, which involves physically splitting fused mitral valve commissures. This can worsen regurgitation if the valve is already leaking, cause embolic events if thrombi are present, or yield poor results if the valve is heavily calcified. In patients with high Wilkins scores, surgical mitral valve replacement may provide better outcomes than PBMC.
Clinical Considerations
In clinical practice, the decision to perform PBMC should be made on a case-by-case basis, taking into account the individual patient's symptoms, valve morphology, and overall clinical condition. Patients with severe symptoms despite medical therapy may be considered for PBMC, even if they have relative contraindications. However, the potential risks and benefits of the procedure should be carefully weighed, and alternative treatments, such as surgical mitral valve replacement, should be considered if necessary, as recommended by the 2006 ACC/AHA guidelines for the management of patients with valvular heart disease 1.
From the Research
Contraindications for Percutaneous Balloon Mitral Commissurotomy (PBMC)
The following are contraindications for PBMC:
- Severe mitral regurgitation [(2,3,4)]
- Presence of left atrial thrombus, although it can be performed in some cases with specialized expertise 2
- Severely calcified mitral valve 4
- Presence of other severe valvular diseases
- Patients with a history of bleeding disorders or those who cannot be taken off anticoagulation therapy
- Presence of severe pulmonary hypertension 4
- Concomitant severe tricuspid regurgitation 4
- Left ventricular dysfunction 4
- Atrial fibrillation 4
- Presence of other conditions that may increase the risk of the procedure, such as active infection or severe debilitation
Relative Contraindications
The following are relative contraindications for PBMC:
- Presence of coronary artery disease
- Presence of other cardiac conditions, such as patent foramen ovale or atrial septal defect
- History of cerebrovascular accident or transient ischemic attack
- Presence of severe renal dysfunction
- Presence of severe liver dysfunction
Special Considerations
PBMC can be performed in special situations, such as: