Balloon mitral valvuloplasty

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1 Echo for selecting and monitoring procedures in mitral valve diseases Balloon mitral valvuloplasty Eric Brochet,MD Cardiology Department Hôpital Bichat. Paris France

2 Conflict of interest : none

3 Balloon mitral valvuloplasty BMV has become the reference treatment in symptomatic patients with severe mitral stenosis, and suitable anatomy 100 % PATIENTS % 70% 38% 20 group 1 group 2 group YEARS Iung et al. Circulation 1999;99:3272-8

4 Balloon mitral valvuloplasty Key role of echocardiography For the selection of candidates For procedure guidance

5 Goals of echocardiography before BMV Quantitation of MS severity Suitability for BMV Analysis of valve anatomy Exclusion of contra-indications

6 Quantitation of MS severity MV area Mean gradient systolic PAP Baumgartner H et al. EAE/ASE Recommendations Eur J of Echocardiography (2009)

7 Mitral valve area v1 v2 PHT

8 2D planimetry Sometimes difficult

9 RT 3D TTE Mitral valve area Quantification of severity (RT 3DTTE)

10 Mitral stenosis 3DTTE MV area 2D and 3D MVA vs Gorlin Experienced vs less experienced operators Zamorano et al, JACC 2004;43: Messika-Zeitoun et al. Eur Heart J :72-79

11 Mitral stenosis Quantification of severity (RT 3DTEE)

12 Exercise echocardiography Difficult situations Severe MS with few or no symptoms Discrepancy between MS severity criteria Evolution of mitral gradient and pulmonary pressure during exercise

13 Goals of echocardiography before BMV Quantitation of MS severity Suitability for BMV Analysis of valve anatomy Exclusion of contra-indications

14 Goals of echocardiography before BMV MV anatomy Commissural fusion +++ Leaflet thickening and mobility Chordal shortening and thickening Degree of calcification, especially in commissural areas

15 Goals of echocardiography before BMV Commissural fusion Symmetric Asymmetric

16 Goals of echocardiography before BMV No commissural fusion

17 Mitral stenosis Commissural fusion Symmetric Asymmetric

18 Goals of echocardiography before BMV MV anatomy Commissural fusion +++ Leaflet thickening and mobility Chordal shortening and thickening Degree of calcification, especially in commissural areas

19 MV anatomy

20 RT 3D TTE anatomy

21 RT 3D TEE anatomy

22 Mitral Valve Score Cormier score Wilkins score

23 Goals of echocardiography before BMV Detailed description of Commissural fusion impairment of leaflets and subvalvular apparatus homogeneity of impairment of valve anatomy (commissural areas+++ in parasternal SAX view)

24 Goals of echocardiography before BMV Quantitation of MS severity Suitability for BMV Analysis of valve anatomy Exclusion of contra-indications

25 Exclusion of contra-indications LA thrombus

26 Exclusion of contra-indications Mitral regurgitation > 2/4

27 Exclusion of contra-indications Other contra indications Severe or bicommissural calcifications Absence of commissural fusion Combined severe aortic or tricuspid valve disease

28 Selection criteria for BMV Decision based on severity of MS ( MVA < 1,5 cm²) and consequences of MS ( symptoms, AF, PAP) Suitability for BMV But also clinical characteristics

29 Management of Severe Symptomatic Mitral Stenosis Symptomatic MS < 1.5 cm² CI to PMC No Yes CI or high risk for surgery Yes No Favourable anatomical characteristics Unfavourable anatomical characteristics Favourable clinical characteristics Unfavourable clinical characteristics PMC Surgery VHD Guidelines Slide-set 2007 European Society of Cardiology

30 Management of Severe Symptomatic Mitral Stenosis Symptomatic MS < 1.5 cm² CI to PMC No Yes CI or high risk for surgery Yes No Favourable anatomical characteristics Unfavourable anatomical characteristics Favourable clinical characteristics Unfavourable clinical characteristics PMC Surgery VHD Guidelines Slide-set 2007 European Society of Cardiology

31 Management of Severe Asymptomatic Mitral Stenosis Asymptomatic MS < 1.5 cm² High risk of embolism or haemodynamic decompensation Yes No Exercise testing Symptoms No symptoms CI to or unfavourable characteristics for PMC No Yes PMC Follow-up VHD Guidelines Slide-set 2007 European Society of Cardiology

32 Goals of echocardiography during BMV Guidance of the transseptal puncture Monitoring of the procedure Detection of early complications

33 Goals of echocardiography during BMV Guidance of the transseptal puncture Monitoring of the procedure Detection of early complications

34 Echo guided transseptal puncture TEE

35 Echo guided transseptal puncture RT3D TEE imaging

36 Echo guided transseptal puncture X Plane imaging

37 Echo guided transseptal puncture ICE imaging

38 Goals of echocardiography during BMV Guidance of the transseptal puncture Monitoring of the procedure Detection of early complications

39 Inoue Stepwise Technique TTE after each inflation commissural splitting Increase in MVA Appearance or increase in MR Check complications

40 Inoue Stepwise Technique Commissural splitting (2D TTE)

41 Inoue Stepwise Technique Commissural splitting (3D TTE)

42 Inoue Stepwise Technique Onset of new MR jet

43 2D TEE during BMV

44 RT3D TEE during BMV

45 RT3D TEE during BMV RT 3D TEE

46 RT3D TEE during BMV RT 3D TEE

47 RT3D TEE during BMV Commissural splitting (3D TEE) BEFORE BMV AFTER BMV

48 ICE during BMV

49 Endpoint of the BMV procedure Immediate good results are defined by final MVA > 1.5 cm² ( 1cm²/m² BSA) complete opening of at least one commissure and MR < 2/4 observed in 80 % of cases

50 Mitral valve area BEFORE PMC AFTER PMC

51 MV gradient Mean gradient < 3 mmhg

52 Mitral PHT PHT not reliable after PMC But provides useful information PHT less than 130 milliseconds :100% specificity and positive predictive value of for good opening of the valve Messika Zeitoun et al J Am Soc Echocardiogr 2005;18:

53 Goals of echocardiography during BMV Guidance of the transseptal puncture Monitoring of the procedure Detection of early complications

54 If the patient is hypotensive.. Tamponade (0.3-1%)

55 Detection of early complications Severe MR ( 2-5%) PRE POST Anterior leaflet tear

56 Detection of early complications Severe MR ( 2-5%) Chordal rupture

57 Detection of early complications Severe MR ( 2-5%) PRE POST Excessive commissural spiltting

58 Summary Key role of echocardiography before BMV Adequate selection of patients Exclusion of contra-indications Key role of echocardiography during BMV Use of echo increases the safety of the procedure and help to obtain the best result in each patient without complication Great value of 3D TTE and 3D TEE techniques before and during BMV

59 Thank You Bichat Cath lab Dr D Himbert Dr JM Juliard Pr A Vahanian Bichat Echo lab Dr D Messika Zeitoun, Dr D Detaint, Dr L Lepage, Dr E Brochet

60

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