Pliability assessment,pre procedure evaluation-tricks in difficult pbmv

Pliability assessment,pre-procedure
evaluation-tricks in difficult pbmv

• Chronic rheumatic activity results in characteristic changes of
the MV diagnostic features are
– fusion of the commissures,
– thickening,fibrosis,retractionf of leaflet edges,
– Shortening,thickening and fusion of chordae
• These anatomic changes lead to a typical functional
appearance of the rheumatic MV.
• In earlier stages of the disease, the relatively flexible leaflets
snap open in diastole into a curved shape because of
restriction of motion at the leaflet tips .
• This diastolic doming is most evident in the motion of the
AML and becomes less prominent as the leaflets become
more fibrotic and calcified
PBMV TIPS AND TRICKS

• The symmetrical fusion of the commissures results in a
small central oval orifice in diastole that on pathologic
specimens is shaped like a fish mouth or buttonhole
because the AML is not in the physiologic open position.
• The most useful descriptor of the severity of obstruction
is the degree of valve opening in diastole, or the MVA.
• In normal adults, the cross-sectional area of the MV
orifice is 4 to 6 cm2

Stages of Mitral Stenosis
From Nishimura RA, Otto CM, Bonow RO, et al: 2014 AHA/ACCF guideline for the management
of patients with valvular heart disease: A report of the ACC Foundation/AHA Task Force on
Practice Guidelines. J Am Coll Cardiol 63:e57, 2014.Pliability assessment,pre-procedure

Parameters assessed by echo
• Preprocedure
• Severity of MS
• Pliabilty
– Calcification
– Valve thickening
– Subvalvular pathology
– Commisural morphology
• MR
• LA thrombus
• IAS
• Other valves
• Assessment of Pulm.htn
• intraprocedural:
– Adequacy of commisural
splitting
– MR
– Complications-tampanode
• Postprocedure
– Adequacy of comm.split
– Residual stenosis
– MR
– ASD

Severity of MS

MVA planimetry
• Best correlation-explanted
valves
• Direct method unlike others
it is not –
flow/compliance/assoc.
valve lesions
• MV becomes funnel shape-
tapers to primary orifice at
its tips
• Ideally-
– Psax- smallest orifice to be
indentified
– scanning slowly from LA to LV
apex
– Max opening-mid diastole
– Plane perpendicular to mitral
orifice
– Lowest gain settings
– Trace contour of inner orifice
– Comm included if open
– Ave.of
• 3 in SR
• 5-10 in AF
– (EAE/ASE guidelines 2009)

MVA planimetry
• Limitations:
– Orthogonality of imaging
plane-assumed
– Level of intersection
– Calcium
– Tracing commisures-
difficult

MLSI
• In diastole in Plax and a4c
• Average of the two
• <=0.8 cm-severe MS
• >=1.1cm-mild MS
• Independent predictor of
success during PBMV(s/sp
90/100%)
• Holmin, Caroline, et al. "Mitral leaflet separation index:
a new method for the evaluation of the severity of
mitral stenosis? Usefulness before and after
percutaneous mitral commissurotomy." Journal of the
American Society of Echocardiography 20.10 (2007):
1119-1124.
Vimal, Raj BS, Paul George, and V. J. Jose. "Mitral leaflet separation
index-a simple novel index to assess the severity of mitral
stenosis." Indian heart journal 60.6 (2007

mobility
• Wilkins score grades it
into 4
• More objective
– Reid score
– Leaflet motion was
expressed as a slope by
dividing the height (H) by
the length (L) of doming of
anterior leaflet.

Leaflet thickness
• More objective is-
• expressed as the ratio
between the thickness of
the tip of MV and
thickness of posterior
wall of aortic root.
• <1.4- normal
• 1.4-2 mild
• 2-5 moderate
• >5 severe
• 2d echo plax
• normal- <4
• Mild 5-8
• marked- >8mm
• Whole /localised to
margins
• As thickness increases
outcome becomes worse

calcification
• imp.is commisural calcium
• Psax
• Echogenicity of Ao.root –ref.
• Calci.-Most imp factor in
deciding eligibilty for pbmv
• Unicomm.not - absolute c/I
but bicommisural is
• Only acoustic shadowing is
specific to calcification alone
• (localized brightness can also
be due to fibrosis)
• For this reason, certain teams-
confirm calcification using f/sPliability assessment,pre-procedure

Calcification score-sutaria etal.

Subvalvular pathology
• Higher grades of SVP-poor
outcomes
• Subvalvular region-
secondary orifice of mitral
valve which gets narrowed
• In plax-standard alignment
should be tilted medially
and laterally
• A4c-extent of subvalvular
shortening and scar is best
viewed

• Sub valvular disease

• Subvalvular disease signs:
– More reliable signs of subvalvular disease
– Even in pts whom preprocedural echo shows no SV
disease
• Difficulty in accordion maneuver(Promptly recognised and
balloon deflated quickly)
• Balloon compression sign(inflation aborted-strategy
reassessed)
• Balloon impasse
• Cogwheel resistance-while withdrawing partially inlated
balloon to anchor at MV(presence of subvalvular disease)

Doppler assessment
• A4c flow aligned to probe
• Ideal -3 cardiac cycles-
average them-SR
• 5 cycles and average-AF
• ALWAYS RECORD HR
• (valve gradient is
proportional to HR)
• Max/peak gr –influenced by
LA compliance,LV diastolic
dys
• Though mean-reliable,also
influenced by HR,mr,co

• PHT
• Milliseconds
• Definition
• MVA=220/PHT
• Tracing deceleration slope of E
wave
• Sometimes skislope-then
traced in middiastole rather
than early diastole
• AF –atleast 5 cycles
• Advantages:Less dependent
on
– HR
– Flow
– Useful in AF /arrythmias
• Disadv:
– Diatolic dys(elderly,htn,as)
– AR underestimates ms severity
– Signi MR underestimates MS
severity
– Compliance changes-occur 48-
72hrs ,so wait ..
– Some pts…concave tracing..pht
not feasible

• LV enlargement and systolic dysfunction are
unusual in MS,and the first reaction should be
to search for
– an associated valvular regurgitation or
– coronary artery disease

Echo Score (Wilkins Score)(Boston or Abascal score)

• A score of less than 8 gives better results and
long term success of the procedure than more
than 8
• There is no absolute contraindication to PMV
in patients with higher echo scores

LIMITATIONS OF WILKINS
(Gold stein and lindsay,2010)
• Echocardiography limited in ability to differentiate nodular fibrosis
from calcification
• Does not assess commissural involvement .
• Does not account for uneven distribution of pathologic
abnormalities.
• Does not account for relative contribution of each variable (no
weighing of variables).
• Frequent underestimation of subvalvular disease.
• Does not use results from TEE or 3D echocardiography

Padial score
• Another scoring system
has been developed to
predict severe MR
• It has the advantage of
taking into account the
– heterogeneity of leaflet
impairment and
– presence of commissural
fibrosis or calcification

Padial score

Nobuyoshi score

MV score
based on real-time 3D echocardiography
Normal=0, mild=1–2, moderate= 3–5, severe >6
(Modified from Anwar et al.)

• The individual RT3DE score points of leaflets and
subvalvular apparatus RT3DE score were summed
to calculate the total RT3DE score, ranging from 0
to 31 points.
• Total score of mild MV involvement was defined
as <8 points, moderate MV involvement 8–13,
and severe MV involvement >14.

• echocardiographic report
should include a
comprehensive description
of mitral anatomy and not
summarize it using a score
alone.
• At present , there are no
large-scale comparative
evaluations of the
predictive value of different
scoring systems,
which could lead to
recommending the use of a
particular one.
• best solution -is to use a
method of analysis with
which one is familiar and to
include valve anatomy
among other clinical and
echocardiographic findings.

PBMC
• Patients with mild to moderate MS who are asymptomatic frequently remain so
for years
• Severe or symptomatic MS, however, is associated with poor long-term outcomes if
the stenosis is not relieved mechanically.
• Percutaneous BMV is the procedure of choice for the treatment of MS.
• Life saving emergency procedure in the patient with mitral stenosis and refractory
pulmonary edema or cardiogenic shock
• PMV is the remarkable landmark intervention in the field of interventional
cardiology that leads to the great help in treatment of stenosed MV

Principle of the procedure

INDICATIONS OF PBMC
• BMV is recommended for symptomatic patients
with moderate to severe MS (i.e., a MVA <1
cm2/m2 of BSA or <1.5 cm2 in normal-sized adults)
• favorable valve morphology,
• no or mild MR,
• no evidence of left atrial thrombus

• BMV also may be considered in sympt. patients in
whom surgery carries high risk for adverse events
or outcomes, even when valve morphology is not
ideal, (restenosis after a previous BMV or previous
commissurotomy who are unsuitable candidates
for surgery because of very high risk).
• Very old, frail patients, patients with associated
severe IHD; patients in whom MS is complicated
by pulmonary, renal, or neoplastic disease; women
of childbearing age in whom MVR is undesirable;
and pregnant women with MS

• BMV may be further considered for patients
with mild MS in whom symptoms cannot be
explained by other causes and who experience
pulmonary hypertension (>25 mm Hg) with
exercise

CONTRAINDICATIONS
• The procedure can be performed at higher risk with
thrombus localized to the LAA, thrombus within the LA
itself is a contraindication to this procedure
• Moderate or severe >2+ MR .
• Mitral stenosis and aortic or tricuspid valve lesions that
require cardiac surgery should be referred for surgery
• Concomitant CAD can be treated with PCI in conjunction
with valvuloplasty when the coronary anatomy is
suitable.

Bahl et al., in a nonrandomized study, compared 1,000 PMVs performed with the Inoue
technique, with 100 procedures performed by the retrograde approach, and showed
similar outcome in terms of success, final MVA, and severe MR.
Regarding complications, cardiac tamponade (2%) and ASD (2.5%) occurred exclusively
with the Inoue technique, since the retrograde technique does not require transseptal
puncture; however, more peripheral vascular complications (3% versus 0.5%) were
recorded with the retrograde technique.172

Bahl, V. K., et al. "Balloon mitral valvotomy: comparison between antegrade Inoue and retrograde
non-transseptal techniques." European heart journal18.11 (1997): 1765-1770.
• Retrograde non-transseptal balloon mitral
valvotomy (RNBMV) using polyethylene
bifoil balloons was performed by the
transarterial route' in all the cases except
in the initial eight cases where a single
balloon was used.
• A 7 French, 110 cm steerable LA catheter
(Cordis Europa NV) was positioned into
the LV over a Radifocus (Terumo Corp.,
Tokyo, Japan) 0.035 inch exchange 260cm
long guidewire
• loop of this catheter was manoeuvered
with the steerable arm to direct the tip
towards the mitral valve.
• Mitral valve dil. With appropriate sized
bifoil balloon catheter (Mansfield, Boston
Scientific Corp. Boston, MA, U.S.A.)
inserted through a 12 French arterial
sheath.
• Since its introduction in 1984 by Inoue
and colleagues various strategies have
been developed for performing this
procedure.
– antegrade approach using single and
double
– transseptal trans-arterial approach and
– non-transseptal retrograde approach.
– Basically all the techniques, except the
one advocated by Stefanadis et al require
transseptal puncture with its inherent
complication of cardiac tamponade in
1-9% cases
Cardiac tamponade and left ventricular
perforation, ever present as a threat with
transseptal techniques, is avoided with the
retrograde technique;
however, local arterial complications are more
frequently noted with the transarterial
technique.
Knowledge of an alternative approach does
have the advantage of 'bailing out' in
case of a failed procedure and vice versa

• Major complications:
– Related to septal puncture
– Related to mr
– Embolic events

Breakage of coiled guidewire
• La stainless steel wire
(toray industries,japan)
• Re use multiple times
• microfractures
• Junction- distal thin coiled
and prox thick part
• Careful inspection of wire
• Nitinol accura PTMC
vascular concepts
• Gooseneck snare tried but failed(wire
loop too big)
• Fashioned a snare with double
looped ptca wire 0.014’’ 300 cm in a
6F mp catheter in mullin sheath
• Wire fragment was caught and
retrieved and pulled back in toto with
sheath
• Shankarappa, Ravindranath K, et al. "Removal
of broken balloon mitral valvotomy coiled
guidewire from giant left atrium using
indigenous snare." Cardiovascular intervention
and therapeutics 26.1 (2011): 60-63.

Balloon rupture
• Inoue :toray int. texas
• Catheter-volume
controlled device made
of pvc with balloon
attached to distal end
• Balloon-2 latex layers
with polyester
micromesh in between
• 2.5 cm unstretched
• Accura omv
catheter:vascular
concepts,essex,uk
• Pvc catheter
• Balloon-2 latex layers
with polyester
micromesh in between
• 2.5 cm unstretched

Balloon rupture
• Mesh breakage
• Inoue balloon 3 layers [latex-
wiremesh-latex]
• Strong rubber-nylon microMesh
regulates max diameter and inner
pressure
– Overinflation
– Inflation in heavily calcified valve
• During preparation-
– Do not exceed max rec volume
– Inject diluted contrast slowly during test
inflations
• Rarely occurs
• Mostly in distal part of balloon
• Any deformity during –portends
rupture of balloon if max. dialations
are done subsequently
• Any deformity-stop procedure-change to
new balloon
• If ruptures
– Latex or wire mesh embolisation
– If air trapped in contrast-air embolism
– So always be doubly sure that air does
not get trapped inside balloon

Ho, Yi‐Lwun, et al. "Inoue balloon deformity and rupture during percutaneous balloon
valvuloplasty." Catheterization and cardiovascular diagnosis 38.4 (1996): 345-350.

Balloon impasse
• Although deflated and
properly aligned inoue
balloon becomes held up or
checked at mitral valve
• 760 pts-seen in 13 pts lau
etal
• Impasse sign –portend
severe mr if usual sizing
method is used
• Sizing should be judiciously
altered –smaller size better
choice
• In the absence of balloon im-passe or
fluoroscopic compression sign, the initial
inflated balloon diameter is RS minus 2
mm.
• In subsequent dilatations, the balloon size
is increased by 1 mm.
• When there is pre-existing mitral
regurgitation or any question of increase
in the degree of mitral regurgitation, the
incrrement is 0.5 mm in the high-pressure
zone
• If the balloon impasse sign is
encountered, regardless of
echocardiographic findings of the mitral
valve, the initial catheter is exchanged for
a smaller PTMC-18 Or 20 catheter for
predilatation.
• Lau, K.-W. and Hung, J.-S. (1995), “Balloon impasse”: A
marker for severe mitral subvalvular disease and a predictor
of mitral regurgitation in inoue-balloon percutaneous
transvenous mitral commissurotomy. Cathet. Cardiovasc.
Diagn., 35: 310–319.

Complications –transseptal puncture
• Suspected tampanode
– Mandatory echo in cathlab
– Any unexplained hypotension
following transseptal
puncture—should r/o
hemopericardium
– Inject contrast-it spreads
beyond expected limits of the
atrium
– Layering of contrast in
pericardial space
– Echo –gold standard
– Loss of cardiac pulsations-
immobility of left heart border
and a pericardial halo on f/s
are clues
• Only a needle puncture-wait
and watch- do not give
heparin
• Defer and postpone to later
• If effusion small and not
increasing and balloon in LA –
better proceed with PBMV
• If already dilated septum with
dilator-keep dilator across the
defect to control leak to some
extent until surgical theatre is
reached
• After dilating the septum
before heparin-screening plax
• Significant -pericardiocentesis

• Heparin reversal-
protamine 1mg per 100
units (received in
prevous 2 hours)
• If heparin stopped
– >30min<2hrs-half dose
– >2hrs-quarter dose
• Max dose of
protamine=50mg
• <2hrs-25mg
• >2hrs-12.5mg
• Calc.dose in 100ml
NS@10ml/min until
completion
• Check aptt 15 min after
completion to ensure
reversal
• AUTOTRANSFUSION

Deflation failure
• Incidence of balloon malfunction
– With Reused-20%
– New-0.1%
• Mech:
– Repeat sterilsation damages latex-
herniation of its walls-contrast can
enter between 2 layers(one way valve)
– forceful skin insertion-kinks the shaft-
commonly at junction of shaft and
balloon –occluding lumen of inflation
tube
– Forceful rapid inflation-
rupture/dissection/herniation of walls
of inner lumen of inflarion tube
– Dilution of contrast-not optimal(1:4)
high viscosity may lead to sticking and
logging of inner walls of inflation tube

• Check proper functioning
exvivo prior
• Avoid excessive strain on
catheter during skin entry
• Verical puncture/entry
should be avoided
• Only gradual and serial
dilatations
• After each use-balloon
thoroughly cleansed of
any residual contrast

Deflation failure
• Emergent situation
• Do’s
• Try to identify cause
• Check uniform shape of
balloon on f/s
• Repeated aspirations 20ml
syringe,check any dye retrieval
for 10min
• Minute warm saline inj
• Larger syringe 50ml
• J-shaped stylet-corrects kink
• Ptca wire –restore patency of
lumen

Deflation failure
• Puncturing using transseptal
punture needle introduced
via mullins cath via fem.vein
to la and placed a
brokenbrough needle inside
the catheter
• After pulling the balloon
catheter against the
IAS,prox.end of inflated
balloon was repeatedly
punctured and deflation
acheived
• If all fail---surgery to
exteriorise the left atrium
• (Patel, T. M.,etal (1996),
Unsuccessful deflation of a
bifoil balloon during
percutaneous mitral
valvuloplasty. Cathet.
Cardiovasc. Diagn., 37: 290–
292.)

Deflation failure
• Spring wire to rupture
balloon internally
• (Lanjewar, Charan P., Pratap J. Nathani,
and PRAFULLA G. KERKAR. "Failure of
deflation of an Inoue balloon during
percutaneous balloon mitral
valvuloplasty." Journal of interventional
cardiology 19.3 (2006): 280-282.

Deflation failure
• Donts
• avoid introducing air while
checking patency
• Do not overinflate the
balloon(myth –overinflation
might lead to rupture)
• Avoid excessive negative
aspiration(may collapse the
luminal walls /promote
sticking of walls with
viscous dye)

Calcification of valve
• Compli:
– tear of valve—MR
– Embolisation of calcium
• When bicommisural cal-pbmv
c/i
• Tanaka etal.reported 13 pts
with unicommisural calcium-
successful pbmv
• Even in leaflet belly calcium
PMV can be considered if
commisures are free of
calcium
• Tanaka, Shinichiro, et al. "Over 10
years clinical outcomes in patients
with mitral stenosis with unilateral
commissural calcification treated with
catheter balloon commissurotomy:
Single-center experience." Journal of
cardiology51.1 (2008): 33-41.

Difficulties in septal
puncture,dilation,and balloon entry
• Large LA
– Late presentations
– Dilated and aneursymal LA-
septum bulges into RA
making puncture difficult
– Because of vertical lie of
septum needle will go
through the septum and
will dissect it and not
enter LA
– There are 2 options
– 1.Increasing the curve of
brockenbrough needle so
that it faces more
posteriorly to enable
puncture
– 2.Probing LA entry
• Needle tip just inside the
tip of mullins sheath the
whole assembly is used to
probe the septum at fossa
ovalis
• Slowly slide and enter LA
• 90%success
(Krishnamoorthy etal)

Problems in needle entry into LA-
needle jerk
• Thick septum-difficulty in
advancing mullins sheath
into LA
• Needle tip will be in LA but
the rest of the system may
not enter LA with gentle
pressure.
• Too much pressure –needle
will jerk and can hit and
perforate the posterior LA
wall
• Withdraw the needle and
redo the puncture at
different point in the
septum
• Pass a thin wire like ptca
0.014’’ guidewire and
introduce iit into LA-then
even if little force is used it
will not perforate LA roof

Difficulty in negotiating the septum
• After septal dilatation
while passing
slenderised balloon into
LA ,there may be
difficulty in tracking it
• Due punture site
– recoil
– Obliqueness
• Overcome by:
– Dilatation with larger
dilator-upsize to 18F
dilator
– Changing the angle of
entry
– Screwdriver manoeveur-
balloon is rotated
clockwise while being
pushed across septum

Balloon catheter stuck at
septum”septal catch”
• After removalof LA wire and
straightener while trying to
advance across septum-balloon
may stuck
• Happens during 2nd or
subsequent dilatations
• To prevent:
– Deep placement of balloon
catheter
– Larger dilator:upsize to 18f
– Insert stylet-direct it
posterolaterally-give clockwise
twist-this aligns it perpendicular to
septum-catheter can be advanced
forward
• LA wire reintroduced into LA –
balloon advanced forward and
placed deep in LA-then can be
withdrawn across mitral valve

• Hair loop entry:
• To overcome problem of stuck at
septum
• Difficulty in crossing mv
• Balloon loop-pushed towards LA
roof till tip hits of LA near MV
• Stylet is withdrawn-so that tip
takes an angle and enters MV
• Since shaft is directed
posterosuperiorly..septal catch
will not hinder forward balloon
movement

• Reverse loop entry:
– To overcome stuck at
septum
– Larger LA
– Also when septal puncture
is low
– Balloon makes loop in
anticlockwise fashion
– Crosses mv from la floor
– Stylet is rotated in
clockwise (c/c
anticlockwise in usual
entry

Difficulty in crossing the valve
• Non ideal puncture sites
– Upward cephalad
– Leftward closer to mitral
valve
– Very low
• Large LA
• Changing stylet shape:
– Usual-preformed J shape
– Slight anterior curve
facilitates LV entry
– If septal puncture is
• High-Curve made bigger
• Low-curve made smaller

• Over the wire entry
– Balloon floatation
catheter
– Mullins sheath tracked
over it into LV
– Once good position
attained in LV-LA wire
put LV and inoue balloon
tracked across MV
– (Lawire can–v ectopics ,vt)
• using JR diagnostic:
• Meier etal:0.020 backup j-
wire and diag JR
• Track mullins sheath
over JR and exchenged
backupwire for 0.025 LA
wire –over which
balloon is tracked

• Direct LA wire into LV (manjunath etal.)
• over-the-wire technique that was
modified and simplified
• steps involved are:
– (1) placing a 0.025-inch Inoue spring
guide wire (coiled guide wire) in the
LA;
– (2) a Mullinsheath was reintroduced
into the LAover the spring guide wire,
and the coiled portion of the guide
wire was withdrawn into the sheath;
– (3) positioning of a Mullin sheath
near the mitral orifice and placement
of a pigtail inoue wire directly into
the LV,
– followed by further advancement of
the Mullin sheath into the LV cavity
for obtaining optimal coiling of the
Inoue wire and
– (4) introducing the Inoue balloon
catheter over the
• Simplified technique
does not involve any
additional –backup
guidewires,JR,float.cath
• Mutiple exchanges can
be avoided
• But carry risk of
inserting gudewire
between chordae

• Balloon floatation
catheter and
wire0.021’’:
• Mehan and meier etal
• Two wire technique:
• Rajpal and joseph etal.

• Catheter sliding method:
• alternative method, -effective when septal
puncture is made too caudally
• ballloon is first directed toward the mitral valve
by twisting the stylet counterclockwise, and
then made more flexible by withdrawing the
stylet clear out of the balloon segment.
• Once the slightly inflated balloon is at the mitral
orifice, cardiac contractions will cause the
balloon segment to tilt upwards during systole.
In diastole, the balloon segment aligns with the
catheter shaft.
• With the operator carefully watching the
rhythmic motion of the cardiac cycle, only the
catheter is advanced forward (with the stylet
kept fixed) during diastole to cross the valve.
• The stylet is then advanced to help align the
catheter with the orifice-apex axis.

Catheterization and Cardiovascular Interventions 80:987–990 (2012)
saltlake utah

Mitral Valvuloplasty With the Inoue Balloon
Tracked Over an Arteriovenous Wire
Anwar Tandar, Rodney Badger,MD, FACC
• 1. Step a: Transeptal atrial puncture: A Brokenbrough Needle
is passed through a Mullins sheath.
• Step b: A Mullins sheath is advanced into the left atrium.
• Step c: A 260 cm 0.32 inch wire is advanced via the Mullins
sheath across the mitral valve into the left ventricle.
• Step d: Using a 5Fr Multipurpose- 1 catheter, a snaring device
(25 mm Amplatz Goose Neck Snare 120 cm, EV3, Plymouth,
MN) is advanced into the left ventricle.
• Step e: The 0.32 inch wire is captured and withdrawn to
• the abdominal aorta while advancing the 0.32 wire from the
• venous system. TEE ensured an appropriate wire position,
free of subvalvular entanglement. The Mullins sheath is
removed.
• Step f: A continuous loop of 0.32 inch wire is ensured not to
compromise any mitral valve or subvalvular structures.
• Step g: The elongated Inoue balloon is advanced over the
0.32 wire across the transeptal puncture and forshortened in
the left atrium.
• Step h: Under TEE and fluoroscopic guidance, the Inoue
balloon is advanced across the mitral valve and serially
inflated while monitoring mitral regurgitation and MV
gradients with TEE.

Entry into secondary orifices
• Balloon may track
between secondary
orifices-severe mr
• Fluroscopy markers:
– Axis of balloon catheter
deviates from more
horizantal valve orifice
apex to more vertical
– No free movement of
partly inflated
– Abnormal balloon shape
• How to overcome??
– Never attempt inflation if
any doubt of entry
– Crossing with partly infla.
– Accordian maneuver(Hung
etal):simultaneously
pushing catheter and
pulling stylet in opposite
direction –partly infla
balloon goes freely along
axis
– Better go fully to apex - come
back –dilate valve
– Balloon impasse

Balloon “popping” into LA
• When MV already been
enlarged by dilations-
balloon may occa.slip into la
during subsequent
infla.with larger balloon.
• To prevent—
– Stylet is advanced far into
balloon segment to stiffen the
catheter
– Distal balloon is infla.slightly
larger than previous
– As soon as hourglass seen-
advanved slightly to prevent
jerking into LA and fully
expanded
• Popping –is a signal of
enlargement of mitralorifice
with wide commisural split
• Usually pliable non calci
• Foretells excellent results
• Occasionally despite
popping sign-suboptimal
results-AF

Small LA
• 2 difficulties:
– Tracking stretched balloon
across septum.
– Length of stretched
balloon more than vertical
LA dimension
– Hence whole length low
profile stretched position-
not possible
– Taking stretcher fully out-
destretched high profile-
trapped at septum
• To overcome this-
stretcher is kept partially
advanced so that the
length of now partly
stretched balloon is equal
to vertical LA dimension

Small LA
• Tracking balloon across
mitral valve:
– Balloon gets stuck at septum
– Double loop technique:
– Make 2 loops in LA with
balloon so that balloon points
towards mitral orifice
– But this is possible only in
short statured patients
– Vijay trehan etal.

LA thrombus
• LA thrombus occurs in 3–13% of
patients with MS
• presence is generally considered
as a c/i for BMV
• Systemic embolization occurs in
0.3–0.8% of patients during or
shortly after the procedure and
represents a potentially
devastating complication
• Dislodgement of thrombus
already present before the
procedure is generally thought to
account for this complication in
majority of the cases, while
embolization of catheter induced
thrombi or calcific embolisms
may be responsible in some cases

LA thrombus
• STEPS:
– 1. a deliberate low IAS puncture-using
a standard Brocken-Borough needle
inserted through the Mullins sheath.
– 2. With the Mullins sheath directed
towards the mitral valve, 0.025 inch
coiled guide wire is directly introduced
into the left ventricle and manipulated
to obtain optimal coiling of the guide
wire in LV
– 3.With the coiled guide wire positioned
in LV, septal dilatation was performed
with the septal dilator introduced over
the coiled guide wire
– 4.After septal dilatation, Accura balloon
catheter was introduced into the left
ventricle over the same coiled guide
wire.
– 5.Balloon was positioned across the MV
and Inflated

LA thrombus
• By adopting these
modifications, LA was
virtually excluded from
the track of septal
dilator and balloon
catheter exchanges and
hence the possibility of
disturbing the thrombus
was negligible
• BMV can be safely and
effectively performed in
selected patients with
LA thrombus (type Ia,
type Ib, and type IIa) by
adopting the modified
over the wire technique
• Manjunath etal.Catheterization
and Cardiovascular Interventions
74:653–661 (2009)

• Thank you

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