Radiation-free monitoring of percutaneous mitral balloon commissurotomy

by Monica Luiza de Alcantara
Ecocardiografia Americas Medical City / Hospital Samaritano and Cardiologia Proecho, Rio de Janeiro, Brazil

Clinical Case

  • Female, 69 year-old
  • Rheumatic mitral valve disease
  • Previous pulmonary oedema
  • NYHA IV

Pre-interventional assessment. Planimetric mitral valve area = 1.2 cm2; mean transmitral gradient= 11 mm Hg; Wilkins score= 6

Real-time full volume 3D transoesophageal acquisition showing the mitral valve from the atrial perspective to guide the positioning of the balloon in the mitral valve orifice (left panel) and balloon inflation (right panel).

Abbreviations: Ao, aorta; MV, mitral valve; RA, right atrium

Real-time full volume 3D transoesophageal acquisition showing the mitral valve after the procedure from both the ventricular (left panel) and the atrial (right panel) perspective to assess the procedure result (post-procedural planimetered mitral valve area= 1.8 cm2) and check for intercurrent complications

3D transoesophageal color zoom acquisition showing a small residual left-to-right interatrial shunt after removal of the guiding catheter. The interatrial defect size is visible on the left side of the interatrial septum. The color jet of the shunt is visible in the right atrium

Combination of 3D and 2D imaging using the transoesophageal probe allows the precise localization of the interatrial septal defect in the muscular part of the posterior septum.

Key Messages

3D echocardiography:

  • Characterization of valve morphology
  • Anatomically sound and accurate measurement of the residual orifice of the stenotic mitral valve that can be performed before (to assess mitral stenosis severity) and after the procedure (to assess its effectiveness)
  • Monitoring PMBC procedure navigation and to assess its effectiveness in a safe and time-effective manner, without the use of radiations (this is particularly valuable in young patients!):
    • Guide the transeptal puncture
    • Locate and define relationships of left atrial appendage and mitral valve orifice and peform visual feedback calibration with catheters while inside the left atrium
    • Allows to identify procedure complications
    • Ensure coaxial trajectory orientation while navigating the catheter through the mitral valve orifice (balloon catheter alignment)
    • Inspect post-inflation commissurotomy results (commissures splitting)
    • Identify occasional complications (iatrogenic valve damage, atrial septal defect at the site of septal puncture, pericardial effusion

References

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  • Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Faletra F, Franke A, Hung J, Perez de Isla L, Kamp O, Kasprzak J, Marwick TM, McCulloch ML, Monaghan MJ, Nihoyannopoulos P, Pandian NG, Pellikka PA, Pepi M, Roberson DA, Lancellotti P, Shernan SK, Shirali GS, Sugeng L, Ten Cate FJ, Vannan MA, Zamorano JL, Zoghbi WA, EAE/ASE Recommendations for Image Acquisition and Display Using Three-Dimensional Echocardiography. Eur Heart J Cardiovasc Imaging. 2012;13(1):1-46