Assessment of mitral valve for PTMC/BMV - echocardiography and fluoroscopy

1. ASSESSMENT OF MITRAL VALVE
FOR PTMC
Dr Satyam Rajvanshi

2. HISTORY

3. • Early in the development of percutaneous
mitral and aortic balloon dilation, the
technique was considered to be experimental,
unproven, and even dangerous.
• However, many invasive cardiologists had
similarly been sceptical when they heard of
the Swiss physician Greuntzig's proposal of
balloon dilation of coronary arteries.
Circulation Vol 82, No 2, August 1990

4. • The surprising success of balloon angioplasty
(1982) made cardiologists receptive to the
possibility that balloons could effectively treat
valvular stenosis.
Circulation Vol 82, No 2, August 1990

6. • Case Series & case reports published from
1985-1988 after Inoue’s publication; Also
Double balloon technique
• Because it was experimental, patients who
were poor candidates for surgical valve
replacement were those initially chosen for
mitral balloon dilation – ELDERLY, SEVERELY
DEFORMED VALVE, HEAVY VALVULAR
CALCIFICATION

7. • Even in these patients, balloon dilation was
suprisingly successful at times
• The impressive results of surgical
commissurotomy relied in part on surgeons'
"almost mystical ability to select (surgical)
candidates”
Circulation Vol 82, No 2, August 1990

8. • Which valves might respond to balloon
dilation seemed to cardiologists an
unanswered question??

9. Br Heart J 1988;60:299-308

10. Circulation Vol 79 No 3, March 1989

11. Circulation Vol 82 No 3, August 1990

12. Predictive variables
• Factors assessed to predict optimal or
suboptimal outcome
• Suboptimal
– Any 1 or more
• Final valve area < 1 cm2 / <1.5 cm2 in later studies
• post-dilatation mean left atrial pressure > 10 mmHg
• Change in area < 25% of the initial valve area in those
with a mitral valve area > 1 cm2 before procedure

13. Variables assessed in early studies
• Clinical
– Age, Sex, Baseline Rhythm, NYHA class
• Echocardiographic
– Structural features of MV and subvalvular
apparatus
– MVA (Planimety)
– LA size
– Grade of MR

14. • Hemodynamic
– MVA
– TransMitral PG
– CO
– PVR
– LVEDP
• Technical
– Balloon used
– Effective dilating area of balloon
– Number of inflations

15. RESULTS
• Clinical
– Age, Sex, Baseline Rhythm, NYHA class
• Echocardiographic
– Structural features of MV and subvalvular
apparatus
– LA size
– MVA (Planimety)
– Grade of MR
Surprisingly, more severe stenosis or smaller
baseline valve area did not predict
Suboptimal outcome;
smaller MVA as likely as larger MVA to
give suboptimal results
Age, AF, NYHA class - weak predictors

16. • Hemodynamic
– MVA
– TransMitral PG
– CO
– PVR
– LVEDP
• Technical
– Balloon used
– Number of inflations
– Effective balloon dilatation area (EBDA)
Flouroscopic Calcium also
Weak predictor

17. • Strongest & best predictor of immediate
hemodynamic optimal result
MITRAL VALVE STRUCTURE

19. SCORE

21. Most patients with a total
echocardiographic score
> 11 had a suboptimal result
Those with a score
< 9 had an optimal result
The score failed to predict
outcome in
those with scores of 9 to 11

22. • Why 8?
• The sensitivity of the total echo
score for predicting a "good"
outcome - calculated for each
score value - proportion of all
patients with a "good"
outcome who had scores equal
to or less than that score value
• The specificity was the
proportion of all patients with
a suboptimal outcome who
had a total echo score above
that score value

24. Echo score relevance
• Higher EBDA and Sinus Rhythm are significant
favourable predictors
• Baseline AF rhythm also independently predicts
restenosis
• Upto 50% pts – MR grade increased by 1+; 50% of
these – MR decreased by 1 grade in follow-up; 30%
pts - MR grade increased by >1+
Score ≤8 ≥8
Immediate optimal result 88% 44%
NYHA class improvement 90% 56%
Re-stenosis at 2 yrs by
Echo
<10% 70%

25. EVALUATION OF PATIENT

26. INDICATION
• SYMPTOMATIC NYHA II or more
• MVA < 1.5 cm2 in a normal sized adult (or < 1 cm2 / m2)
• Favourable valve morphology

28. • Reasonable (IIa) in
– symptomatic patients in whom surgery carries high
risk for adverse events or outcomes, even when valve
morphology is not ideal,
• restenosis after a previous BMV or previous
commissurotomy who are unsuitable candidates for surgery
because of very high risk – very old, frail patients;
associated severe ischemic heart disease; pulmonary, renal,
or neoplastic disease;
• women of childbearing age in whom mitral valve
replacement is undesirable;
• Pregnant women with MS.

29. CONTRAINDICATIONS
• MR > 2+
• Left atrial thrombus
• Severe commisural calcification (Bicommisural
heavy – Grade 4 calcification)

30. IF INDICATED
• ECG
• CHEST RADIOGRAPH
• ECHOCARDIOGRAPHY

31. ECG

32. • LAE
• RAE
• RVH
• Atrial arrhythmias

36. • P wave duration and P wave dispersion
correlate with MS severity
Pacing Clin Electrophysiol 2008;31:1620-4
• RAD & RBBB presence correlates with MS
severity
Cardiology 2006; 105:219-22

37. • Acute hemodynamic changes following BMV
produce corresponding changes in ECG,
mainly in P wave and QRS axis
Indian Heart J 1998;50:179-82

38. RADIOGRAPHY

39. CHEST RADIOGRAPHY
• LAE
• Calcification
• PVH
• PAH

42. VENTRICULOGRAPHY
• MV doming and calcification
• MR severity

43. • Subvalvular disease (Atkins)
Mitral-subvalvular distance (ES)/AoV-Apex distance (ED)
<0.2 – Severe subvalvular disease
End-systole End-diastole

44. ECHOCARDIOGRAPHY

45. Parameters assessed
• Severity of MS
• Pliability of valve (suitability)
• MR
• LA thrombus
• IAS
• Other ass. Valvular ds
• PAH

46. M-mode

47. • DE amplitude
more than 18
mm – pliable
valve
• EF slope less
than 20
mm/sec –
Severe MS

49. MS severity by planimetry
• PSAX
• MAX opening in mid diastole
• Plane perpendicular to orifice
• Lowest gain setting
• Open commissures included
• Avg 3 cycles in SR, 5-10 in AF

51. • Limitation
– Gain
– Calcification
– Commissure
– Plane

52. MV separation index < 0.8
> 1.1

53. Valve mobility

54. • Wilkins grading 1-4
• Reid grading 0-2 -- Extent of doming

55. Valve thickening
• < 4 mm normal
• 5-8 mm – MILD
• >8 mm – MARKED
• Valve thickness/post Aortic wall thickness
<1.5 – Normal
<2 – Mild
2-5 – Moderate
>5 – Marked /Severe

56. Valve calcification

59. SubValve thickening

60. • PLAX
• A4C/A2C

61. IAS

62. LA thombus

63. Scoring
• Wilkins
• Reid (Br Heart J 1977;39:1088-92)
• Lung-Cormier (Antunes MJ, Acquired Heart valve ds, 1995)
• Padial (JACC 1996;27:1225-31)
• Massachusetts General Hospital (MGH)
• Ain Shams (Echocardiography 2009; 26:119-27)
• RT3DE

64. Wilkins Score

65. Reid
Score

66. Lung and Cormier score

67. Padial Score
• Significant MR post BMV
– Uneven MV thickening
– Severe subvalvular ds
– Commisural calcification

68. Cutoff 10

69. Ain Shams
• Calcification
– Leaflet margin – 2
– Leaflet Body – 4
– Commisure – 6
• Subvalvular thickening
– Less than half - 4
– More than half - 4
– Full length - 6
Cutoff - 4

70. RT3DE

72. • Preprocedural MR
Does not predict success directly
Benefit of using larger balloon only in
absence of significant MR
• TEE
LA and LAA clot
Underestimates subvalvular ds

73. Scoring system problems
• Subjective, Semiquantitative
• Echo diff of nodular fibrosis from calcium
• Subvalve ds underestimation
• Non inclusion of commisural calcium
• Uneven distribution of pathology
• Combination of scores solves some of these
problems

74. TAKE HOME MESSAGE
• BMV is feasible, safe, and successful, provided
that proper assessment has been done pre-
procedure
• Check Indications & Contraindications
• Echo scoring – Combine scores, include
commisural calcium score
• TEE to rule out LA clot esp in patients with AF
• Periprocedural monitoring and follow-up is
essential