Catheter-Based Evaluation and Treatment of Rheumatic Heart Disease

Abstract In the modern era, the role of invasive evaluation in rheumatic heart disease is limited to confirmation of individual lesion severity in multivalvular heart disease remaining ambiguous on echocardiography; accurate estimation of pulmonary artery pressure; as an essential accompaniment of therapeutic percutaneous invasive procedures; and for presurgical coronary evaluation. Cardiac catheterization typically begins with right heart catheterization for estimation of pulmonary capillary wedge pressure (PCWP) and pulmonary artery pressure, followed by oximetric studies for estimation of the cardiac output using Fick’s principle. For evaluation of mitral stenosis, valve area is calculated using the Gorlin formula, which requires essential information from a simultaneous left atrial and ventricular pressure trace. The severity of aortic stenosis is estimated by directly recording the gradient across the valve and the severity of regurgitant lesions is estimated by a visual classification scale. Percutaneous mitral balloon commissurotomy (PMBC) is the most fruitful percutaneous intervention in rheumatic heart disease and remains the treatment of choice in mitral stenosis patients with a suitable valve. PBMC is accomplished by splitting the commissures by inflating a balloon placed transseptally across the mitral valve. Isolated rheumatic tricuspid stenosis can also be successfully treated by balloon tricuspid valvuloplasty. The role of percutaneous interventions remains less well established for other rheumatic valvular lesions such as rheumatic mitral regurgitation and aortic stenosis. The skill set for invasive hemodynamic evaluation and PMBC continues to be essential for an interventional cardiologist.