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Pliability assessment,pre procedure evaluation-tricks in difficult pbmv

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PBMV-TIPS AND TRICKS

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Pliability assessment,pre procedure evaluation-tricks in difficult pbmv

  1. 1. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  2. 2. • 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
  3. 3. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  4. 4. 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 evaluation-tricks in difficult pbmv
  5. 5. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  6. 6. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  7. 7. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  8. 8. Severity of MS Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  9. 9. 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) Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  10. 10. MVA planimetry • Limitations: – Orthogonality of imaging plane-assumed – Level of intersection – Calcium – Tracing commisures- difficult Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  11. 11. 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv 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
  12. 12. 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  13. 13. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  14. 14. 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 evaluation-tricks in difficult pbmv
  15. 15. Calcification score-sutaria etal. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  16. 16. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  17. 17. • Sub valvular disease Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  18. 18. • 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) Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  19. 19. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  20. 20. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  21. 21. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  22. 22. Echo Score (Wilkins Score)(Boston or Abascal score) Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  23. 23. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  24. 24. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  25. 25. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  26. 26. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  27. 27. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  28. 28. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv Padial score
  29. 29. Nobuyoshi score Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  30. 30. MV score based on real-time 3D echocardiography Normal=0, mild=1–2, moderate= 3–5, severe >6 (Modified from Anwar et al.) Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  31. 31. • 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  32. 32. • 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  33. 33. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  34. 34. Principle of the procedure Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  35. 35. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  36. 36. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  37. 37. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  38. 38. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  39. 39. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  40. 40. 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  41. 41. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv 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
  42. 42. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  43. 43. • Major complications: – Related to septal puncture – Related to mr – Embolic events Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  44. 44. 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  45. 45. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  46. 46. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  47. 47. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  48. 48. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv Ho, Yi‐Lwun, et al. "Inoue balloon deformity and rupture during percutaneous balloon valvuloplasty." Catheterization and cardiovascular diagnosis 38.4 (1996): 345-350.
  49. 49. 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  50. 50. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  51. 51. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  52. 52. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  53. 53. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  54. 54. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  55. 55. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  56. 56. 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.) Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  57. 57. 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  58. 58. 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) Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  59. 59. 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  60. 60. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  61. 61. 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) Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  62. 62. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  63. 63. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  64. 64. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  65. 65. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  66. 66. • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  67. 67. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  68. 68. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  69. 69. Difficulty in crossing the valve • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  70. 70. Difficulty in crossing the valve • 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  71. 71. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  72. 72. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  73. 73. Difficulty in crossing the valve • Balloon floatation catheter and wire0.021’’: • Mehan and meier etal • Two wire technique: • Rajpal and joseph etal. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  74. 74. Difficulty in crossing the valve • 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  75. 75. Difficulty in crossing the valve Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv Catheterization and Cardiovascular Interventions 80:987–990 (2012) saltlake utah
  76. 76. 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  77. 77. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  78. 78. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  79. 79. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  80. 80. 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. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  81. 81. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  82. 82. 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 Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  83. 83. 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) Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  84. 84. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  85. 85. • Thank you Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv
  86. 86. Pliability assessment,pre-procedure evaluation-tricks in difficult pbmv

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