Is mitral balloon valvuloplasty (percutaneous transluminal mitral valvuloplasty, PTMV) a percutaneous procedure?

Mitral Balloon Valvuloplasty: A Percutaneous Procedure

Yes, mitral balloon valvuloplasty (also known as percutaneous transluminal mitral valvuloplasty or PTMV) is definitively a percutaneous procedure performed via a catheter-based approach. 1

Procedure Characteristics

• Mitral balloon valvuloplasty emerged in the mid-1980s as a catheter-based approach in which one or more large balloons are inflated across the mitral valve to treat mitral stenosis 1
• The procedure involves a transseptal approach, with balloon catheters inserted percutaneously and advanced to the mitral valve position 2
• It has become the preferred procedure compared to surgical approaches for selected patients with mitral stenosis 1
• Two main techniques are used: the Inoue balloon (single hourglass-shaped balloon) which is now most common, and the double-balloon technique 1, 3

Efficacy and Outcomes

• The procedure typically results in doubling of the mitral valve area (from approximately 1.0 to 2.0 cm²) with a 50-60% reduction in transmitral gradient 1
• Success rates range from 80-95% of patients, defined as achieving a mitral valve area greater than 1.5 cm² and a decrease in left atrial pressure to less than 18 mm Hg 1
• Event-free survival (freedom from death, repeat valvotomy, or mitral valve replacement) is 50-65% over 3-7 years, with better outcomes (80-90%) in patients with favorable valve morphology 1

Complications

• Mortality rates range from 0-0.5% in experienced centers 2
• Common complications include:
  • Severe mitral regurgitation (2-10% of cases) 1, 2
  • Residual atrial septal defect (up to 12% with double-balloon technique, less than 5% with Inoue balloon) 1
  • Less frequent complications include left ventricular perforation (0.5-4.0%), embolic events (0.5-3%), and myocardial infarction (0.3-0.5%) 1

Patient Selection

• Best candidates have pliable, noncalcified valves with minimal fusion of the subvalvular apparatus 1
• The procedure is indicated for:
  • Symptomatic patients (NYHA class II-IV) with moderate or severe mitral stenosis and favorable valve morphology 1
  • Asymptomatic patients with moderate or severe mitral stenosis who have pulmonary hypertension 1
• Contraindications include:
  • Left atrial thrombus 1
  • Moderate to severe mitral regurgitation 1
  • Mild mitral stenosis 1

Comparison to Surgical Approaches

• Randomized trials have shown comparable initial results between percutaneous balloon valvuloplasty and surgical commissurotomy 1, 4
• The percutaneous approach offers advantages of being less invasive, avoiding thoracotomy, and typically having lower costs 4
• Some studies have shown better long-term hemodynamic results with percutaneous balloon valvuloplasty compared to closed commissurotomy 1, 4

Important Considerations

• The procedure should be performed only by skilled operators at institutions with extensive experience due to its technical complexity and steep learning curve 1, 5
• Outcomes are highly dependent on proper patient selection, with valve morphology being the most important factor in determining success 1
• Transesophageal echocardiography should be performed before the procedure to rule out left atrial thrombus and assess mitral regurgitation severity 1

In summary, mitral balloon valvuloplasty is a well-established percutaneous procedure that has revolutionized the treatment of mitral stenosis, particularly in developing countries where rheumatic heart disease remains prevalent 5.