Balloon Mitral Valvuloplasty (BMV Procedure)

Mitral stenosis, most commonly secondary to rheumatic heart disease, is the most important indication for planning a BMV procedure. Occasionally it may be considered for other conditions for mitral stenosis like congenital mitral stenosis or for cor triatriatum in rare cases.

Like Balloon Mitral Valvuloplasty for the mitral valve, it can also be done for the pulmonary valve (BPV) i.e. balloon pulmonary valvuloplasty and tricuspid valve (BTV) i.e. balloon tricuspid valvuloplasty.

Patients have to be carefully selected for this procedure.

Criteria are -

• Severe mitral stenosis i.e. mitral valve area less than 1cm2.
• At least moderate mitral stenosis i.e. mitral valve area less than 1.5cm2 with symptoms or significant pulmonary artery hypertension.
• Mitral valve should not be very calcific, especially at the commissures and also there should not be significant subvalvular narrowing.
• Wilkins score was used as a guide to decide on the feasibility of the valve to undergo the balloon procedure. Score of 8 or less was considered favorable for BMV.
• Criteria for Wilkins score included mitral valve mobility, thickness, calcification, sub valvular apparatus thickening.

Pre Procedural Preparation for BMV

• Necessary diagnostic tests and imaging studies (e.g., echocardiogram, cardiac catheterization).
• As mentioned previously, BMV is done for patients with severe mitral stenosis. Echocardiogram is the most important diagnostic test to identify mitral stenosis, assess the severity and also to assess the feasibility of the valve for BMV.
• Occasionally TEE i.e. transesophageal echo may be done to better assess the valve for feasibility for BMV procedure.
• Preoperative patient education and consent process patients are properly explained and educated about the procedure including its risks and benefits and then informed consent is taken.
• Patients are usually admitted a few hours before the procedure and should be fasting for at least 6 hours prior to the procedure.
• Once admitted, routine bloods including for blood group identification and cross matching is sent in case blood may be needed. A surgeon is kept on standby if any complication arises during the procedure.

Detailed step-by-step Balloon Mitral Valvuloplasty (BMV Procedure)

• Patient is taken to the cath lab.
• Cleaning of the groins is done with betadine or similar antiseptic scrubs.
• Ultrasound guided puncture of the femoral vein in the groins is done and sheath is inserted using seldinger technique.
• A catheter is inserted from the femoral vein and introduced in the right atria.
• Brockenbrough transseptal puncture needle is taken through the catheter and the inter atrial septum is punctured to enter the left atria. This is done on both TEE and fluoroscopy guidance.
• Then a left atria retention wire is passed through the catheter and kept in the left atria. Then the special balloon catheter is passed through it to enter the left atria.
• The balloon catheter is then advanced in the left ventricle, across the mitral valve. The balloon is then inflated across the mitral valve under fluoroscopy guidance.
• Pressures in the left atrium and pulmonary arteries, before and after the procedure are checked.
• All the catheters are removed and the sheath at the groin site is also removed. Patients lie flat for a few hours and are later mobilized.
• If echocardiogram parameters are fine, then patients can be discharged the next day.

Types of balloons and catheters used 

Mainly two types of balloon catheters are available in the market inoue balloon catheter & accura balloon catheter.

Immediate post-procedure monitoring and care 

Post procedure patients are shifted to the cardiac ICU for monitoring of vitals and also to look for any complications at the groin site. Patients have to be observed for any new symptoms as due to this procedure there could be complications of acute mitral regurgitation or pericardial injury and tamponade, both of which can be life threatening.

Typical recovery timeline and expectations

Usually +, if all goes well, patients are discharged the next day. We advise rest for a few days at home and then, they can gradually resume their daily activities over the next couple of weeks. Usually the patients will experience a better quality of life with less symptoms of shortness of breath or fatigability.

Follow-up appointments and long-term care considerations

Post discharge, these patients are closely followed up for 3 months and if results are good, then they can be followed up every 6 months.

Clinical outcomes and success rates

BMV procedure is successful in >95% cases. Though the outcomes and success depend on the operators and also the disease extent of the mitral valve.

Improvements in symptoms and quality of life

With the increase in the mitral valve area and the drop in pressure gradients across it, there is improved blood flow across the valve. This causes improvement in the symptoms and better quality of life.

Long-term durability and effectiveness of the procedure

Usually this procedure lasts for around a decade as there is gradual restenosis of the valve secondary to the rheumatic affection of the valve. Post restenosis, a redo BMV may be attempted or the patients may be subjected to mitral valve replacement, depending on the condition of the diseased mitral valve.

Intraprocedural and immediate post procedure risks

Mitral valve injury with significant acute mitral regurgitation - this condition requires immediate surgical intervention with mitral valve replacement.

Pericardial injury with tamponade - this needs immediate pericardial drain with removal of blood from the pericardial sac. If it continues to re accumulate then the cardiac surgeon intervenes immediately to fix the pericardial perforation.

Long term complication

Restenosis of the mitral valve. As discussed earlier, this condition can be fixed with redo BMV or cardiac surgery with mitral valve replacement or open mitral valvotomy.

Benefits of BMV Procedure

This is a minimally invasive reasonably safe procedure in experienced hands. It avoids general anesthesia, incision on the chest and need for long term blood thinning medications. This procedure can buy significant time before these patients eventually need open heart surgery for their mitral valve narrowing.

In pregnant females with significant mitral stenosis, this procedure can help in opening up the significant mitral valve narrowing. This reduces the strain on the heart as later stages of pregnancy and delivery can cause increased workload on the heart. Thus facilitating better outcomes of pregnancy and childbirth.