VALVULAR HEART MEAS
Transesophagea) Echocardiographic Monitoring of Percutaneous Mitral Balloon Valvulotomy lsidre Vilacosta, MD, Elena Iturralde, MD, Jo& Albert0 San Romh, MD, Manuel G6mez-Recio, MD, Claudio Romero, MD, Javier Jimhez, MD, and Luis Martinez-Elbal, MD This study was designed to evaluate the usefulness of performing transesophageal echocardiography (TEE) during percutaneous mitral baltoon valvulotomy (PMBV). TEE was performed in 35 consecutive patients wRh symptomatic severe mitral stenosis during PMBV (group A). Another group of 27 pattents wRh mitral stenosis who underwent PMBV without TEE was used for comparison (group B). TEE was most helpful in guiding transseptal puncture, aiding in proper posRiordng of the balloon during the dilatation procedure and enablng early detectton of compltcattons. The resuRs show that PMBV when aided by TEE has a tendency to decrease the freque~y of stgntftcant mitral regurgitation without compromi&g the final mitral valve area. TEE decreased the x-ray exposure time and was web-toterated. Thus, TEE provides information that makes thts interventtonal catheteriutton procedure safer and eader to pertor= (Am J Cardiol1992;70:1040-1044)
P
ercutaneousmitral balloon valvulotomy (PMBV) has been establishedas a nonsurgical, alternative therapy for mitral stenosis.1-3Twodimensional echocardiography is an invaluable adjunct for patient selection.4l5 Furthermore, 2dimensional and Doppler echocardiography can be readily performed after PMBV to assessresults. Transthoracic and transesophageal echocardiography (TEE) have also been used for guiding the transseptal needle across the atria1 septum.6*7Scattered reports of the usefulnessof transthoracic echocardiography and TEE during PMBV have been published.*y9TEE provides excellent imagesof the atria1 chambers, interatrial septum and mitral morphology without interfering with catheterization techniques.lOThis study evaluates the usefulnessof TEE during PMBV. MEWIODB
SWy p&entsr From March 1990 to April 1991, PMBV was performed in 35 consecutive patients (27 women and 8 men, mean age 53 f 11 years, range 26 to 65) with symptomatic mitral stenosis (group A). There were 15 patients in sinus rhythm and 20 in atria1 fibrillation. Five patients were in New York Heart Association functional class IV, 16 in class III, and 14 in class II. Four patients had undergone closed mitral commissurotomypreviously. Informed consent was ob mined from all patients. Patients with left atria1 thrombus or severemitral regurgitation detected by transthoracic echocardiographyor TEE were excluded from the study. Initially, TEE in PMBV was not routine in our institution, but this policy changedwhen TEE becameavailable. To better determine the usefulnessof TEE during PMBV, 27 patients (22 women and 5 men, mean age 49 f 12 years, range 25 to 60) without transesophageal echocardiographically monitored PMBV were used for comparison (group B). Fourteen patients were in atria1 fibrillation, and 13 were in sinus rhythm. Four patients were in functional class IV, 14 in class III, and 9 in class II. Seventeenpatients (11 in group A and 6 in group B) had concomitant, mild mitral regurgitation. Pembeom bdbon mitral valvulotemy: All patients underwent diagnostic left and right heart cathe terization before PMBV. Inoue balloon was used for PMBV in all patients. Transseptal catheterization was From the Departments of Cardiology, Hospital Universitario de San performed with an 8Fr Mullins transseptaldilator and a Carlos, and Hcspital de la Princes, Madrid, Spain. Manuscript re modiied Brockenbrough needle.After entry in the left ceived February 27, 1992; revised manuscript received and accepted atrium, 10,000 units of heparin were administered. SiJune 22,1992. Address for reprints: Isidre Vilacosta, MD, Alchtara 57, 6’ I, multaneous pressuretracings of the left atrium and ventricle were recorded.Cardiac output was measuredwith Madrid, 28006,Spain. 1040
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
OCTOBER 15. 1992
the thermodilution method, and mitral valve area was calculated with the Gorlin formula. A stainlesssteel guide wire was advancedin the left atrium and usedto place the Inoue balloon catheterin the left atrium. After entering the left atrium, the balloon was passed through the mitral orifice into the left ventricle with continuous fluoroscopic and echocardiographicguidance. Balloon inflations were then performeduntil hemodynamicand echocardiographicmeasurementswere satisfactoryor complicationsappeared.Mitral regurgitation was evaluatedwith tine left ventriculographyand its severity was graded by the Seller’s classification. Bight-sided heart oximetry was performedto evaluate interatrial shunting. w@ry: TEE was perm-WI formed during PMBV using a commerciallyavailable Toshiba SSH-160 echocardiographmachineinterfaced with a ~-MHZ transducer,mountedon a flexible endoscope.After administering3 to 8 mg of intravenousdiazepamand 25 to 75 mg of intravenousmeperidine,and topically anesthetizingthe posteriorpharynx with 10% xylocainespray, the transesophagealprobe was introduced in the esophagusand positionedposteriorto the left atrium. In eachpatient from group A, the siteof the interatrial septal puncture was chosenon the basisof echocardiographicfindings.The probewasaimedto enable visualizationof the maximal length of the atria1 septum.Special emphasiswas given to visualizingthe relation betweenthe atria1septumand aorta to ensure that the needletip was not in the vicinity of the aorta. After the transseptalneedleand surroundingsheathap pearedin the right atrium, they were directedunder 2dimensionalechocardiographyto the thinnestportion of the atrial septum(fossaovalis).To ensureproper positioning, the atria1septumwas expectedto bulge toward the left atrium if some pressurewas applied on the transseptalcatheter (tent sign) (Figure 1). After the needlehad crossedthe atria1 septum,it was snapped back to its original position (Figure 2). Contrast echocardiographyperformed during flushing of the needle confirmedits location in the left atrium after the puncture. After entering the left atrium, the balloon was guided through the stenoticmitral valveorifice assisted by a combinationof echocardiographicand fluoroscopic imaging. Before inflation, adequatepositioningof the balloon was routinely assessedby TEE. Before,during
and after ballooninflations,presenceand degreeof mitral regurgitation was semiquantitativelyassessedby transesophagealcolor Doppler echocardiography.Furthermore,maximalmitral leaflet separation(i.e., maximal distanceduring diastolebetweenthe 2 tips of mitral valveleaflets)was measuredbeforeand after eachballoon inflation in the transesophageal echocardiographic 4-chamberview. Finally, after PMBV, the presenceand sizeof interatrial shuntingwas assessed. All patients from group B underwent TEE 3 to 6 monthsafter PMBV to assessresults. W end statistkal anaiysisr Student’s t and chisquaretestswere usedfor comparinghemodynamicparameters and clinical results. The examined factors wereage,sex,cardiacrhythm, history of commissurotomy, echocardiographicsubgrouping,mitral valve area before and after PMBV, balloon diameter normalized to body surfacearea,degreeof mitral regurgitationaccording to left ventriculography,proceduretime and xray exposure.A p value
Transesophagea) Echocardiographic Monitoring of Percutaneous Mitral Balloon Valvulotomy lsidre Vilacosta, MD, Elena Iturralde, MD, Jo& Albert0 San Romh, MD, Manuel G6mez-Recio, MD, Claudio Romero, MD, Javier Jimhez, MD, and Luis Martinez-Elbal, MD This study was designed to evaluate the usefulness of performing transesophageal echocardiography (TEE) during percutaneous mitral baltoon valvulotomy (PMBV). TEE was performed in 35 consecutive patients wRh symptomatic severe mitral stenosis during PMBV (group A). Another group of 27 pattents wRh mitral stenosis who underwent PMBV without TEE was used for comparison (group B). TEE was most helpful in guiding transseptal puncture, aiding in proper posRiordng of the balloon during the dilatation procedure and enablng early detectton of compltcattons. The resuRs show that PMBV when aided by TEE has a tendency to decrease the freque~y of stgntftcant mitral regurgitation without compromi&g the final mitral valve area. TEE decreased the x-ray exposure time and was web-toterated. Thus, TEE provides information that makes thts interventtonal catheteriutton procedure safer and eader to pertor= (Am J Cardiol1992;70:1040-1044)
P
ercutaneousmitral balloon valvulotomy (PMBV) has been establishedas a nonsurgical, alternative therapy for mitral stenosis.1-3Twodimensional echocardiography is an invaluable adjunct for patient selection.4l5 Furthermore, 2dimensional and Doppler echocardiography can be readily performed after PMBV to assessresults. Transthoracic and transesophageal echocardiography (TEE) have also been used for guiding the transseptal needle across the atria1 septum.6*7Scattered reports of the usefulnessof transthoracic echocardiography and TEE during PMBV have been published.*y9TEE provides excellent imagesof the atria1 chambers, interatrial septum and mitral morphology without interfering with catheterization techniques.lOThis study evaluates the usefulnessof TEE during PMBV. MEWIODB
SWy p&entsr From March 1990 to April 1991, PMBV was performed in 35 consecutive patients (27 women and 8 men, mean age 53 f 11 years, range 26 to 65) with symptomatic mitral stenosis (group A). There were 15 patients in sinus rhythm and 20 in atria1 fibrillation. Five patients were in New York Heart Association functional class IV, 16 in class III, and 14 in class II. Four patients had undergone closed mitral commissurotomypreviously. Informed consent was ob mined from all patients. Patients with left atria1 thrombus or severemitral regurgitation detected by transthoracic echocardiographyor TEE were excluded from the study. Initially, TEE in PMBV was not routine in our institution, but this policy changedwhen TEE becameavailable. To better determine the usefulnessof TEE during PMBV, 27 patients (22 women and 5 men, mean age 49 f 12 years, range 25 to 60) without transesophageal echocardiographically monitored PMBV were used for comparison (group B). Fourteen patients were in atria1 fibrillation, and 13 were in sinus rhythm. Four patients were in functional class IV, 14 in class III, and 9 in class II. Seventeenpatients (11 in group A and 6 in group B) had concomitant, mild mitral regurgitation. Pembeom bdbon mitral valvulotemy: All patients underwent diagnostic left and right heart cathe terization before PMBV. Inoue balloon was used for PMBV in all patients. Transseptal catheterization was From the Departments of Cardiology, Hospital Universitario de San performed with an 8Fr Mullins transseptaldilator and a Carlos, and Hcspital de la Princes, Madrid, Spain. Manuscript re modiied Brockenbrough needle.After entry in the left ceived February 27, 1992; revised manuscript received and accepted atrium, 10,000 units of heparin were administered. SiJune 22,1992. Address for reprints: Isidre Vilacosta, MD, Alchtara 57, 6’ I, multaneous pressuretracings of the left atrium and ventricle were recorded.Cardiac output was measuredwith Madrid, 28006,Spain. 1040
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
OCTOBER 15. 1992
the thermodilution method, and mitral valve area was calculated with the Gorlin formula. A stainlesssteel guide wire was advancedin the left atrium and usedto place the Inoue balloon catheterin the left atrium. After entering the left atrium, the balloon was passed through the mitral orifice into the left ventricle with continuous fluoroscopic and echocardiographicguidance. Balloon inflations were then performeduntil hemodynamicand echocardiographicmeasurementswere satisfactoryor complicationsappeared.Mitral regurgitation was evaluatedwith tine left ventriculographyand its severity was graded by the Seller’s classification. Bight-sided heart oximetry was performedto evaluate interatrial shunting. w@ry: TEE was perm-WI formed during PMBV using a commerciallyavailable Toshiba SSH-160 echocardiographmachineinterfaced with a ~-MHZ transducer,mountedon a flexible endoscope.After administering3 to 8 mg of intravenousdiazepamand 25 to 75 mg of intravenousmeperidine,and topically anesthetizingthe posteriorpharynx with 10% xylocainespray, the transesophagealprobe was introduced in the esophagusand positionedposteriorto the left atrium. In eachpatient from group A, the siteof the interatrial septal puncture was chosenon the basisof echocardiographicfindings.The probewasaimedto enable visualizationof the maximal length of the atria1 septum.Special emphasiswas given to visualizingthe relation betweenthe atria1septumand aorta to ensure that the needletip was not in the vicinity of the aorta. After the transseptalneedleand surroundingsheathap pearedin the right atrium, they were directedunder 2dimensionalechocardiographyto the thinnestportion of the atrial septum(fossaovalis).To ensureproper positioning, the atria1septumwas expectedto bulge toward the left atrium if some pressurewas applied on the transseptalcatheter (tent sign) (Figure 1). After the needlehad crossedthe atria1 septum,it was snapped back to its original position (Figure 2). Contrast echocardiographyperformed during flushing of the needle confirmedits location in the left atrium after the puncture. After entering the left atrium, the balloon was guided through the stenoticmitral valveorifice assisted by a combinationof echocardiographicand fluoroscopic imaging. Before inflation, adequatepositioningof the balloon was routinely assessedby TEE. Before,during
and after ballooninflations,presenceand degreeof mitral regurgitation was semiquantitativelyassessedby transesophagealcolor Doppler echocardiography.Furthermore,maximalmitral leaflet separation(i.e., maximal distanceduring diastolebetweenthe 2 tips of mitral valveleaflets)was measuredbeforeand after eachballoon inflation in the transesophageal echocardiographic 4-chamberview. Finally, after PMBV, the presenceand sizeof interatrial shuntingwas assessed. All patients from group B underwent TEE 3 to 6 monthsafter PMBV to assessresults. W end statistkal anaiysisr Student’s t and chisquaretestswere usedfor comparinghemodynamicparameters and clinical results. The examined factors wereage,sex,cardiacrhythm, history of commissurotomy, echocardiographicsubgrouping,mitral valve area before and after PMBV, balloon diameter normalized to body surfacearea,degreeof mitral regurgitationaccording to left ventriculography,proceduretime and xray exposure.A p value
