Percutaneous mitral commissurotomy

Rheumatic fever is the most common cause of acquired heart disease in children and young adults worldwide, mainly in developing countries, and is the reason that a large number of patients with mitral stenosis will require some modality of treatment during their life span. The early therapeutic approach for this condition was solely surgical, but since the early 1960s, several balloon catheter interventional techniques have emerged as alternatives to surgical treatment. In 1976 Inoue described a novel single-balloon device designed specifically for percutaneous transvenous mitral commissurotomy (PMC), and in 1982 the first clinical application of Inoue's technique was successfully accomplished. Ever since several clinical trials established PMC as an effective and safe procedure for severe mitral stenosis in more than 30,000 patients worldwide, percutaneous balloon techniques have been considered the method of choice in selected patients (functional class >II, mitral valve area <1.5 cm2, and Wilkins' score <8) for several reasons. PMC is a nonsurgical method with results similar to those of surgical intervention, but without the unnecessary risks and complications of general anesthesia and extracorporeal circulation pump. Both PMC and surgical commissurotomy yield comparable acute and long-term results and similar restenosis rates. Moreover, PMC is the strategy of choice in symptomatic pregnant women with mitral stenosis, as well as in some cases with restenosis after a previous PMC. Patient selection and procedural technique are reviewed in detail.