What are the contraindications to mitral valve valvuloplasty?

Contraindications to Mitral Valve Valvuloplasty

The primary contraindications to percutaneous mitral valve valvuloplasty (PMC) include left atrial thrombus, moderate-to-severe mitral regurgitation, severe or bicommissural calcification, absence of commissural fusion, and unfavorable valve morphology. 1

Absolute Contraindications

• Left atrial thrombus - The most important contraindication due to risk of systemic embolization during the procedure 1
• Moderate to severe mitral regurgitation (>2+) - Can worsen significantly after balloon dilation 1, 2
• Severe or bicommissural calcification - Associated with poor procedural outcomes and increased risk of complications 1
• Absence of commissural fusion - The procedure works by splitting fused commissures; without fusion, the procedure is ineffective 1
• Mitral valve area >1.5 cm² - Not considered clinically significant stenosis requiring intervention 1

Relative Contraindications

• Unfavorable valve morphology characterized by:

  • Echocardiographic score >8 (Wilkins score) 1
  • Cormier score 3 (any degree of valve calcification as assessed by fluoroscopy) 1
  • Severe subvalvular apparatus involvement 1

• Severe concomitant valvular disease:

  • Severe aortic valve disease 1
  • Severe combined tricuspid stenosis and regurgitation 1

• Concomitant coronary artery disease requiring bypass surgery 1

Clinical Contraindications

• Advanced age - Older patients typically have more complex valve pathology and calcification 1
• History of previous commissurotomy - May indicate more advanced disease 1
• NYHA class IV heart failure - Higher procedural risk 1
• Permanent atrial fibrillation - Associated with higher risk of left atrial thrombus 1
• Severe pulmonary hypertension - May indicate more advanced disease 1

Special Considerations

• When left atrial thrombus is located only in the left atrial appendage, PMC may still be considered in patients with contraindications to surgery, provided:

  • Oral anticoagulation is administered for 2-6 months
  • Repeat transesophageal echocardiography confirms thrombus resolution 1
  • If thrombus persists, surgery is indicated 1

• Heavily calcified posterior leaflets are at higher risk of tearing during the procedure, which can lead to severe mitral regurgitation requiring surgical intervention 2

• Severe functional tricuspid regurgitation may be better addressed with combined mitral valve surgery and tricuspid valve repair rather than PMC alone, especially in patients with atrial fibrillation or right ventricular enlargement 3

Procedural Considerations

The decision between PMC and surgical intervention should be made by a Heart Team after careful evaluation of:

• Valve anatomy
• Patient characteristics
• Local expertise
• Surgical risk

PMC should only be performed by experienced operators with immediate surgical backup available for potential complications such as severe mitral regurgitation, which occurs in approximately 7.5% of procedures with the Inoue balloon technique 2.