Abstract
The efficacy, safety and applicability of Inoue balloon technique for BMV are clearly established worldwide in selected subset of patients with rheumatic mitral stenosis (MS). However, in altered cardiac anatomy it offers technical challenges. Distorted cardiac anatomy and cardiac malpositions considerably increase the complications involved in interatrial septal puncture and left ventricular entry during BMV. There are only a few reports worldwide on successful BMV in altered cardiac anatomy using the standard Inoue technique. Here we describe a case of a 27-year-old female with situs inversus and dextrocardia, where BMV was successfully performed with a few modifications of the standard Inoue technique previously described in similar patients.
1
Introduction
Case Report. A 27-year-old married female with a history of rheumatic fever in childhood presented with dyspnea on exertion (NYHA class II) since two years. Clinical and echocardiographic evaluation done revealed situs inversus, dextrocardia and severe rheumatic mitral stenosis. Her mitral valve area (MVA) was 0.8–0.9 cm 2 with mitral valve score of 7 with IAS bulging into the right atrium. BMV was planned, and the preprocedural transesophageal echocardiogram (TEE) was done which ruled out left atrial thrombus.
Femoral arterial and venous punctures were made on the left side. 2,500 IU of intravenous unfractionated heparin was administered. Right heart catheterization was performed, showing severe pulmonary hypertension with mean PA pressure of 47 mmHg. A 6 Fr pigtail catheter was placed in the noncoronary aortic sinus. Next, fluoroscopic imaging was inverted left-to-right by built-in software in the radiographic system (Philips Medical Systems). This created a pseudo-AP view when the C-arm was in the AP position and a pseudo-right anterior oblique (RAO) 30°view when the C-arm was in left anterior oblique (LAO) 30° view. Pulmonary angiography was performed in the pseudo-AP and lateral views with the inverted settings, and the IAS and its relation to the noncoronary aortic sinus were seen in levophase. Next, septal descent was performed in the pseudo-AP view with the needle kept in the 7 o’clock position. After achieving the standard fluoroscopic positions in pseudo-RAO i.e LAO view, pseudo-AP and lateral views, the septum, the septal puncture was done in a lateral view. The pressure gradient between the LA and left ventricle (LV) was noted.
The IAS was dilated with a 14 F septal dilator and a 24 mm Inoue balloon was introduced over the Inoue wire to the LA. Left ventricular entry was attempted with a stylet to the tip of the balloon followed by clockwise rotation in the LA in a pseudo-RAO view. However, the LV could not be entered despite multiple attempts using this standard method. Next using Mullins sheath and Inoue wire, keeping Mullins sheath near the mitral valve, Inoue wire was crossed into the left ventricle. Inoue balloon was negotiated over same wire across the septum into LA and then into the left ventricle. Graded inflations were done at 24 and 25 mm. The LA mean pressure fell from mean 30 mm to 4 mmHg, across the mitral valve. Echocardiography showed a well-divided bilateral commissure with an MVA of 1.8 cm 2 and no mitral regurgitation ( Table 1 ; Figs. 1–4 ).
| Parameters | PRE- BMV | POST- BMV |
|---|---|---|
| LA Pressure | 45/35(30) | __ 13/6(8) |
| LV Pressure | 100/5 | 110/8 |
| Mean Gradient Across the Mitral Valve | 30 mmHg | 4 mmHg |
| MVO / 2D Echo | 0.8–0.9 cm 2 | 1.7–1.8 cm 2 |
| MR | No MR | No MR |
| Aorta | __ 101/57(78) | __ 110/67(80) |
| PA | __ 74/27(47) | __ 45/12(27) |
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