Glass Syringe Record

Mitral Valvuloplasty

Percutaneous Ballon Mitral Valvuloplasty (PTMV)

Mechanism

Percutaneous mitral valvuloplasty is more appropriately called percutaneous mitral commissurotomy because the balloon dilatation improves the valve orifice by separating the fused mitral commissures. As shown by echocardiographic, fluoroscopic, and anatomic studies, the expanding balloon splits fused commissures in the same manner as a surgical commissurotomy.

Indications

Symptomatic Mitral Stenosis

Pulmonary oedema

Pulmonary Hypertension

with Abnormal LV function.

Contraindications

Thrombus within the LA

Moderate or Severe Mitral Regirgitation

Aortic or Tricuspid valve lesions

Patient Selection

Patients should be selected for percutaneous transluminal mitral valvuloplasty based on both clinical and anatomic factors. In most cases they should be symptomatic, and mitral valve area as measured by echocardiography and hemodynamics should be <1.5 cm2. Unlike for valve surgery, the presence of pulmonary hypertension or abnormal left ventricular function is not a contraindication. Patients with anatomically suitable valves who have developed restenosis (commissural refusion) after prior surgical or balloon commissurotomy can also undergo percutaneous mitral valvuloplasty with results almost as good as previously untreated patients,

Although the procedure can be performed in patients of almost any age, the best clinical results are observed in younger patients, with less predictable long-term results occurring in patients older than 70 years, who are more likely to have deformed and calcified valves. Percutaneous mitral valvuloplasty is a particularly valuable tool in treating the symptomatic pregnant woman with critical mitral stenosis. It can also be a lifesaving emergency procedure in the patient with mitral stenosis and refractory pulmonary edema or cardiogenic shock.

Asymptomatic patients should be considered for percutaneous mitral commissurotomy when they develop pulmonary hypertension or new-onset atrial fibrillation . A pulmonary artery peak systolic pressure >50 mm Hg at rest or 60 mm Hg with exercise in an otherwise asymptomatic patient represents disease severity that has reached the point where percutaneous commissurotomy should be considered . New atrial fibrillation is less clear an indication but should be considered, especially in patients with mitral valve morphology well suited for percutaneous commissurotomy.

Anatomic Factors in Patient Selection for Balloon Mitral Valvuloplasty

High-quality transthoracic and transesophageal echocardiography (TEE) is an essential part of proper patient selection. TEE prior to the planned valvuloplasty procedure excludes the presence of left atrial thrombus and moderate or greater mitral regurgitation. In addition to ensuring that there are no anatomic contraindications, echocardiography provides valuable information that helps the interventional cardiologist select patients and predict results . The ideal patient has pliable, noncalcified mitral leaflets and mild subvalvular disease. As the degree of subvalvular disease increases, the quality of the result with percutaneous mitral valvuloplasty decreases.

Mitral Valve Scoring (ECHOCARDIOGRAPHIC SCORING SYSTEM)

* Leaflet mobility

Highly mobile valve with restriction of only the leaflet tips Midportion and base of leaflets have reduced mobility Valve leaflets move forward in diastole mainly at the base No or minimal forward movement of the leaflets in diastole

* Valvular thickening

Leaflets near normal (4.5 mm) Midleaflet thickening, marked thickening of the margins Thickening extends through the entire leaflets (5-8 mm) Marked thickening of all leaflet tissue (>8-10 mm)

* Subvalvular Thickening

Minimal thickening of chordal structures just below the valve Thickening of chordae extending up to one third of chordal length Thickening extending to the distal third of the chordae Extensive thickening and shortening of all chordae extending down to the papillary muscle

* Valvular Calcification

A single area of increased echo brightness Scattered areas of brightness confined to leaflet margins Brightness extending into the midportion of leaflets Extensive brightness through most of the leaflet tissue

Adding each of the components determines final score (maximum, 16 points). From Wilkins GT, Weyman AE, Abascal VM, et al

Patients with significant valve deformity and echocardiographic scores >8 should not be excluded a priori from consideration for percutaneous mitral valvuloplasty. There is no absolute contraindication to percutaneous mitral valvuloplasty in patients with higher echocardiographic scores, but patients with echocardiographic scores >8 require an individualized approach. The duration of palliation may be less than in patients with ideal valve morphology, and the acute procedure success rate is lower. When valve deformity is associated with other clear indications for open heart surgery, the decision is relatively simple. This includes patients with associated significant aortic stenosis or insufficiency, multivessel coronary artery disease, or those with severe tricuspid regurgitation in need of repair. When none of these indications are present or clear, percutaneous commissurotomy in patients with significant valve deformity can be a successful palliative therapy. This is an especially useful strategy in patients with borderline aortic insufficiency or stenosis, in whom a waiting period after mitral commissurotomy may allow for a more timely decision for double-valve replacement at a later date.

Inoue Balloon Technique

All antegrade approaches begin with the crucial first step of successful trans-septal catheterization. This technique not only requires successful access to the left atrium, but must also be through the proper part of the atrial septum to allow easy access to the mitral valve. After successful placement of a Mullins-type dilator and sheath into the left atrium and confirmation of its position by a hand injection of contrast, the patient is anticoagulated with heparin. Baseline hemodynamics are then recorded, confirming the appropriate degree of mitral stenosis. Subsequently, a special solid-core coiled 0.025-inch guidewire is introduced into the left atrium, and the Mullins sheath dilator system is removed. The femoral vein and interatrial septum are then dilated with a long 14F dilator over the coiled guidewire within the left atrium. The previously prepared, tested, and now slenderized Inoue balloon is then introduced over the guidewire into the left atrium. The Inoue balloon is made of nylon and rubber micromesh.

After the slenderized balloon has been positioned within the left atrium, the stretching tube is removed, and a preshaped “J”stylet is introduced into the Inoue balloon. The distal portion of the balloon is inflated slightly to aid in crossing the valve and to prevent intrachordal passage. By maneuvering the balloon catheter while rotating and withdrawing the stylet, the balloon tip will move anteriorly and inferiorly toward the mitral orifice. After the balloon catheter is across the mitral orifice, the distal portion of the balloon is inflated more fully and the catheter is pulled back gently to confirm that the inflated distal portion of the balloon is secure across the mitral valve. As further volume is added to the balloon, the proximal end inflates to lock the valve between the proximal and distal balloon. Inflation to precalibrated volume then dilates the valve orifice to the corresponding preset size. It is then allowed to deflate passively before it is withdrawn into the left atrium. The pressure gradient across the mitral valve is measured after each balloon dilatation, and echocardiography may be used to assess the mitral valve area, leaflet mobility,

If the first inflation has not resulted in a satisfactory increase in the mitral valve area, and the degree of mitral regurgitation has not increased, the balloon is then readvanced across the mitral valve and inflation repeated with the balloon diameter increased by 1 or 2 mm by delivery of slightly more of the precalibrated syringe volume in a stepwise dilatation process that is repeated until the desired result is achieved.

Complications

In skilled hands, the failure rate of the procedure should be <5%. Failure usually results from the inability to safely puncture the interatrial septum because of anatomic difficulties or, in some cases, to position the balloon catheter successfully across the mitral valve. The procedural mortality rate varies from 0 to 3% in most series. Hemopericardium related to trans-septal catheterization, atrial puncture, or, rarely, left ventricular apical perforation by the balloon or wires varies in incidence from 0.5 to 10%. Systemic embolization has been encountered in 0.5 to 5% of cases. These complications diminish with increasing operator experience.

Severe mitral regurgitation is fortunately uncommon, ranging in incidence from 2 to 9%, and is related to noncommissural leaflet tearing or chordal rupture. Leaflet tears are largely unpredictable and unpreventable, but chordal rupture can be minimized by careful technique. Usually, in these circumstances one or both of the mitral commissures were too tightly fused to be split successfully by the balloon, and the leaflets have torn along noncommissural lines. Most cases of severe mitral regurgitation occur in patients with unfavorable mitral valve anatomy. Same-day surgical mitral valve replacement is necessary in 2 to 3%. Usually even severe mitral regurgitation is well tolerated for a time by the patient, and in the acute setting is usually responsive to intravenous nitroglycerin or nitroprusside. In general, elective surgical replacement rather than repair of the valve will be necessary when severe mitral regurgitation occurs because of the severity of the underlying valvular and subvalvular disease

See also

Aortic valvuloplasty

References

^ Lau KW, Ding ZP, Gao W, et al. Percutaneous balloon mitral valvuloplasty in patients with mitral restenosis after previous surgical commissurotomy. Eur Heart J 1996;17:1367.

^ Gupta S, Vora A, Lokhandwalla Y, et al. Percutaneous balloon mitral valvotomy in mitral restenosis. Eur Heart J 1996;17:1560.

^ a b ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/ American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol 1998;32:1486: 1588.

^ Padial LR, Freitas N, Sagie A, et al. Echocardiography can predict which patients will develop severe mitral regurgitation after percutaneous mitral valvulotomy. J Am Coll Cardiol 1996;27: 1225.

^ Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J 1988;60: 299.

^ Iung B, Cormier B, Ducimetiere P, et al. Immediate results of percutaneous mitral commissurotomy. A predictive model on a series of 1,514 patients. Circulation 1996;94:2124.

^ Chern MS, Chang HJ, Lin FC, Wu D. String-plucking as a mechanism of chordal rupture during balloon mitral valvuloplasty using Inoue balloon catheter [see comment]. Cathet Cardiovasc Intervent 1999;47:213: 217.

^ Acar C, Jebara VA, Grare PH, et al. Traumatic mitral insufficiency following percutaneous mitral dilation of anatomic lesions and surgical implications. Eur J Cardiothorac Surg 1992; 6:660: 664.

v  d  e

Health science Medicine  Surgery  Vascular surgery and other vascular procedures (ICD-9-CM V3 38-39)

Aortic aneurysm / dissection

Open AAA repair  Endoluminal AAA repair (EVAR)

Carotid stenosis

Carotid endarterectomy  Carotid stenting

Varicose veins

Ambulatory phlebectomy  Laser ablation  Sclerotherapy  Vein stripping

Peripheral arterial occlusive disease

Angioplasty with/out Stenting  Balloon embolectomy  Peripheral arterial bypass surgery  Thrombectomy

Portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS)  Distal splenorenal shunt procedure

Other vascular procedures

Venous cutdown  Cardiopulmonary bypass  Cardioplegia  Hemodialysis/Hemofiltration  Revascularization

Imaging

Angiography (Digital subtraction angiography, Cerebral angiography, Aortography, Fluorescein angiography, Radionuclide angiography, Magnetic resonance angiography)

Venography (Portography)

vascular navs: anat/physio/dev, noncongen/systemic vasculitis/congen/neoplasia, symptoms+signs/eponymous, proc

Categories: Cardiac surgery | Cardiology
About the Author

I am an expert from China Toys Suppliers, usually analyzes all kind of industries situation, such as moroccan candle lantern , votive glass holders.

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Bleeding Syringe Prop $8.99 Bleeding Syringe – Realistic-looking plastic hypodermic syringe. As the plunger is pulled out, blood fills the chamber and when pushed down, blood seems to disappear. Plastic needle comes with syringe and must be placed on separately. Each syringe is

PerioTherapy Syringe $4 A re-usable plastic syringe that allows users to squeeze just the right amount of PerioGel under the gum line to assist in gum healing and fresher breath.

Terumo Needless Syringe Only, 600/cs $78.47 Terumo Needless Syringe Only, 600/cs