Percutaneous transvenous

mitral commissurotomy
(PTMC)

Dr. Asim Kumar Biswas

MD Final Part Student
NHFH&RI
(PTMC) was introduced in 1984 by the Japanese surgeon Kanjie Inoue.

Till then surgery was the only treatment for patients with mitral stenosis.
Indication
(PTMC) is recommended for symptomatic patients with moderate to
severe MS (i.e., a MVA <1 cm2/m2 of BSA or <1.5 cm2 in normal-sized
adults) with-
• favorable valve morphology,
• no or mild MR,
• no evidence of left atrial thrombus
Expanding Indication of PTMC
• Mitral restenosis
• Moderate Mitral Regurgitation of central Jet
• Hybrid Therapy AR, AS, CABG
• Mitral Stenosis with LA Clot (Type Ia,Ib, IIa)
CONTRAINDICATIONS
• Thrombus within the LA
• Moderate or severe >2+ MR
• Massive or bicommissural calcification
• Mitral stenosis with associated other Valvular diseases requiring
cardiac surgery
• Concomitant CAD requiring CABG
Patient selection
The selection of patients for PTMC procedure is a complex decision involving the
consideration of-
• the clinical profile
• valve morphology

Exclusion of contraindication
Valve morphology
• Most investigators use the Wilkins score , in which a total score under 8 is considered
to represent favorable anatomy for PMC
Limitations of Wilkins score
• Presence of LA thrombus is not considered
• Assessment of commissural involvement is not included or
underestimated.
• Echocardiography limited in ability to differentiate nodular fibrosis
from calcification
• Doesn’t account for uneven distribution of pathologic abnormalities.
• Doesn’t account for relative contribution of each variable (no
weighting of variables).
• Doesn’t use results from TEE or 3D echocardiography
THE BEST PATIENTS FOR PTMC

Optimal candidates for PMV are those patients meeting the following characteristics:
(1) age 45 years old or younger
(2) normal sinus rhythm
(3) echocardiographic score less than or equal to 8
(4) no history of previous surgical commissurotomy
(5) pre-PMV MR less than or equal to 1+.
Procedure
There are two approaches—
trans-arterial
&
trans-venous
Main techniques—
• Inoue technique
• double-balloon technique
• metallic valvulotome
• retrograde technique
Inoue technique
Instruments

BROCKENBROUGH NEEDLE
MULLINS INTRODUCER SHEATH
 Inoue-Balloon Catheter
Selection of Appropriate Balloon Size
A simple equation to obtain the reference size:
height [cm]
+ 10
10
DOUBLE-BALLOON TECHNIQUE
METALLIC
COMMISSUROTOME
Desired endpoint of the procedure
(1) mitral valve area of more than 1 cm2/m2 of the body surface area, usually
doubles
(2) 50% – 60% reduction of transmitral gradient
(3) complete opening of at least one commissure
L A pressure curve
Definition of good immediate results
The two definitions frequently employed are-

1. a final valve area larger than 1.5 cm2 and an increase of at least 25% in the valve area
2. a final valve area larger than 1.5 cm2 without mitral regurgitation greater than 2/4
RESULTS
• Immediate result is decrease in left atrial pressure and a slight increase in cardiac index.
• A gradual decrease in pulmonary arterial pressure and pulmonary vascular resistance is
seen.
• High pulmonary vascular resistance continues to decrease in the absence of re-stenosis.
• Improvement in the pump function of the left atrium and the LAA and decrease in left
atrial stiffness also occur.
COMPLICATIONS
• MR during PMV can occur because of following (from 2 to 9%)
• Tearing or stretching of commissures
• Failure of leaflet co-aptation
• Rupture of mitral leaflet
• Rupture of chordae
• Damage to papillary muscles .
• Cardiac perforation resulting hemopericardium (2-4%), If hypotension occurs during
and after PTMC, hemopericardium must be suspected.
• Embolism is encountered in 0.5% to 5% of cases.
• ASD, upto 10%, mostly close by 6 months.
PTMC During Pregnancy

Procedure is best avoided until organogenesis is complete (5

months after conception) unless the patient is severely
symptomatic and refractory to optimal medical therapy.
PTMC During Pregnancy

•Inoue balloon is preferred technique because of shorter procedure

time and low radiation exposure
•External shielding during procedure
•Saving fluoroscopic images and avoiding high dose cineradiography
•Reducing the frame rate of fluoroscopy (e.g. 15 frames/sec or
lower).
•Avoid angulated projections—AP projection is preferred