Prior to 1984, surgical mitral commissurotomy was the primary intervention for patients suffering from severe mitral stenosis (MS). This approach remained the standard until Inoue and colleagues introduced percutaneous mitral balloon valvuloplasty (PMBV)—also referred to as percutaneous mitral commissurotomy (PMC) or percutaneous mitral valvotomy (PMV). Since its clinical adoption, PMBV has shown promising short- and mid-term results and has largely supplanted surgery as the treatment of choice in appropriately selected patients with rheumatic MS.
Between 2016 and 2019, Elkaryoni et al. conducted a retrospective analysis using data from the Nationwide Readmission Database, focusing on 1109 individuals who underwent PBMV (955 with rheumatic MS and 154 with non-rheumatic MS). The results revealed no statistically significant changes over the years in terms of in-hospital mortality, 30-day readmission rates, or 90-day hospitalization following the procedure. Nonetheless, the data suggested a potential increase in both early post-procedure mortality and readmissions, along with a 29% rise in 90-day hospitalization after PBMV.
The mitral valve serves as a gateway between the left atrium (LA) and the left ventricle (LV) of the heart. It opens during diastole to permit blood flow into the ventricle and closes during systole to prevent backflow into the atrium. For the valve to function properly, coordination among six anatomical components is essential:
Left atrial wall
Mitral annulus
Valve leaflets
Chordae tendineae
Papillary muscles
Left ventricular wall
Indications
Class I Recommendations (Definitive Indications)
Diagnostic Evaluation: Transthoracic echocardiography (TTE) is recommended to confirm mitral stenosis (MS), determine severity, check for additional valve abnormalities, assess pulmonary artery pressure, and evaluate valve structure for PMBV suitability.
Pre-Procedural Assessment: Transesophageal echocardiography (TEE) is necessary to rule out left atrial thrombus and assess the extent of mitral regurgitation (MR) before proceeding with the intervention.
Who Should Receive PMBV: Patients showing symptoms with severe MS (mitral valve area ≤1.5 cm²) and favorable valve anatomy, provided there is no significant MR or atrial thrombus.
Symptomatic individuals in NYHA Class II–IV with moderate to severe MS and suitable valve characteristics.
Asymptomatic patients with moderate or severe MS and pulmonary hypertension (PA systolic pressure >50 mmHg at rest or >60 mmHg with exercise).
Women with severe MS planning pregnancy, if the valve anatomy is favorable.
Surgical intervention is preferred for patients ineligible for PMBV, who have failed previous attempts, or are already scheduled for cardiac surgery for other conditions.
Class IIb Recommendations
PMBV may be considered in the following scenarios:
Asymptomatic patients with severe MS who have new-onset atrial fibrillation, provided the valve structure is suitable.
Symptomatic patients with valve area slightly above 1.5 cm² but with evidence of functional MS based on elevated pressures during exercise.
Patients with severe symptoms and poor valve anatomy who are high surgical risk or ineligible for surgery.
Individuals with moderate MS (1.6–2.0 cm²) scheduled for other cardiac procedures.
Asymptomatic patients needing moderate-risk non-cardiac surgery, if their valve is unsuitable for PMBV but intraoperative monitoring can be ensured.
Contraindications
According to ACC/AHA Guidelines (Class III Recommendations)
PMBV is not advised in patients with mild mitral stenosis, as the risks outweigh the benefits in this group.
The procedure should be avoided in those with moderate to severe mitral regurgitation or the presence of a left atrial thrombus, due to increased risk of complications.
Pre-procedural transesophageal echocardiography (TEE) is essential to detect thrombi, especially in the left atrial appendage.
If a thrombus is identified, 3 months of anticoagulation therapy with warfarin may help resolve it.
Prognostic tools have been proposed to assess the likelihood of thrombus resolution in patients considered for PMBV.
According to ESC/EACTS Guidelines
PMBV is not recommended in the following situations:
Mitral valve area >1.5 cm² unless no other cause explains the patient’s symptoms and valve anatomy is favorable.
Left atrial thrombus, which poses a risk of embolization.
More than mild mitral regurgitation, which could worsen with the procedure.
Severe or bi-commissural calcification, which may limit valve mobility and procedural success.
Absence of commissural fusion, as this undermines the mechanical goal of the procedure.
Coronary artery disease requiring bypass surgery, as these patients are better managed surgically in a combined procedure.
Outcomes
PMBV has shown favorable outcomes in patients with symptomatic mitral stenosis (MS), even when moderate mitral regurgitation (MR) is present. In a study involving 104 patients, those with moderate MR (group 2) demonstrated comparable procedural success and complication rates to those with mild or no MR (group 1). No cardiovascular deaths occurred within 30 days in either group. Severe MR developed in 3.2% of group 1 and 10% of group 2 patients post-PMBV, though only group 1 patients required mitral valve replacement. PMBV significantly increased mitral valve area and reduced pulmonary artery pressures in both groups. The overall success rate was 77.7% for mild/no MR and 60% for moderate MR. These findings suggest PMBV is a viable and safe option in selected patients with significant MS and moderate MR, potentially delaying the need for surgical valve replacement while improving functional outcomes. However, careful patient selection remains critical.
Equipment
Inoue Balloon Catheter: A single balloon system, typically sized according to the patient’s body surface area. Specifically designed for gradual and controlled dilation of the mitral valve.
Transseptal Puncture Equipment: Includes transseptal sheaths and needles to access the left atrium via the fossa ovalis.
Fluoroscopy Unit: Provides real-time X-ray imaging to guide catheter movement and balloon placement.
Echocardiography Systems:
Transthoracic (TTE), Transesophageal (TEE), or Intracardiac Echocardiography (ICE)
Hemodynamic Monitoring Tools
Contrast Media and Injectors
Patient Preparation
Before undergoing PMBV, patients are typically positioned lying flat (supine) to ensure optimal access and imaging. The procedure is most performed under moderate sedation, allowing the patient to remain comfortable while maintaining spontaneous breathing. Preparation also includes standard pre-procedural protocols such as intravenous access, ECG monitoring, and ensuring fasting status. The choice of equipment may vary depending on the procedural technique planned, but proper positioning and sedation are consistent elements of patient preparation.
Patient Position
During PMBV, the patient is placed in the supine position (lying flat on their back). This positioning facilitates optimal access for transseptal catheterization, ensures stable imaging with fluoroscopy and echocardiography, and helps maintain patient comfort and procedural safety under sedation or anesthesia.
Technique
Inoue Balloon Technique
Step 1: Vascular Access
A 7-French sheath is inserted into the right femoral vein for transseptal access. Additional sheaths may be placed:
In the left femoral vein (or a second sheath on the right) for a pulmonary artery catheter.
In the left femoral artery for left heart pressure monitoring (e.g., using a pigtail catheter).
Step 2: Transseptal Puncture
The goal is to cross from the right atrium (RA) into the left atrium (LA) via the fossa ovalis. It is performed using a Brockenbrough needle and Mullins sheath. The imaging guidance (either fluoroscopy or echocardiography) is used to safely target the fossa ovalis. After successful puncture, entry into the LA is confirmed by:
Pressure waveform
Oxygen saturation
Contrast injection
Step 3: Inoue Balloon Preparation
The Inoue balloon is selected based on patient height (typically 24–30 mm).
Formula: Balloon size = height in cm / 10 + 10
The balloon is flushed with saline to remove air. It is then sized and elongated using the gold and silver hubs, preparing it for insertion.
Step 4: Insertion and Positioning
The Inoue balloon is introduced into the left atrium over the Inoue wire.
It is then carefully maneuvered across the mitral valve into the left ventricle, typically using counterclockwise rotation. This rotation helps orient the balloon anteriorly through the valve.
Step 5: Balloon Dilation
The balloon is inflated in three stages:
Distal segment
Proximal segment
Central waist
Successful dilation is indicated by disappearance of the central waist on fluoroscopy, confirming that the valve commissures have split.
Step 6: Hemodynamic Assessment
Before and after balloon dilation, pressures across the mitral valve are measured.
This includes:
Transmitral gradient (LA to LV pressure difference)
Mitral valve area, using pressure data or echocardiography
These confirm procedural success and assess for complications such as mitral regurgitation.
Step 1: Vascular Access
Insert a sheath into the femoral vein to gain access to the right heart.
Step 2: Transseptal Puncture
Perform a transseptal puncture using a Brockenbrough needle and Mullins sheath to enter the left atrium through the fossa ovalis (thin part of the interatrial septum).
Step 3: Advance Balloon-Tipped Catheter
Guide a balloon-tipped catheter through the left atrium into the left ventricle.
Step 4: Insert Exchange Guidewires
Through the lumen of the balloon-tipped catheter, insert one or two guidewires.
Position them into the left ventricular apex or occasionally the ascending aorta for stability.
Step 5: Remove Balloon-Tipped Catheter
Carefully withdraw the balloon-tipped catheter, leaving the guidewires in place.
Step 6: Dilate the Atrial Septum
Advance a 6–8 mm peripheral angioplasty balloon over a guidewire to the septum puncture site.
Inflate the balloon to widen the septal opening for smoother passage of larger balloons.
Step 7: Advance Valvotomy Balloons
Thread two valvotomy balloons (15–20 mm in diameter) over the guidewires. Position both balloons across the stenotic mitral valve.
Step 8: Balloon Inflation
Simultaneously inflate both balloons using hand-held syringes. This action splits the fused commissures of the mitral valve. Quickly deflate and remove the balloons to minimize hypotension.
Step 9: Post-Dilation Assessment
Measure mitral valve area and transmitral gradient using hemodynamic data or echocardiography. Check for new or worsened mitral regurgitation.
Multitrack Technique
Step 1: Equipment Setup
Use the Multitrack Mitral Dilatation Kit (NuMED) which includes:
Two balloon catheters
Multitrack angiographic catheter
Extra-stiff 0.035″ guidewire with a 6-cm floppy J-tip
Septal dilator (14 Fr, 65 cm long)
Step 2: Vascular Access and Transseptal Puncture
Gain access through the femoral vein.
Perform transseptal catheterization using a standard technique to enter the left atrium.
Step 3: Advance Guidewire
Insert the extra-stiff 0.035” guidewire through the transseptal puncture and advance it into the left ventricular apex.
The preformed curve of the J-tip facilitates optimal positioning.
Step 4: Septal Dilation
Use the septal dilator to widen the atrial septal puncture.
The dilator has a guidewire lumen and tapered tip for safe advancement.
Step 5: Balloon Loading and Positioning
Load both balloon catheters onto the same guidewire.
One is a 10-cm shaft balloon with the multitrack tip.
The second is a 16-cm monorail balloon catheter.
Advance both balloons across the mitral valve into the left ventricle.
Step 6: Pressure Monitoring
The multitrack angiographic catheter with side holes allows for continuous pressure monitoring without removing the guidewire.
Step 7: Balloon Inflation
Simultaneously inflate both balloons across the stenotic mitral valve. This effectively splits the commissures and relieves the obstruction.
Step 8: Completion and Assessment
Deflate and remove balloons. Measure transmitral gradient and valve area. Assess for mitral regurgitation or procedural complications.
Metallic commissurotomy
Step 1: Pre-Procedural Assessment
Perform right heart catheterization to record right ventricular and pulmonary artery pressures and saturations. In selected cases, conduct left ventriculography (LV angiogram) to assess mitral regurgitation and measure LV end-diastolic pressure (LVEDP). Position a pigtail catheter in the aortic root for baseline aortic pressure measurement.
Step 2: Transseptal Puncture
Use an 8F Mullins catheter and Brockenbrough needle for transseptal puncture. After puncture, remove the needle and dilator and advance the Mullins sheath into the left atrium. Record left atrial pressure and oxygen saturation. Administer heparin 100 U/kg IV for anticoagulation.
Step 3: Access to Left Ventricle
Advance a floating balloon catheter through the Mullins sheath into the left ventricle via the mitral valve. Then, advance the Mullins sheath over the balloon catheter into the left ventricle and remove the balloon catheter.
Step 4: Guidewire Insertion
Introduce a stainless steel guidewire through the Mullins sheath and position it in the left ventricular cavity. Remove the Mullins sheath, leaving the guidewire in place.
Step 5: Tract Dilation
Dilate the femoral access site and interatrial septal puncture using 14F and 18F dilators.
Step 6: Commissurotome Positioning
Advance the metallic commissurotome (valvotome) over the guidewire and position it across the mitral valve. Withdraw the guidewire slightly to ensure the bead on the guidewire seats against the valvotome tip.
Step 7: Valve Dilatation
Control the opening of the valvotome using the attached plier and clippers. Perform controlled dilation of the mitral valve, typically to 30–40 mm, depending on the case. Most cases require two inflations, commonly at 37 mm.
Step 8: Post-Dilatation Assessment
Withdraw the valvotome and reintroduce the Mullins sheath into the left ventricle. Remove the guidewire and record the transmitral pressure gradient. In most cases, perform two dilations before pressure measurement. Conduct a final left ventriculogram and record pulmonary artery pressures.
Approach considerations
PMBV can be performed via antegrade (transvenous) or retrograde (transarterial) approaches. The antegrade approach is the standard method, typically accessed through the femoral vein with transseptal puncture to reach the left atrium. A jugular vein route is less common but possible. The retrograde approach, which avoids creating an atrial septal defect, is rarely used today due to its technical difficulty and higher risk of arterial injury.
Complications
Mortality: Occurs in up to 3% of cases, often due to left ventricular perforation or poor patient health.
Severe Mitral Regurgitation (MR): Seen in 2–19% of cases, usually due to leaflet or commissural tearing.
Atrial Septal Defect (ASD): Common post-procedure, mostly small and hemodynamically insignificant; large right-to-left shunts are rare.
Hemopericardium: Reported in 0.5–12%, often from transseptal puncture or guidewire injury; may require emergency pericardiocentesis.
Embolic Events: Occur in 0.5–5%, with potential for permanent disability or death.
Complete Heart Block: Occurs in about 1.5%, typically transient; rarely requires permanent pacing.
Procedure Failure: Seen in 1–17%, usually from technical challenges or unfavorable valve anatomy.
»
Home » Procedure » Percutaneous Mitral Balloon Valvuloplasty
Percutaneous Mitral Balloon Valvuloplasty
Updated :
December 3, 2025
Prior to 1984, surgical mitral commissurotomy was the primary intervention for patients suffering from severe mitral stenosis (MS). This approach remained the standard until Inoue and colleagues introduced percutaneous mitral balloon valvuloplasty (PMBV)—also referred to as percutaneous mitral commissurotomy (PMC) or percutaneous mitral valvotomy (PMV). Since its clinical adoption, PMBV has shown promising short- and mid-term results and has largely supplanted surgery as the treatment of choice in appropriately selected patients with rheumatic MS.
Between 2016 and 2019, Elkaryoni et al. conducted a retrospective analysis using data from the Nationwide Readmission Database, focusing on 1109 individuals who underwent PBMV (955 with rheumatic MS and 154 with non-rheumatic MS). The results revealed no statistically significant changes over the years in terms of in-hospital mortality, 30-day readmission rates, or 90-day hospitalization following the procedure. Nonetheless, the data suggested a potential increase in both early post-procedure mortality and readmissions, along with a 29% rise in 90-day hospitalization after PBMV.
The mitral valve serves as a gateway between the left atrium (LA) and the left ventricle (LV) of the heart. It opens during diastole to permit blood flow into the ventricle and closes during systole to prevent backflow into the atrium. For the valve to function properly, coordination among six anatomical components is essential:
Left atrial wall
Mitral annulus
Valve leaflets
Chordae tendineae
Papillary muscles
Left ventricular wall
Class I Recommendations (Definitive Indications)
Diagnostic Evaluation: Transthoracic echocardiography (TTE) is recommended to confirm mitral stenosis (MS), determine severity, check for additional valve abnormalities, assess pulmonary artery pressure, and evaluate valve structure for PMBV suitability.
Pre-Procedural Assessment: Transesophageal echocardiography (TEE) is necessary to rule out left atrial thrombus and assess the extent of mitral regurgitation (MR) before proceeding with the intervention.
Who Should Receive PMBV: Patients showing symptoms with severe MS (mitral valve area ≤1.5 cm²) and favorable valve anatomy, provided there is no significant MR or atrial thrombus.
Symptomatic individuals in NYHA Class II–IV with moderate to severe MS and suitable valve characteristics.
Asymptomatic patients with moderate or severe MS and pulmonary hypertension (PA systolic pressure >50 mmHg at rest or >60 mmHg with exercise).
Women with severe MS planning pregnancy, if the valve anatomy is favorable.
Surgical intervention is preferred for patients ineligible for PMBV, who have failed previous attempts, or are already scheduled for cardiac surgery for other conditions.
Class IIb Recommendations
PMBV may be considered in the following scenarios:
Asymptomatic patients with severe MS who have new-onset atrial fibrillation, provided the valve structure is suitable.
Symptomatic patients with valve area slightly above 1.5 cm² but with evidence of functional MS based on elevated pressures during exercise.
Patients with severe symptoms and poor valve anatomy who are high surgical risk or ineligible for surgery.
Individuals with moderate MS (1.6–2.0 cm²) scheduled for other cardiac procedures.
Asymptomatic patients needing moderate-risk non-cardiac surgery, if their valve is unsuitable for PMBV but intraoperative monitoring can be ensured.
According to ACC/AHA Guidelines (Class III Recommendations)
PMBV is not advised in patients with mild mitral stenosis, as the risks outweigh the benefits in this group.
The procedure should be avoided in those with moderate to severe mitral regurgitation or the presence of a left atrial thrombus, due to increased risk of complications.
Pre-procedural transesophageal echocardiography (TEE) is essential to detect thrombi, especially in the left atrial appendage.
If a thrombus is identified, 3 months of anticoagulation therapy with warfarin may help resolve it.
Prognostic tools have been proposed to assess the likelihood of thrombus resolution in patients considered for PMBV.
According to ESC/EACTS Guidelines
PMBV is not recommended in the following situations:
Mitral valve area >1.5 cm² unless no other cause explains the patient’s symptoms and valve anatomy is favorable.
Left atrial thrombus, which poses a risk of embolization.
More than mild mitral regurgitation, which could worsen with the procedure.
Severe or bi-commissural calcification, which may limit valve mobility and procedural success.
Absence of commissural fusion, as this undermines the mechanical goal of the procedure.
Coronary artery disease requiring bypass surgery, as these patients are better managed surgically in a combined procedure.
PMBV has shown favorable outcomes in patients with symptomatic mitral stenosis (MS), even when moderate mitral regurgitation (MR) is present. In a study involving 104 patients, those with moderate MR (group 2) demonstrated comparable procedural success and complication rates to those with mild or no MR (group 1). No cardiovascular deaths occurred within 30 days in either group. Severe MR developed in 3.2% of group 1 and 10% of group 2 patients post-PMBV, though only group 1 patients required mitral valve replacement. PMBV significantly increased mitral valve area and reduced pulmonary artery pressures in both groups. The overall success rate was 77.7% for mild/no MR and 60% for moderate MR. These findings suggest PMBV is a viable and safe option in selected patients with significant MS and moderate MR, potentially delaying the need for surgical valve replacement while improving functional outcomes. However, careful patient selection remains critical.
Inoue Balloon Catheter: A single balloon system, typically sized according to the patient’s body surface area. Specifically designed for gradual and controlled dilation of the mitral valve.
Transseptal Puncture Equipment: Includes transseptal sheaths and needles to access the left atrium via the fossa ovalis.
Fluoroscopy Unit: Provides real-time X-ray imaging to guide catheter movement and balloon placement.
Echocardiography Systems:
Transthoracic (TTE), Transesophageal (TEE), or Intracardiac Echocardiography (ICE)
Hemodynamic Monitoring Tools
Contrast Media and Injectors
Before undergoing PMBV, patients are typically positioned lying flat (supine) to ensure optimal access and imaging. The procedure is most performed under moderate sedation, allowing the patient to remain comfortable while maintaining spontaneous breathing. Preparation also includes standard pre-procedural protocols such as intravenous access, ECG monitoring, and ensuring fasting status. The choice of equipment may vary depending on the procedural technique planned, but proper positioning and sedation are consistent elements of patient preparation.
During PMBV, the patient is placed in the supine position (lying flat on their back). This positioning facilitates optimal access for transseptal catheterization, ensures stable imaging with fluoroscopy and echocardiography, and helps maintain patient comfort and procedural safety under sedation or anesthesia.
Inoue Balloon Technique
Step 1: Vascular Access
A 7-French sheath is inserted into the right femoral vein for transseptal access. Additional sheaths may be placed:
In the left femoral vein (or a second sheath on the right) for a pulmonary artery catheter.
In the left femoral artery for left heart pressure monitoring (e.g., using a pigtail catheter).
Step 2: Transseptal Puncture
The goal is to cross from the right atrium (RA) into the left atrium (LA) via the fossa ovalis. It is performed using a Brockenbrough needle and Mullins sheath. The imaging guidance (either fluoroscopy or echocardiography) is used to safely target the fossa ovalis. After successful puncture, entry into the LA is confirmed by:
Pressure waveform
Oxygen saturation
Contrast injection
Step 3: Inoue Balloon Preparation
The Inoue balloon is selected based on patient height (typically 24–30 mm).
Formula: Balloon size = height in cm / 10 + 10
The balloon is flushed with saline to remove air. It is then sized and elongated using the gold and silver hubs, preparing it for insertion.
Step 4: Insertion and Positioning
The Inoue balloon is introduced into the left atrium over the Inoue wire.
It is then carefully maneuvered across the mitral valve into the left ventricle, typically using counterclockwise rotation. This rotation helps orient the balloon anteriorly through the valve.
Step 5: Balloon Dilation
The balloon is inflated in three stages:
Distal segment
Proximal segment
Central waist
Successful dilation is indicated by disappearance of the central waist on fluoroscopy, confirming that the valve commissures have split.
Step 6: Hemodynamic Assessment
Before and after balloon dilation, pressures across the mitral valve are measured.
This includes:
Transmitral gradient (LA to LV pressure difference)
Mitral valve area, using pressure data or echocardiography
These confirm procedural success and assess for complications such as mitral regurgitation.
Step 1: Vascular Access
Insert a sheath into the femoral vein to gain access to the right heart.
Step 2: Transseptal Puncture
Perform a transseptal puncture using a Brockenbrough needle and Mullins sheath to enter the left atrium through the fossa ovalis (thin part of the interatrial septum).
Step 3: Advance Balloon-Tipped Catheter
Guide a balloon-tipped catheter through the left atrium into the left ventricle.
Step 4: Insert Exchange Guidewires
Through the lumen of the balloon-tipped catheter, insert one or two guidewires.
Position them into the left ventricular apex or occasionally the ascending aorta for stability.
Step 5: Remove Balloon-Tipped Catheter
Carefully withdraw the balloon-tipped catheter, leaving the guidewires in place.
Step 6: Dilate the Atrial Septum
Advance a 6–8 mm peripheral angioplasty balloon over a guidewire to the septum puncture site.
Inflate the balloon to widen the septal opening for smoother passage of larger balloons.
Step 7: Advance Valvotomy Balloons
Thread two valvotomy balloons (15–20 mm in diameter) over the guidewires. Position both balloons across the stenotic mitral valve.
Step 8: Balloon Inflation
Simultaneously inflate both balloons using hand-held syringes. This action splits the fused commissures of the mitral valve. Quickly deflate and remove the balloons to minimize hypotension.
Step 9: Post-Dilation Assessment
Measure mitral valve area and transmitral gradient using hemodynamic data or echocardiography. Check for new or worsened mitral regurgitation.
Step 1: Equipment Setup
Use the Multitrack Mitral Dilatation Kit (NuMED) which includes:
Two balloon catheters
Multitrack angiographic catheter
Extra-stiff 0.035″ guidewire with a 6-cm floppy J-tip
Septal dilator (14 Fr, 65 cm long)
Step 2: Vascular Access and Transseptal Puncture
Gain access through the femoral vein.
Perform transseptal catheterization using a standard technique to enter the left atrium.
Step 3: Advance Guidewire
Insert the extra-stiff 0.035” guidewire through the transseptal puncture and advance it into the left ventricular apex.
The preformed curve of the J-tip facilitates optimal positioning.
Step 4: Septal Dilation
Use the septal dilator to widen the atrial septal puncture.
The dilator has a guidewire lumen and tapered tip for safe advancement.
Step 5: Balloon Loading and Positioning
Load both balloon catheters onto the same guidewire.
One is a 10-cm shaft balloon with the multitrack tip.
The second is a 16-cm monorail balloon catheter.
Advance both balloons across the mitral valve into the left ventricle.
Step 6: Pressure Monitoring
The multitrack angiographic catheter with side holes allows for continuous pressure monitoring without removing the guidewire.
Step 7: Balloon Inflation
Simultaneously inflate both balloons across the stenotic mitral valve. This effectively splits the commissures and relieves the obstruction.
Step 8: Completion and Assessment
Deflate and remove balloons. Measure transmitral gradient and valve area. Assess for mitral regurgitation or procedural complications.
Metallic commissurotomy
Step 1: Pre-Procedural Assessment
Perform right heart catheterization to record right ventricular and pulmonary artery pressures and saturations. In selected cases, conduct left ventriculography (LV angiogram) to assess mitral regurgitation and measure LV end-diastolic pressure (LVEDP). Position a pigtail catheter in the aortic root for baseline aortic pressure measurement.
Step 2: Transseptal Puncture
Use an 8F Mullins catheter and Brockenbrough needle for transseptal puncture. After puncture, remove the needle and dilator and advance the Mullins sheath into the left atrium. Record left atrial pressure and oxygen saturation. Administer heparin 100 U/kg IV for anticoagulation.
Step 3: Access to Left Ventricle
Advance a floating balloon catheter through the Mullins sheath into the left ventricle via the mitral valve. Then, advance the Mullins sheath over the balloon catheter into the left ventricle and remove the balloon catheter.
Step 4: Guidewire Insertion
Introduce a stainless steel guidewire through the Mullins sheath and position it in the left ventricular cavity. Remove the Mullins sheath, leaving the guidewire in place.
Step 5: Tract Dilation
Dilate the femoral access site and interatrial septal puncture using 14F and 18F dilators.
Step 6: Commissurotome Positioning
Advance the metallic commissurotome (valvotome) over the guidewire and position it across the mitral valve. Withdraw the guidewire slightly to ensure the bead on the guidewire seats against the valvotome tip.
Step 7: Valve Dilatation
Control the opening of the valvotome using the attached plier and clippers. Perform controlled dilation of the mitral valve, typically to 30–40 mm, depending on the case. Most cases require two inflations, commonly at 37 mm.
Step 8: Post-Dilatation Assessment
Withdraw the valvotome and reintroduce the Mullins sheath into the left ventricle. Remove the guidewire and record the transmitral pressure gradient. In most cases, perform two dilations before pressure measurement. Conduct a final left ventriculogram and record pulmonary artery pressures.
PMBV can be performed via antegrade (transvenous) or retrograde (transarterial) approaches. The antegrade approach is the standard method, typically accessed through the femoral vein with transseptal puncture to reach the left atrium. A jugular vein route is less common but possible. The retrograde approach, which avoids creating an atrial septal defect, is rarely used today due to its technical difficulty and higher risk of arterial injury.
Complications
Mortality: Occurs in up to 3% of cases, often due to left ventricular perforation or poor patient health.
Severe Mitral Regurgitation (MR): Seen in 2–19% of cases, usually due to leaflet or commissural tearing.
Atrial Septal Defect (ASD): Common post-procedure, mostly small and hemodynamically insignificant; large right-to-left shunts are rare.
Hemopericardium: Reported in 0.5–12%, often from transseptal puncture or guidewire injury; may require emergency pericardiocentesis.
Embolic Events: Occur in 0.5–5%, with potential for permanent disability or death.
Complete Heart Block: Occurs in about 1.5%, typically transient; rarely requires permanent pacing.
Procedure Failure: Seen in 1–17%, usually from technical challenges or unfavorable valve anatomy.
Both our subscription plans include Free CME/CPD AMA PRA Category 1 credits.
Digital Certificate PDF
On course completion, you will receive a full-sized presentation quality digital certificate.
medtigo Simulation
A dynamic medical simulation platform designed to train healthcare professionals and students to effectively run code situations through an immersive hands-on experience in a live, interactive 3D environment.
medtigo Points
medtigo points is our unique point redemption system created to award users for interacting on our site. These points can be redeemed for special discounts on the medtigo marketplace as well as towards the membership cost itself.
Community Forum post/reply = 5 points
*Redemption of points can occur only through the medtigo marketplace, courses, or simulation system. Money will not be credited to your bank account. 10 points = $1.
All Your Certificates in One Place
When you have your licenses, certificates and CMEs in one place, it's easier to track your career growth. You can easily share these with hospitals as well, using your medtigo app.
