|Year : 2020 | Volume
| Issue : 3 | Page : 121-126
Mitral valve assessment and scoring before balloon mitral valvuloplasty
Satyam Rajvanshi1, Ranjit Kumar Nath2, Rajeev Bharadwaj2
1 Rajvansh Heart and Vascular Centre, Muzaffarnagar, Uttar Pradesh, India
2 Department of Cardiology, ABVIMS and Dr. RML Hospital, New Delhi, India
|Date of Submission||05-Jun-2020|
|Date of Decision||20-Jun-2020|
|Date of Acceptance||12-Jul-2020|
|Date of Web Publication||26-Nov-2020|
Dr. Rajeev Bharadwaj
Department of Cardiology, ABVIMS and Dr. RML Hospital, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None
Management of symptomatic rheumatic mitral stenosis (MS) by nonsurgical techniques has been the therapeutic modality of choice in low- and middle-income countries such as India. In comparison to surgical interventions, catheter-based balloon dilatation has been preferred in cases of rheumatic MS. Various scoring systems, including three-dimensional (3D), 2D transthoracic, and transesophageal echo and fluoroscopy, have been summarized in this review for the evaluation of the morphology of the valve apparatus, including calcification, and subvalvular involvement for predicting favorable outcomes.
Keywords: Balloon mitral valvuloplasty, mitral stenosis, rheumatic valve disease, severity scoring for rheumatic mitral stenosis
|How to cite this article:|
Rajvanshi S, Nath RK, Bharadwaj R. Mitral valve assessment and scoring before balloon mitral valvuloplasty. Heart India 2020;8:121-6
| Introduction|| |
Rheumatic heart disease causing damage to the cardiac valves is a common disease occurring in the third-world countries including India. Although majority of the advanced valvular heart disease requires surgical intervention to give relief to their symptoms, rheumatic mitral valve (MV) stenosis was initially evaluated for percutaneous valvuloplasty in the early 80's and was found to be successful. However, their success is dependent upon different clinical and morphologic characteristics of the MV and if not selected properly by prior evaluation, the procedure can be counterproductive leading to serious life-threatening complications. Hence, evaluation of the valve morphology and other characteristics has been extensively studied, and today balloon mitral valvuloplasty (BMV) is a standard procedure for treating symptomatic rheumatic MV stenosis if the preprocedure morphology of the valve and other clinical characteristics are suitable.
| History|| |
Surgical commisurotomy was proposed as a treatment for mitral stenosis (MS) in the first decade of the 20th century. First successful closed mitral commisurotomy was performed in 1923 by Elliot cutler. The technique was established by 1940s. Open mitral commisurotomy (OMC) and replacement of MV became surgical procedures of choice after cardiopulmonary bypass was developed in 1960s.
Kanji Inuoe, Japanese cardiovascular surgeon, designed a balloon catheter system in 1976. Initially, it was tried as a means to separate fused commissars of MV during OMC. The system was redesigned in 1980. The first human clinical application of BMV percutaneously was successful in 1982 and initial reports of six patients was published in 1984. Subsequently, the reports of polyethylene cylindrical balloons, double balloons being used for this purpose were published by Lock et al. and Al Zaibag et al. Palacios et al. published the first report of successful use in calcific MS.
The surgeons chose the patients for commisurotomy versus valve replacement on the basis of valve structure and pathology. Because percutaneous balloon dilation was considered experimental, patients who were poor candidates for surgical valve replacement were those initially chosen for it – elderly, severely deformed valve, and heavy valvular calcification. For the cardiologists, which valves might respond favorably to percutaneous balloon dilation was still an unanswered question.
| Procedural Characteristics and Result|| |
From 1988 to 1990, various research papers were published analyzing the factors affecting the immediate and long-term outcomes of percutaneous balloon dilation.,,,, Various factors which were analysed in relation to outcome included clinical factors such as age, sex, NYHA class, baseline rhythm, echocardiographic, and hemodynamic factors such as MV structure, MV area (MVA), left atrial (LA) size, mitral regurgitation (MR) grade, cardiac output, transmitral gradient, pulmonary vascular resistance, left ventricular (LV) end diastolic pressure, and technical factors such as type of balloon, effective balloon dilatation area, number of inflations, and presence of fluoroscopic calcium.
The “Suboptimal” outcome post-BMV has been earlier defined  as the presence of any one of the following: (a) a final valve area <1.0 cm 2, (b) a post-dilatation mean LA pressure >10 mmHg, or (c) a change in area <25% of the initial valve area in those with a MVA >1.0 cm 2 before the procedure, (d) presence of more than moderate MR. More recent papers define “optimal” result as final MVA 1.50 cm 2 or greater (or increase in MVA by at least 50%) without increase in severity of MR by more than 1 grade.
The strongest predictor of immediate outcome of balloon dilation was MV structure. An echocardiographic scoring system was introduced by Wilkins et al. to score valve structures [Table 1]. This score included four variables – leaflet mobility, leaflet thickening, calcification, and subvalvular thickening. Each variable was given a score from 1 to 4, and total score was given for a valve out of 16. Most patients with a total echocardiographic score of more than 11 had a suboptimal result. Most patients with a score of <9 had an optimal result. The score failed to predict the outcome in those with scores of 9–11. The sensitivity and specificity to predict an optimal outcome were maximal at score of 8.,
Wilkins' score has various shortcomings. Echocardiography in general is limited in ability to differentiate nodular fibrosis from calcification. Wilkins' score does not assess commissural calcification. It does not account for the uneven distribution of pathological abnormalities, and relative contribution of each variable, thus underestimates subvalvular disease. In general, more the number of variables assessed, more is the inter- and intra-observer variability in assessing scores.
Reid et al. proposed another MV morphological scoring system by including commissural calcium scoring along with leaflet motion, thickness, and subvalvular disease. They concluded that leaflet mobility was the only independent morphological feature predicting change in MVA post-BMV. The presence of commissural calcium, Pre-BMV MVA, and LA size (correlates with duration of disease) also predicted BMV outcome in multivariate analysis. Total morphological score showed a weaker relationship with outcome.
French 3-group grading by Lung and Cormier is another scoring system giving greater importance to subvalvular pathology and presence of fluoroscopic calcium [Table 2]. Fluoroscopy was used to classify patients with calcified valves as limited ability of echocardiography to differentiate nodular fibrosis from calcification. Higher group, smaller MVA (<1 cm 2), higher Age (>50 yrs), and history of previous commisurotomy were the main predictors of suboptimal outcome.
Severe MR remains as one of the most important complications of this technique, with an incidence between 1.4% and 19%., This complication confers an adverse prognosis and frequently requires intensive treatment and urgent MV surgery. MR Echocardiographic score was developed by Padial et al. to predict the development of significant MR after BMV [Table 3]. Padial et al. emphasized that uneven valvular thickening and presence of thin segments in thickened valves is major cause for the development of severe MR post BMV. The cut-off value of 10 in Padial MR score gave 90% sensitivity and 97% specificity to predict the development of severe MR post-BMV.
The total score is the sum of these echocardiographic features (maximum 16).
Many reports have stressed the importance of commissural morphology as shown in [Figure 1] in determining the outcome of BMV ,,,,,, and demonstrated commissural splitting as the pivotal mechanism by which MVA is increased during the procedure., Commissural calcification also predicts the occurrence of substantial MR post BMV., This complication occurs if resistance to commissural splitting, offered by calcification in one or both commissars, leads to leaflet tear. Transthoracic echocardiography (TTE) grading of commissural calcification 0-4 using parasternal short-axis views has been shown to be a significant predictor of optimal BMV outcome with poor outcome if score is 3 or more [Table 4] and [Table 5]. Some reports have found its influence greatest in patients with a Wilkins echo score <8. Calcification of one commissure or more predicts a <50% probability of achieving a valve area above 1.50 cm 2.
|Figure 1: Patterns of commissural calcification and thickness of mitral valve leaflets. Different levels of thickening and calcification of mitral valve leaflets in short axis view. (a) Thickened and minimally calcific leaflets but the commissural lines are free of calcification indicating favorable outcome, (b) Valve thickness and calcification in transesophageal echo in the same patient, (c) Very thickened and moderately calcific valve with one commissure calcific but the other is having a thin line of calcification-free zone leading to opening of one commissures with commissural mitral regurgitation with another small jet of central mitral regurgitation (d), the other commissure didn't open|
Click here to view
Transesophageal echocardiography (TEE) assessment of commissural morphology and calcification is a significant predictor of BMV outcome., Commissural assessment by TEE in comparison with TTE offers superior resolution of the MV apparatus and overcomes problems caused by anterior leaflet shadowing, thereby allowing more accurate localization of mitral calcification. A novel TEE method for systematic scanning of the whole length of the mitral commissars has been proposed. A commissural score from 0 to 4 has been proposed. Higher score predicted better BMV outcome. TEE score was more accurate in predicting poor outcome in patients with Wilkins score 8 or less.,
[Table 6] Rifaie et al. proposed novel echocardiographic score which composed of only two variables: leaflet/commissural calcification and subvalvular disease as shown in [Figure 2]. PTMC was done by standard double-balloon technique. This score was easier to use and cutoff value of total score 4 or more (out of 12) had better specificity (82.9% vs. 74.3%) and sensitivity (86% vs. 60%) compared to Wilkins' score for the prediction of suboptimal outcome and severe MR following BMV.
|Table 6: Novel echocardiographic score by Osama et al., Ain Shams University|
Click here to view
|Figure 2: Subvalvular disease and outcome after mitral valvuloplasty. Different levels of subvalvular disease and outcome. (a) Severe subvalvular thickening in transthoracic and (b) transesophageal echocardiography, (c) Poor opening of the valve after valvuloplasty in 2-Dimensional as well as (d) transesophageal echocardiography|
Click here to view
Nunes et al. proposed yet another novel grading involving four predictors: Presence of MVA <1 cm 2, quantitative assessment of commissural morphology (Commissural Area ratio >1.25), limited valve mobility (Maximal leaflet mobility 12 mm or less), and severe subvalvular disease [Table 7]. Higher scores were shown to be more accurate than Wilkins score in predicting suboptimal outcome post BMV.
Real time three-dimensional echocardiography (RT3DE) provides more detailed morphologic analysis of MV apparatus including calcification and subvalvular involvement [Table 8]., Three-dimensional (3D) echo, though more informative, is more time-consuming and complex, compared to conventional 2D echo. 3D Echo variables complement 2D echo in MV pre-BMV assessment. Anwar et al. proposed a 3D echo score to predict BMV outcome more accurately. Individual RT3DE score points of leaflets and subvalvular apparatus summed to calculate the total score, ranging from 0 to 31 points. Total score of mild MV involvement was defined as <8 points, moderate MV involvement 8–13, and severe MV involvement >14. Higher scores correlated with poor BMV outcome.
| Conclusions|| |
Meticulous evaluation of the MV with all available evaluation tools is the key for selecting proper patient to undergo BMV. Chest X-ray may help in detecting any abnormality of thoracic cage, making septal puncture difficult or challenging. TTE is the cornerstone of morphological evaluation of the valve leaflets, but if possible TEE will give added advantage in this process. Furthermore, TEE easily rules out any hidden thrombi in the LA appendage, especially in the elderly and with atrial fibrillation. Preprocedure plain fluoroscopy in the catheterization table before starting the procedure may pick-up rare patient with significant calcification that was missed by other evaluation modalities. If we use all these assessment and scoring modalities, more successful procedure can be expected minimizing complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Dr Satyam Rajvanshi: concept and design. Dr Ranjit k. Nath: expert on the subject and critical review of the article. Dr Rajeev Bharadwaj(corresponding author): drafting and design of the article and critical interpretation of the literature associated with the subject.
| References|| |
Beck CS, Cutler EC. A cardiovalvulotome. J Exp Med 1924;40:375-9.
Inuoe K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commisurotomy by a new balloon catheter. J Thorac Cardivasc Surg 1984;87:394-402.
Lock JE, Khalilullah M, Shrivastava S, Bahl V, Keane JF. Percutaneous catheter commissurotomy in rheumatic mitral stenosis. N Engl J Med 1985;313:1515-8.
Al Zaibag M, Ribeiro PA, Al Kasab S, Al Fagih MR. Percutaneous double-balloon mitral valvotomy for rheumatic mitral-valve stenosis. Lancet 1986;1:757-61.
Palacios IF, Lock JE, Keane JF, Block PC. Percutaneous transvenous balloon valvotomy in a patient with severe calcific mitral stenosis. J Am Coll Cardiol 1986;7:1416-9.
Smucker M. Percutaneous mitral balloon Valvulotomy or valvuloplasty. Circ 1990;82:643-5.
Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IF. Percutaneous balloon dilatation of the mitral valve: An analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J 1988;60:299-308.
Herrmann HC, Wilkins GT, Abascal VM, Weyman AE, Block PC, Palacios IF. Percutaneous balloon mitral valvotomy for patients with mitral stenosis. Analysis of factors influencing early results. J Thorac Cardiovasc Surg 1988;96:33-8.
Abascal VM, Wilkins GT, Choong CY, Thomas JD, Palacios IF, Block PC, et al
. Echocardiographic evaluation of mitral valve structure and function in patients followed for at least 6 months after percutaneous balloon mitral valvuloplasty. J Am Coll Cardiol 1988;12:606-15.
Palacios IF, Block PC, Wilkins GT, Weyman AE: Follow-up of patients undergoing percutaneous mitral balloon valvulotomy: Analysis of factors determining restenosis. Circulation 1989;79:573-9.
Abascal VM, Wilkins GT, O'Shea JP, Choong CY, Palacios IF, Thomas JD, et al
. Prediction of successful outcome in 130 patients undergoing percutaneous balloon mitral valvotomy. Circulation 1990;82:448-56.
Nunes MC, Tan TC, Elmariah S, do Lago R, Margey R, Cruz-Gonzalez I, et al
. The echo score revisited: Impact of incorporating commissural morphology and leaflet displacement to the prediction of outcome for patients undergoing percutaneous mitral valvuloplasty. Circulation 2014;129:886-95.
Goldstein SA, Lindsay J Jr., Do we need more echo scores for balloon mitral valvuloplasty? J Am Soc Echocardiogr 2010;23:23-5.
Reid CL, Otto CM, Davis KB, Labovitz A, Kisslo KB, McKay CR. Influence of mitral valve morphology on mitral balloon commissurotomy: Immediate and six-month results from the NHLBI Balloon Valvuloplasty Registry. Am Heart J 1992;124:657-65.
Lung B, Cormier B, Porte JM, Nallet O, Michel PL, Acar J, et al
. Immediate results of percutaneous mitral commisurotomy: A predictive model on series of 1514 patients. Circulation 1996;94:2124-30.
Abascal VM, Wilkins GT, Choong CY, Block PC, Palacios IF, Weyman AE. Mitral regurgitation after percutaneous balloon mitral valvuloplasty in adults: Evaluation by pulsed Doppler echocardiography. J Am Coll Cardiol 1988;11:257-63.
Pos JR, Feldman T, Isner J, et al.
Inoue balloon mitral valvotomy in patients with severe valvular and subvalvular deformity. J Am Coll Cardiol, 25 (1995), pp. 1129-36.
Padial LR, Freitas N, Sagie A, Newell JB, Weyman AE, Levine RA, et al
. Echocardiography can predict which patients will develop severe mitral regurgitation after percutaneous mitral valvulotomy. J Am Coll Cardiol 1996;27:1225-31.
Fatkin D, Roy P, Morgan JJ, Feneley MP. Percutaneous balloon mitral valvotomy with the Inoue single-balloon catheter: Commissural morphology as a determinant of outcome. J Am Coll Cardiol 1993;21:390-7.
Cannan CR, Nishimura RA, Reeder GS, Ilstrup DR, Larson DR, Holmes DR, et al
. Echocardiographic assessment of commissural calcium: A simple predictor of outcome after percutaneous mitral balloon valvotomy. J Am Coll Cardiol 1997;29:175-80.
Iung B, Garbarz E, Doutrelant L, Berdah P, Michaud P, Farah B, et al
. Late results of percutaneous mitral commissurotomy for calcific mitral stenosis. Am J Cardiol 2000;85:1308-14.
Sutaria N, Northridge DB, Shaw TR. Significance of commissural calcification on outcome of mitral balloon valvotomy. Heart 2000;84:398-402.
Sutaria N, Shaw TRD, Prendergast BD. Effect ofcommissural fusion on outcome of balloon mitralvalvotomy: A transoesophageal study. Heart 1998;80:37.
Agarwal BL, Kapoor A, Singh R, Tewari S, Radhakrishnan S, Shrivastava S, et al
. Predictive accuracy of commissural morphology and its role in determining the outcome following Inoue balloon mitral valvotomy. Indian Heart J 2002;54:39-45.
Hernandez R, Macaya C, Bañuelos C, Alfonso F, Goicolea J, Iñiguez A, et al
. Predictors, mechanisms and outcome of severe mitral regurgitation complicating percutaneous mitral valvotomy with the Inoue balloon. Am J Cardiol 1992;70:1169-74.
Sutaria N, Shaw TR, Prendergast B, Northridge D. Transoesophageal echocardiographic assessment of mitral valve commissural morphology predicts outcome after balloon mitral valvotomy. Heart 2006;92:52-7.
Sarath Babu D, Ranganayakulu KP, Rajasekhar D, Vanajakshamma V, Pramod Kumar T. Assessment of mitral valve commissural morphology by transoesophageal echocardiography predicts outcome after balloon mitral valvotomy. Indian Heart J 2013;65:269-75.
Rifaie O, Esmat I, Abdel-Rahman M, Nammas W. Can a novel echocardiographic score better predict outcome after percutaneous balloon mitral valvuloplasty? Echocardiography 2009;26:119-27.
Anwar AM, Attia WM, Nosir YF, Soliman OI, Mosad MA, Othman M, et al
. Validation of a new score for the assessment of mitral stenosis using real-time three-dimensional echocardiography. J Am Soc Echocardiogr 2010;23:13-22.
Soliman OI, Anwar AM, Metawei AK, McGhie JS, Geleijnse ML, Ten Cate FJ. New scores for the assessment of mitral stenosis using real-time three-dimensional echocardiography. Curr Cardiovasc Imaging Rep 2011;4:370-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]