PTMC/PBMC
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This document provides information about percutaneous transvenous mitral commissurotomy (PTMC), a procedure used to treat mitral stenosis. It discusses the stages and severity of mitral stenosis, indications and contraindications for PTMC, assessment of valve morphology, the PTMC procedure technique, instruments used, balloon size selection, post-procedure evaluation, complications, follow-up care, and long-term prognosis. PTMC is performed to improve the opening of a stenosed mitral valve by splitting the fused commissures using a balloon catheter, and is an important therapeutic option for treating symptomatic mitral stenosis.
PTMC/PBMC
- 1. WELCOME
- 2. Percutaneous Transvenous Mitral Commissurotomy (PTMC) Dr. Md. Ahasanul Kabir Phase B Resident UCC, BSMMU Chairperson: Assoc. Prof. Dr. Tanjima Parveen
- 3. • PTMC is an important therapeutic tool in treatment of mitral stenosis • First performed by K. Inoue in 1984 followed by Lock in 1985. • Based on principle that balloon dilatation in the stenosed mitral valve improves the valve opening by splitting the fused mitral commissures.
- 4. Stages and Severity of Mitral Stenosis Stage Definition A At risk of MS B Progressive MS C Asymptomatic severe MS D Symptomatic severe MS Valve anatomy Valve haemodynamics Haemodynamic consequences Symptoms
- 5. Mitral Stenosis Severity Mild MS MVA > 1.5 cm2, Mean gradient < 5 mm Hg, PASP < 30 mm Hg Moderate MS MVA 1-1.5 cm2, Mean gradient 5-10 mm Hg, PASP 30-50 mm Hg Severe MS MVA < 1.0 cm2, Mean gradient > 10 mm Hg, PASP > 50 mm Hg
- 7. INDICATIONS Symptomatic patients (NYHA functional class II, III, or IV), with moderate or severe MS and valve morphology favorable for PMV in the absence of left atrial thrombus or moderate to severe MR Asymptomatic patients with moderate or severe MS and valve morphology that is favorable for PMV, who have pulmonary hypertension (pulmonary artery systolic pressure > 50 mm Hg at rest or > 60 mm Hg with exercise) in the absence of left atrial thrombus or moderate to severe MR
- 8. INDICATIONS…. PMV is reasonable for patients with moderate or severe MS who have a non pliable calcified valve, are in NYHA functional class III–IV, and are either not candidates for surgery or at high risk for surgery PMV may be considered for asymptomatic patients with moderate or severe MS and valve morphology favorable for PMV who have new- onset atrial fibrillation in the absence of left atrial thrombus or moderate to severe MR
- 9. INDICATIONS…. PMV may be considered for symptomatic patients (NYHA FC II, III, or IV) with MV area > 1.5 cm2 if there is evidence of hemodynamically significant MS based on PA systolic pressure > 60 mm Hg, pulmonary artery wedge pressure of 25 mm Hg or more, or mean MV gradient > 15 mm Hg during exercise PMV may be considered as an alternative to surgery for patients with moderate or severe MS who have a nonpliable calcified valve and are in NYHA class III–IV
- 10. Contraindications for PTMC 1. Mitral valve area >1.5 cm2 2. Left atrial thrombus 3. More than mild mitral regurgitation 4. Severe or bi-commissural calcification 5. Absence of commissural fusion 6. Severe concomitant aortic valve disease or severe combined tricuspid stenosis and regurgitation requiring surgery 7. Concomitant coronary artery disease requiring surgery
- 11. Assessment of valve morphology according to Wilkins score Grade Mobility Thickening 1 Highly mobile with only leaflet tips restricted Near normal (4–5 mm) 2 Mild leaflet restriction; base portions have normal mobility Marginal thickening (5–8 mm) with normal thickness of mid leaflets 3 Valve moves forward in diastole, mainly from base Thickening of entire leaflet (5– 8 mm) 4 No or minimal diastolic movement of valve Extensive thickening of all leaflet tissues (> 8–10 mm)
- 12. Wilkins…. Grade Calcification Subvalvular thickening 1 Single area of echo brightness Minimal thickening below leaflets 2 Scattered areas of increased brightness along leaflet margins Chordal thickening up to one-third of chordal length 3 Brightness extending to the mid portion of leaflets Thickening extending to distal one-third of chords 4 Extensive brightness throughout the leaflet tissue Extensive thickening to papillary muscles
- 13. Assessment of valve morphology according to Cormier score Echocardiographic group Mitral valve anatomy Group 1 Pliable non-calcified anterior mitral leaflet and mild subvalvular disease(i.e thin cordae ≥ 10mm long) Group 2 Pliable non-calcified anterior mitral leaflet and severe subvalvular disease(i.e thickened cordae < 10mm long) Group 3 Calcification of mitral valve of any extent as assessed by fluoroscopy, whatever the state of subvalvular status
- 14. Pre-procedural Care • History • Physical examination • TTE • TEE • If the pt. is on warfarin, it has to be stopped 5 days before the procedure.
- 15. • Transvenous or Antegrade Approach • Inoue balloon technique • Double balloon technique. • Transarterial or Retrograde Approach Technique
- 16. Instruments • Puncture needle • Vascular access sheath: 6F for arterial and 9F for venous line • 2 pressure lines for arterial and venous pressure monitoring • J-tipped Guide wire(0.035’) • Pigtail catheter • Terumo guide wire(0.032’) • Mullins sheath • Broken Brough needle. • Plastic dilator 14F • Spring guidewire (0.025’) • PTMC Balloon catheter • Balloon stretching metal tube. • Stylet/ Shaper • Calibrated inflation syringe • Calipers
- 21. FORMULA FOR BALOON SIZE Height in Cms 10 10+
- 22. Selection of Baloon size • Standardization by patient’s Height Type Diameter(mm) Height(cm) PTMC-30 26-30 >180 PTMC-28 24-28 >160 PTMC-26 22-26 >147 PTMC-24 20-24 <147
- 23. PTMC procedure
- 24. Post procedure evaluation • Symptomatic improvement • Ausculation of precordium • Decrease in intensity of MDM • Appearance of PSM • Lung bases • Two-dimensional and Doppler echocardiography • Commissural separation • Mitral valve area • MR grading • Haemodynamics assessment
- 26. Successful PTMC PTMC successful when • final MVA is > 1.5 cm2 • mean mitral gradient < 5 mmHg • with no major complications.
- 27. Complication Cardiac Complication Local Complication • Failure of the procedure (<5%) • Hemopericardium (Aortic rupture, LA free wall rupture) ( 0.5 to 10%) – Pericardial Effusion/tamponade • Systemic Embolization (0.5 to 5%) • Mitral Regurgitation (2-9%) • ASD (5%) • Infective endocarditis • Mortality (1-2%) • Restenosis (2-60%) Bleeding Hematoma Arteriovenous fistula Infection
- 28. Follow up • Echocardiography, preferably > 72 hours after the procedure. • If H/o AF, warfarin should be restarted 2 to 3 days after the procedure. • Clinical follow-up examination should be performed at least once a year and more often if symptoms develop. • Follow-up echocardiography once-a-year basis
- 29. During the recovery • A tight dressing on the puncture site is applied. • Pt should lay flat for about 6 hrs after the procedure • IV antibiotics should be given • Measures should be taken immediately if patient develops fever, chest pain, swelling or pain in groin or leg, or bleeding at the groin site. • Patient may return to most of their normal activities the day after the procedure. • Warfarin, if stopped, can be started the next day
- 30. Prognosis • Long-term studies with follow-up for up to 20 years are available. • Among 912 patients with a median age of 48 years, cardiovascular survival without reintervention and cardiovascular survival without surgery was 38% and 46% at 20 years. • In another study of 547 patients with a mean age of 31 years, freedom from restenosis at 10 and 19 years was 78% and 26%, respectively.
- 32. Thank You
- 33. References • The Cardiac Catheterization Handbook, Morton J. Kern, 6th edition • Interventional Cardiac Catheterization Handbook, Morton J. Kern, 4rd edition • Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th edition • Manual of Cardiovascular Medicine, Brain P. Griffin, 4th edition • 2014 ACC/AHA guideline for management of patients with Valvular Heart Disease • 2017 ESC/EACTS guidelines on management of Valvular Heart Disease • Prof Syed Ali Ahsan’s Patient Record • Youtube and Internet Contents