International Journal of Cardiology 191 (2015) 294–295
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
An alternative method of percutaneous mitral valvuloplasty. Matching electrophysiology with interventional cardiology techniques Manolis Vavuranakis ⁎, Costas Stratos, Konstantinos Kalogeras, Constantina Aggeli, Dimitrios Tsiachris, Sophia Vaina, Angelos_Michail Kolokathis, Dimitrios Vrachatis, Maria Lavda, Maria Kariori, Gerasimos Siasos, Dimitrios Tousoulis Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece
a r t i c l e
i n f o
Article history: Received 16 April 2015 Accepted 18 April 2015 Available online 21 April 2015 Keywords: Mitral valvuloplasty Electrophysiology Steering catheter
Percutaneous mitral valvuloplasty (PMV) has been established as the procedure of choice for severe mitral stenosis (MS) beyond surgical treatment [1–3]. The technique was first developed by Inoue, who designed a double lumen coaxial balloon catheter [4]. In case that Inoue balloon is not available, the precise and stable inflation of a conventional balloon is difficult and may cause injury to the left ventricle (LV). Currently available electrophysiology equipment may permit ideal orientation and stabilization of a conventional balloon during PMV. We report a case where the valvuloplasty was successfully conducted through a steerable guiding catheter used for atrial fibrillation ablation, with a conventional valvuloplasty balloon under temporary rapid ventricular pacing. A 58 year old female with a known history of severe MS of rheumatic etiology and permanent atrial fibrillation over the last 7 years, presented with progressive exertional dyspnea. Transthoracic and transesophageal echocardiograms revealed severe MS with a mean mitral valve gradient of 17 mm Hg and a calculated valve area 0.71 cm2. Valve leaflets were thickened with decreased mobility and the left atrium was significantly enlarged (55 mm). There was mild subvalvular chordal thickening and valvular calcification confined to leaflet margins. Accordingly, the calculated Wilkins score was 8. Finally, the left ventricle
⁎ Corresponding author at: 13 Astypaleas, Anoixi, Attiki 14569, Greece. E-mail addresses: [email protected] (M. Vavuranakis), [email protected] (K. Kalogeras).
http://dx.doi.org/10.1016/j.ijcard.2015.04.149 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
ejection fraction and dimensions were within normal limits. The patient was referred for percutaneous mitral valvuloplasty. Under general anesthesia with transesophageal echo guidance, the transseptal puncture was conducted (Brockenbrough needle, Medtronic). Due to left atrium (LA) enlargement, the fossa ovalis was displaced and a pigtail in the non-coronary cusp, as well as a coronary sinus decapolar CS catheter (Johnson) were used to facilitate transseptal needle orientation (Fig. 1A). A FlexCath steerable sheath (12F, Medtronic) was positioned against the mitral orifice. A left ventriculography by hand contrast injection, through a pigtail, precisely localized the mitral valve orifice and ensured coaxial orientation of the FlexCath. The FlexCath has the ability of a single plain 90° width turning edge, permitting a variety of manipulations. Afterwards, a long ‘J wire’ (0.035 mm, 200 cm) was easily advanced through the appropriate oriented FlexCath sheath across the mitral orifice into the LV (Fig. 1B) and subsequently a 6F pigtail over it. A super stiff guide wire (0.035 mm, Brecker Guidewire Confida, Medtronic) was then inserted through the pigtail into the LV (Fig. 1C). According to patient somatometric parameters, a single cavity Numed 26 mm balloon was chosen and advanced across the stenotic mitral valve. PMV was then successfully performed with simultaneous rapid ventricular pacing at 180 bpm in order to avoid balloon translocation during inflation (Fig. 1D, Video 1). The transmitral pressure gradient showed a more than 50% reduction (8 mm Hg), while the calculated orifice increased to 1.5 cm2. However, mild mitral valve regurgitation was created. The patient had no complication associated with the procedure and was discharged after a therapeutic INR was obtained. In this case, we performed a successful balloon valvuloplasty in a severe stenotic mitral valve with a conventional cylindrical balloon under temporary rapid ventricular pacing. With this technique, we have shown that by combining electrophysiology and interventional cardiology equipment, effective and stable balloon inflation is feasible without Inoue balloon availability. By rapid ventricular pacing, similarly to what achieved during percutaneous balloon aortic valvuloplasty, LV is not forcefully contracted against the stiff wire and the balloon is easily stabilized. As a result, the balloon inflation is performed quite steadily, achieving a predictable inflation. PMV registries report major complications in 0.1–4% and minor in 0–9.6% [5,6]. Many of the aforementioned complications may be created during transseptal puncture or the persistent/aggressive efforts to cross the stenotic mitral valve. The vertical orientation of the transseptal
M. Vavuranakis et al. / International Journal of Cardiology 191 (2015) 294–295
295
Fig. 1. (A) Coronary sinus decapolar CS catheter in place (white arrow) with transseptal sheath with needle in superior vena cava and pigtail in non-coronary cusp (B) long ‘J wire’ advanced through the FlexCath sheath (red arrow) and across the mitral orifice into the left ventricle (C) super stiff guide wire inserted into the left ventricle (D) balloon inflation across the mitral valve under rapid ventricular pacing.
puncture level against the mitral orifice makes frequently the valve crossing demanding. By utilizing the FlexCath electrophysiology guiding catheter, crossing the mitral valve becomes easier. This technique may prevent some of the procedure complications, shorten the duration of the procedure and make it more effective. In conclusion, PMV performing with a single cavity conventional balloon under temporary rapid ventricular pacing with simultaneous use of an electrophysiology steerable guiding catheter for valve crossing, is feasible with a potential safer profile. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.04.149.
Conflicts of interest None.
References [1] M. Nobuyoshi, T. Arita, S. Shirai, N. Hamasaki, H. Yokoi, M. Iwabuchi, et al., Percutaneous balloon mitral valvuloplasty: a review, Circulation 119 (2009) e211–e219. [2] A. Vahanian, O. Alfieri, F. Andreotti, M.J. Antunes, G. Baron-Esquivias, H. Baumgartner, et al., Guidelines on the management of valvular heart disease (version 2012), Eur. Heart J. 33 (2012) 2451–2496. [3] F. Tomai, A. Gaspardone, F. Versaci, A.S. Ghini, L. Altamura, L. De Luca, et al., Twenty year follow-up after successful percutaneous balloon mitral valvuloplasty in a large contemporary series of patients with mitral stenosis, Int. J. Cardiol. 177 (2014) 881–885. [4] K. Inoue, T. Owaki, T. Nakamura, F. Kitamura, N. Miyamoto, Clinical application of transvenous mitral commissurotomy by a new balloon catheter, J. Thorac. Cardiovasc. Surg. 87 (1984) 394–402. [5] Complications and mortality of percutaneous balloon mitral commissurotomy. A report from the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry, Circulation 85 (1992) 2014–2024. [6] C.I. Stefanadis, C.G. Stratos, S.G. Lambrou, V.K. Bahl, D.V. Cokkinos, V.A. Voudris, et al., Retrograde nontransseptal balloon mitral valvuloplasty: immediate results and intermediate long-term outcome in 441 cases—a multicenter experience, J. Am. Coll. Cardiol. 32 (1998) 1009–1016.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
An alternative method of percutaneous mitral valvuloplasty. Matching electrophysiology with interventional cardiology techniques Manolis Vavuranakis ⁎, Costas Stratos, Konstantinos Kalogeras, Constantina Aggeli, Dimitrios Tsiachris, Sophia Vaina, Angelos_Michail Kolokathis, Dimitrios Vrachatis, Maria Lavda, Maria Kariori, Gerasimos Siasos, Dimitrios Tousoulis Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece
a r t i c l e
i n f o
Article history: Received 16 April 2015 Accepted 18 April 2015 Available online 21 April 2015 Keywords: Mitral valvuloplasty Electrophysiology Steering catheter
Percutaneous mitral valvuloplasty (PMV) has been established as the procedure of choice for severe mitral stenosis (MS) beyond surgical treatment [1–3]. The technique was first developed by Inoue, who designed a double lumen coaxial balloon catheter [4]. In case that Inoue balloon is not available, the precise and stable inflation of a conventional balloon is difficult and may cause injury to the left ventricle (LV). Currently available electrophysiology equipment may permit ideal orientation and stabilization of a conventional balloon during PMV. We report a case where the valvuloplasty was successfully conducted through a steerable guiding catheter used for atrial fibrillation ablation, with a conventional valvuloplasty balloon under temporary rapid ventricular pacing. A 58 year old female with a known history of severe MS of rheumatic etiology and permanent atrial fibrillation over the last 7 years, presented with progressive exertional dyspnea. Transthoracic and transesophageal echocardiograms revealed severe MS with a mean mitral valve gradient of 17 mm Hg and a calculated valve area 0.71 cm2. Valve leaflets were thickened with decreased mobility and the left atrium was significantly enlarged (55 mm). There was mild subvalvular chordal thickening and valvular calcification confined to leaflet margins. Accordingly, the calculated Wilkins score was 8. Finally, the left ventricle
⁎ Corresponding author at: 13 Astypaleas, Anoixi, Attiki 14569, Greece. E-mail addresses: [email protected] (M. Vavuranakis), [email protected] (K. Kalogeras).
http://dx.doi.org/10.1016/j.ijcard.2015.04.149 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
ejection fraction and dimensions were within normal limits. The patient was referred for percutaneous mitral valvuloplasty. Under general anesthesia with transesophageal echo guidance, the transseptal puncture was conducted (Brockenbrough needle, Medtronic). Due to left atrium (LA) enlargement, the fossa ovalis was displaced and a pigtail in the non-coronary cusp, as well as a coronary sinus decapolar CS catheter (Johnson) were used to facilitate transseptal needle orientation (Fig. 1A). A FlexCath steerable sheath (12F, Medtronic) was positioned against the mitral orifice. A left ventriculography by hand contrast injection, through a pigtail, precisely localized the mitral valve orifice and ensured coaxial orientation of the FlexCath. The FlexCath has the ability of a single plain 90° width turning edge, permitting a variety of manipulations. Afterwards, a long ‘J wire’ (0.035 mm, 200 cm) was easily advanced through the appropriate oriented FlexCath sheath across the mitral orifice into the LV (Fig. 1B) and subsequently a 6F pigtail over it. A super stiff guide wire (0.035 mm, Brecker Guidewire Confida, Medtronic) was then inserted through the pigtail into the LV (Fig. 1C). According to patient somatometric parameters, a single cavity Numed 26 mm balloon was chosen and advanced across the stenotic mitral valve. PMV was then successfully performed with simultaneous rapid ventricular pacing at 180 bpm in order to avoid balloon translocation during inflation (Fig. 1D, Video 1). The transmitral pressure gradient showed a more than 50% reduction (8 mm Hg), while the calculated orifice increased to 1.5 cm2. However, mild mitral valve regurgitation was created. The patient had no complication associated with the procedure and was discharged after a therapeutic INR was obtained. In this case, we performed a successful balloon valvuloplasty in a severe stenotic mitral valve with a conventional cylindrical balloon under temporary rapid ventricular pacing. With this technique, we have shown that by combining electrophysiology and interventional cardiology equipment, effective and stable balloon inflation is feasible without Inoue balloon availability. By rapid ventricular pacing, similarly to what achieved during percutaneous balloon aortic valvuloplasty, LV is not forcefully contracted against the stiff wire and the balloon is easily stabilized. As a result, the balloon inflation is performed quite steadily, achieving a predictable inflation. PMV registries report major complications in 0.1–4% and minor in 0–9.6% [5,6]. Many of the aforementioned complications may be created during transseptal puncture or the persistent/aggressive efforts to cross the stenotic mitral valve. The vertical orientation of the transseptal
M. Vavuranakis et al. / International Journal of Cardiology 191 (2015) 294–295
295
Fig. 1. (A) Coronary sinus decapolar CS catheter in place (white arrow) with transseptal sheath with needle in superior vena cava and pigtail in non-coronary cusp (B) long ‘J wire’ advanced through the FlexCath sheath (red arrow) and across the mitral orifice into the left ventricle (C) super stiff guide wire inserted into the left ventricle (D) balloon inflation across the mitral valve under rapid ventricular pacing.
puncture level against the mitral orifice makes frequently the valve crossing demanding. By utilizing the FlexCath electrophysiology guiding catheter, crossing the mitral valve becomes easier. This technique may prevent some of the procedure complications, shorten the duration of the procedure and make it more effective. In conclusion, PMV performing with a single cavity conventional balloon under temporary rapid ventricular pacing with simultaneous use of an electrophysiology steerable guiding catheter for valve crossing, is feasible with a potential safer profile. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.04.149.
Conflicts of interest None.
References [1] M. Nobuyoshi, T. Arita, S. Shirai, N. Hamasaki, H. Yokoi, M. Iwabuchi, et al., Percutaneous balloon mitral valvuloplasty: a review, Circulation 119 (2009) e211–e219. [2] A. Vahanian, O. Alfieri, F. Andreotti, M.J. Antunes, G. Baron-Esquivias, H. Baumgartner, et al., Guidelines on the management of valvular heart disease (version 2012), Eur. Heart J. 33 (2012) 2451–2496. [3] F. Tomai, A. Gaspardone, F. Versaci, A.S. Ghini, L. Altamura, L. De Luca, et al., Twenty year follow-up after successful percutaneous balloon mitral valvuloplasty in a large contemporary series of patients with mitral stenosis, Int. J. Cardiol. 177 (2014) 881–885. [4] K. Inoue, T. Owaki, T. Nakamura, F. Kitamura, N. Miyamoto, Clinical application of transvenous mitral commissurotomy by a new balloon catheter, J. Thorac. Cardiovasc. Surg. 87 (1984) 394–402. [5] Complications and mortality of percutaneous balloon mitral commissurotomy. A report from the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry, Circulation 85 (1992) 2014–2024. [6] C.I. Stefanadis, C.G. Stratos, S.G. Lambrou, V.K. Bahl, D.V. Cokkinos, V.A. Voudris, et al., Retrograde nontransseptal balloon mitral valvuloplasty: immediate results and intermediate long-term outcome in 441 cases—a multicenter experience, J. Am. Coll. Cardiol. 32 (1998) 1009–1016.
![[Percutaneous balloon valvuloplasty in mitral stenosis].](/assets/img/hold.png)
