Percutaneous Mitral Valvotomy

This second edition provides cardiologists and trainees with the latest advances and techniques in percutaneous mitral valvotomy (PMV).

Divided into seven sections, the book begins with an overview of procedures and patient evaluation.

The following sections discuss numerous techniques and potential complications, and the final chapters discuss PMV in special situations such as in pregnancy and in patients with atrial fibrillation; and long-term outcomes.

Each technique is illustrated by photographs and diagrams and the comprehensive text is further enhanced by an accompanying interactive DVD ROM providing procedural and echo videos.

Key points

• Second edition covering latest advances and techniques in percutaneous mitral valvotomy (PMV)
• Highly illustrated with clinical photographs and diagrams
• Includes DVD ROM demonstrating surgical procedures
• Previous edition (9789350255612) published in 2012

Harikrishnan S MD DM FRCP FACC
Professor in Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, India

SECTION 1: INTRODUCTION 1. Prelude 3-6 Harikrishnan S 2. Rheumatic Heart Disease—An Epidemiological Mystery 7–14 Biju Soman 3. Anatomy of the Mitral Valve 15–24 Yoav Turgeman, Hosam Hasan-Ali, Syamkumar Menon, Raghuram A Krishnan • Mitral Subvalvular Apparatus 18 • Mitral Valve Orifice 22 4. Pathological Aspects of Rheumatic Mitral Stenosis 25–37 Ruma Ray, Prasenjit Das • Normal Mitral Valve 25 • Rheumatic Mitral Stenosis 26 5. Pathophysiology, Natural History and Hemodynamics of Mitral Stenosis 38-50 Krishnakumar M, Mahesh Kumar S, Arun SR • Natural History of Mitral Stenosis 38 • Pathophysiology of Mitral Stenosis 39 • Obstructive Physiology of Mitral Stenosis 41 • Chamber Dynamics in Mitral Stenosis: Left Atrium and Left Ventricle 42 • Pulmonary Circulation 44 • Hemodynamics of Mitral Valve Stenosis 44 • Hemodynamics of Percutaneous Balloon Mitral Valvotomy 47 SECTION 2: EVALUATION PRIOR TO PERCUTANEOUS MITRAL VALVOTOMY 6. Mitral Stenosis— Evaluation and Medical Management 53-59 Harikrishnan S, Stigimon Joseph • Clinical History 53 • Medical Management 55 • Mixed Valve Lesions 58 7. Percutaneous Mitral Valvotomy—Indications, Contraindications and Mechanism 60–66 Harikrishnan S • Mechanism of Percutaneous Balloon Mitral Valvotomy 60 • Indications and Contraindications for PMV 61 • PMV—Special Considerations 62 • Practical Approach in the Developing World 64 Prelims.indd 21 07-07-2017 16:11:39 xxii Percutaneous Mitral Valvotomy 8. Stress Testing Prior to Percutaneous Mitral Valvotomy 67–70 P Shanmuga Sundaram, Harikrishnan S • Treadmill Exercise Testing in Patients with Mitral Stenosis 68 • Dobutamine Stress Echocardiography 68 9. Electrocardiogram in Mitral Stenosis 71–78 Krishnakumar Nair, Diego Chemello, Raja Selvaraj • Terminology 71 • Left Atrial Abnormality 72 • Right Atrial Abnormality 73 • Combined Atrial Abnormality 74 • Right Ventricular Hypertrophy 74 • Atrial Arrhythmias 75 • Mitral Stenosis Severity and the ECG 76 • Effects of Mitral Valvotomy on Electrocardiographic Changes of Mitral Stenosis 76 • Clinical Significance 76 10. Radiological Evaluation in Mitral Stenosis 79–85 Bhavesh Harivadan, Harikrishnan S • Chest Roentgenography 79 • Left Ventricular Angiography in Mitral Stenosis 82 11. Balloon Mitral Valvotomy—Role of Echocardiography 86–124 Hosam Hasan-Ali, Harikrishnan S • Anatomical Background 86 • Pathophysiology of Mitral Stenosis 86 • Echocardiographic Assessment in MS Prior to Percutaneous Mitral Valvotomy 87 • Subvalvar Pathology 96 • Left Atrium 97 • Assessment of Lesions in Other Valves 100 • Transesophageal Echocardiography in PMV 101 • Doppler Assessment of Mitral Valve 105 • Pressure Half-Time 106 • Pulmonary Hypertension 108 • Periprocedural Monitoring 108 • Post-PMV Assessment 109 • Left Atrial Function 110 • Exercise Echocardiography 110 • Predictive Value of Echocardiographic Assessment of MV Morphology Before PMV 111 12. Three-dimensional Echocardiography in PMV: The Latest Tool 125–133 Gadage Siddharth, Sivasubramonian Sivasankaran 13. Subvalvular Apparatus in Rheumatic Mitral Stenosis— Methods of Assessment and Therapeutic Implications 134-142 Yoav Turgeman • Anatomy and Function of Subvalvular Apparatus 135 • Methods of Assessment of the SVA 136 Prelims.indd 22 07-07-2017 16:11:39 xxiii • Impact of SVA Deformity on the Results of PBMV 140 • Clinical Implications and Conclusion 140 14. Atrial Function in Mitral Stenosis—Effect of Percutaneous Mitral Valvuloplasty 143-150 Tomás F Cianciulli, María C Saccheri SECTION 3: PMV—PROCEDURE, TECHNICAL CONSIDERATIONS AND PERIPROCEDURAL MONITORING 15. Transseptal Puncture 153–168 Harikrishnan S, Krishnakumar Nair • Anatomy of the Atrial Septum 153 • How to Perform Transseptal Puncture 155 • Landmarks for Septal Puncture 161 • Septal Puncture Without Arterial Stick 167 • Probing the Septum 168 16. Use of Safe-Sept Guidewire in Transseptal Access 169–173 Carlo de Asmundis, Darragh Moran, Jayakeerthi Yoganarasimha Rao Gian-Battista Chierchia, Pedro Brugada • Indications 169 • Technical Aspects 169 17. Percutaneous Mitral Valvotomy—Procedure 174–183 Harikrishnan S, Sanjay G, Rajesh Muralidharan • Preparation of the Patient (SCTIMST Protocol) 174 • Obtaining the Vascular Access 174 • Preparation of the Septal Puncture System and the Balloon 175 • Steps of Percutaneous Mitral Valvotomy 176 18. Periprocedural Monitoring during PMV 184–190 S Venkiteshwaran, Suchith Majumdar • Other Formulas to Calculate Mitral Valve Area (MVA) 188 19. Anesthetic Management during Percutaneous Mitral Valvuloplasty 191–195 Thomas Koshy • Patient Evaluation Prior to PMV 191 • Precatheterization Preparation 192 • Premedication and Fasting Guidelines 192 • Patient Monitoring During PMV 193 • Patient Sedation 193 • General Anesthesia 194 • Management of Complications 194 • PMV and the Anesthesiologist 195 20. Intracardiac Echocardiography Imaging in Percutaneous Balloon Mitral Valvuloplasty 196–206 Santhosh KG Koshy, Antwon Robinson Contents Prelims.indd 23 07-07-2017 16:11:39 xxiv Percutaneous Mitral Valvotomy SECTION 4: PMV—TECHNIQUES AND GADGETS 21. Different Techniques and Devices for Percutaneous Mitral Valvuloplasty—Introduction 209–211 Mohammad A Sherif • Historical Background 209 • Techniques Available for Percutaneous Mitral Valvotomy 210 22. The Single Balloon Mitral Valvotomy Catheters 212–224 Harikrishnan S, Krishnakumar M, Suji K • Comparison Between Inoue and Accura Balloons with Respect to Safety and Efficacy 222 • Blue Arrow PBMV Balloon 223 23. Double Balloon Technique 225–231 Mohammad A Sherif, Arun Gopalakrishnan • Double Balloon-Technique (DBT) 225 • Balloon Sizing 226 • Double Balloon Technique—Advantages and Disadvantages 228 24. Mitral Valvotomy by Metallic Commissurotome 232–238 Mohammad A Sherif, Harikrishnan S • Description of the Device 232 • Mechanism of Valvotomy with Metallic Commissurotome 234 • Technique 234 • Technical Considerations 235 • Complications 236 • Initial and Long-Term Results 237 25. JOMIVA Balloon 239–241 Sajy Kuruttukulam • Technique 239 26. Other Gadgets for Percutaneous Mitral Valvotomy 242–245 Mohammad A Sherif, Harikrishnan S • Multi-Track System 242 • NucleusTM Balloon 244 27. Percutaneous Mitral Valvuloplasty—Comparative Analysis of Different Gadgets 246–252 Mohammad A Sherif • Inoue Versus Double Balloon 247 • Inoue Balloon Technique Versus Percutaneous Metallic Commissurotomy 249 28. Reuse and Resterilization of PMV Hardware 253–258 Suji K, Sethu Parvathy VK • Methods of Sterilization 254 • Resterilization Process of the PMV Hardware 255 Prelims.indd 24 07-07-2017 16:11:40 xxv • Sterilization Using Hydrogen Peroxide 255 • Resterilization of Inoue Balloon 256 SECTION 5: COMPLICATIONS FOLLOWING PMV 29. Device-related Complications during Percutaneous Mitral Valvotomy 261–267 Harikrishnan S • Breakage of Coiled Left Atrial (LA) Wire 261 • Entrapment of the Pigtail Guidewire 262 • Balloon Rupture During PMV 264 • Balloon Impasse 266 30. Complications of Transseptal Puncture and Management 268–274 Harikrishnan S, Meera R • Suspected Pericardial Tamponade 268 • Management 269 • Reversal of Heparin—Protamine 270 • Autotransfusion 271 • Thrombus Formation in the Septal Puncture Site 271 31. Neurological Complications Related to Percutaneous Mitral Valvotomy 275–281 Sajith Sukumaran • Systemic Embolism in Patients with Mitral Stenosis 275 • Factors Associated with Systemic Embolization 276 • Percutaneous Balloon Mitral Commissurotomy and Systemic Embolism 277 • Prevention of Cardioembolic Stroke in Rheumatic Mitral Stenosis During Percutaneous Mitral Interventions 277 • Periprocedural Stroke and Treatment Options 278 32. Thromboembolic Complications during Balloon Mitral Valvotomy 282–288 Dash PK 33. Arrhythmias and Its Management during Percutaneous Mitral Valvotomy 289–296 Shomu R Bohora • Arrhythmias During PMV 28 xxvi Percutaneous Mitral Valvotomy SECTION 6: PMV IN SPECIAL SITUATIONS 37. Percutaneous Mitral Valvotomy in Pregnancy 319–329 Shyam Sundar Reddy • Mitral Stenosis and Pregnancy 319 • Medical Therapy 320 • Interventions in Mitral Stenosis in Pregnancy 321 • Percutaneous Mitral Valvotomy (PMV) in Pregnancy 321 • PMV in Pregnancy—Procedural Details 322 • Short- and Long-term Outcomes Following PMV in Pregnancy 324 38. Percutaneous Mitral Valvotomy in Juvenile Mitral Stenosis 330–334 Randeep Singla • Indication for PMV in Juvenile Mitral Stenosis 330 • Valve Morphology 330 • PMV Procedure in Juvenile Mitral Stenosis 330 • Vascular Access 331 • Balloon Selection and Dilatation 331 • Complications 331 39. Transjugular Percutaneous Mitral Valvotomy 335–340 Boonjong Saejueng, Sudaratana Tansuphaswadikul • Transjugular Interatrial Septal Puncture 336 • Procedure of Septal Puncture 336 • Mitral Valve Dilatation Procedure 337 • Complications 340 40. Percutaneous Prosthetic Mitral Balloon Valvotomy 341–346 Col. Subroto Kumar Datta • Case Selection/Indication 341 • Evaluation 342 • Echo 342 • Selection and Sizing of Balloon 343 • Procedure 343 • Follow-Up 344 • Discussion 344 41. Tackling Subvalvular Disease during Balloon Mitral Valvotomy 347–353 CN Manjunath, Prabhavathi, BC Srinivas 42. Over-the-Wire Techniques during PMV 354–359 KS Ravindranath, Ravi S Math, CN Manjunath 43. PMV Performed with other Percutaneous Interventions 360–370 Dinesh Choudhary, Harikrishnan S • PMV and Percutaneous Valvotomy of Other Valves 360 • Which Valve to Tackle First? 360 • PMV and Percutaneous Aortic Valvotomy 361 • BAV Along with PMV—Techniques 362 • PMV and Balloon Tricuspid Valvotomy 367 • Triple Valve Intervention 368 • Percutaneous Coronary Intervention and PMV 368 Prelims.indd 26 07-07-2017 16:11:40 xxvii 44. Balloon Tricuspid Valvotomy along with PMV 371–375 Harikrishnan S, Amit Kumar Chaurasia 45. PMV in Patients with Atrial Fibrillation 376–384 Krishnakumar M • Mechanism of Atrial Fibrillation in Mitral Stenosis 376 • Restoration and Maintenance of Sinus Rhythm in Mitral Stenosis 380 46. Percutaneous Mitral Valvotomy in Dextrocardia 385–388 Harikrishnan S, Krishnakumar Nair 47. Balloon Mitral Valvotomy—Left Femoral Vein Approach and in Venous Anomalies 389–393 Rajesh Muralidharan • BMV in Other Venous Anomalies 392 48. Retrograde Nontransseptal Balloon Mitral Valvuloplasty 394–398 Harikrishnan S, Arun Gopalakrishnan 49. Percutaneous Mitral Valvotomy in Technically Challenging Situations 399–415 Harikrishnan S, Rohan Vijay Ainchwar • Calcification of the Valve 399 • Left Atrial Thrombi 400 • Difficulty at the Groin Puncture Site 400 • Difficulty in Septal Puncture, Dilatation and Balloon Entry 401 • Difficulty in Negotiating the Atrial Septum 403 • Balloon Catheter Stuck at Septum—Septal Catch 403 • Techniques Facilitating Entry of Balloon Across Mitral Valve 406 • Entry of Balloon Through the Secondary Orifices 410 • Failure to Dilate the Valve 411 • Popping of the Balloon Back to Left Atrium 411 • Small Left Atrium 412 • Percutaneous Mitral Valvotomy in Small Children 413 50. Left Atrial Appendage Occlusion and Percutaneous Mitral Valvotomy 416–426 Dale Murdoch, Darren Walters • Background and Rationale 416 51. Percutaneous Treatment of Lutembacher’s Syndrome: Balloon Mitral Valvotomy and Device Closure of Atrial Septal Defect 427–439 Shiv Bagga, Saujatya Chakraborty, Ramalingam Vadivelu • Pathophysiology 427 • Treatment of Lutembacher’s Syndrome 427 • Percutaneous Treatment of Lutembacher’s Syndrome 428 • Step-by-Step Technique for Percutaneous Therapy of Lutembacher’s Syndrome 435 52. Percutaneous Mitral Valvotomy in Mitral Restenosis 440–450 Krishnakumar Nair, Harikrishnan S • Definition 440 Contents Prelims.indd 27 07-07-2017 16:11:40 xxviii Percutaneous Mitral Valvotomy • Prevalence 441 • Predictors of Restenosis 441 • Pathology 442 • Management 443 SECTION 7: LONG-TERM OUTCOME FOLLOWING PMV 53. Left Atrial Thrombosis in Rheumatic Mitral Stenosis 453–461 Sonny P Jacob 54. Comparison of Percutaneous Mitral Valvotomy and Surgical Mitral Commissurotomy 462–467 Sanjay G • PMV Vs Surgical Commissurotomy in Special Situations 464 55. Mitral Regurgitation Following Percutaneous Mitral Valvotomy 468–475 Rachel Daniel, Anees Thajudeen • Mechanism of Mitral Regurgitation Following PMV 468 • Incidence 471 • Clinical Course of MR 472 • Surgical Management of MR Following PMV 474 56. Atrial Septal Defects Following Percutaneous Mitral Valvotomy 476–479 Harikrishnan S, Kiron Sukulal 57. Pulmonary Hypertension in Rheumatic Mitral Stenosis— Influence of Percutaneous Mitral Valvotomy 480–491 Harikrishnan S, Chandrasekharan C Kartha • PH in Rheumatic Mitral Valve Disease 484 • Effect of Balloon Mitral Valvotomy on PH 486 58. Long-term Follow-up of Patients Undergoing Percutaneous Mitral Valvotomy 492–499 Rachel Daniel • Mitral Restenosis and Long-Term Outcome 494 • Follow-up and Management of Patients After PMV 494 • Infective Endocarditis Prophylaxis 495 59. Setting A New PMV Program 500–503 Ajeet Arulkumar, Harikrishnan S Index 505