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Concurrent aortic and mitral balloon valvuloplasty by the retrograde non-transseptal technique
International Journal of Cardiology 52 (1995) 13-15
Concurrent aortic and mitral balloon valvuloplasty by the retrograde non-transseptal technique Vinay K. Bahl*, Subhash Chandra, Rajnish Juneja Department of Cardiology, Cardiothoracic
Sciences Centre, Ail India Institute of Medical Science, New Delhi 110029, India
Received 5 June 1995; revision accepted 26 July 1995
Abstract Balloon valvuloplasty for combined aortic and mitral stenosis is now being increasingly practised. Transseptal catheterisation forms an integral part of this procedure. We describe a casewhere the retrograde non-transseptal approach was used for dilating both valves in a single intervention. Keywords:
Retrograde; Transseptal
1. Introduction
Patients with combined aortic and mitral stenosis can be managed either by surgery or balloon dilatation. However, concurrent aortic and mitral valve balloon dilatation, tirst reported by Kritzer et al. [l] in 1987, has several potential advantages over the surgical treatment modalities [2]. In most reported casesof simultaneous mitral and aortic balloon valvuloplasty, mitral dilatation was performed by transvenous transseptal techniques. Aortic valve was either dilated antegradely [l], retrogradely [3,4] and, in one large seriesof 10 cases[5], both valves were dilated retrogradely by Babic’s technique [6]. In an effort to avoid the mandatory septal puncture, Stefanadis et al. [7] designed a steerable catheter with which l
Corresponding author.
retrograde left atria1 entry is easy and predictable. Results of mitral valve dilatation with their retrograde non-transseptal technique have been similar to the conventional transseptal techniques. We describe its application for the first time in a case of concurrent mitral and aortic stenosis. 2. Case report
A 30-year-old female, with complaint of exertional dyspnoea (New York Heart Association class III) of 5 years duration, was clinically diagnosed to have non-calcific severe mitral and significant aortic stenosis. Chest X-ray revealed a cardiothoracic ratio of 54%, left atria1 enlargement, severepulmonary venous and arterial hypertension. The QRS axis was + 120”, PR interval was 0.22 with evidence of left atria1 enlargement and incomplete right bundle branch block on the elec-
0167-5273/95/$09.50 0 1995Elsevier Science Ireland Ltd. All rights reserved SSDI 0167-5273(95)02449-7
14
V.K. Bahl et al. /International
Journal of Cardiology 52 (1995) 13-15
trocardiogram. Shewas in sinus rhythm. Echocardiography showed an enlarged left atrium (40 mm) without any evidence of clot and normal sized left ventricle with mildly diminished ejection fraction. Mitral valve area was 0.8 cm* with an echo score of 6. Aortic valve was thick with a peak systolic gradient of 51 mmHg across it, and the annulus measured 19 mm. There was no significant aortic or mitral regurgitation. Cinefluoroscopy did not reveal any valvular calcification. Shewas receiving digoxin, diuretics and penicillin prophylaxis. After obtaining an informed consent, diagnostic catheterization was performed via the left femoral vessels. Basal hemodynamic data was recorded (Table 1). Cardiac output was obtained using Fick’s principle and mitral valve area was calculated by Gorlin’s formula. Left ventriculography showed no mitral regurgitation and aortic root angiography revealed trivial aortic regurgitation. A 14F arterial sheath was placed in the right femoral artery. The pigtail catheter was removed over a 0.038” heavy duty guide wire and the aortic valve was dilated initially with a 17-mm balloon (Mansfield Inc.) and tinally with a 19-mmballoon (Fig. 1). The balloon was removed over the exchange guide wire and a 8F pigtail catheter put into the left ventricle. After repeat hemodynamic measurements the pigtail catheter was removed, leaving a 0.035” exchange Table1 Hemodynamic data
-69 LV Aorta CI (Vmin/mz) PsG WV) MDG (MV) EDG (MV) MVA (em’)
Basal
Post AVBD Post BMV
20 120/S-10 IO/40 2 50 13 12-13 0.7
30 120/10-14 100156 20 14 -
10 lOO/lO 88/50 3.8 12 6 0 1.9
AVBD, aortic valve balloon dilatation; BMV, balloon mitral valvuloplasty; PCW (M), mean pulmonary capillary wedge pressure;LV, left ventricle; CI, cardiac index; PSG (AV), peak systolii gradient across aortic valve; MDG (MV), mean diastolic gradient acrossmitral valve; EDG (MV), end diastolic gradient across mitral valve; MVA, mitral valve area (all pressures are in mmHg).
Fig. 1. Right anterior oblique view showing an inflated balloon across the aortic valve.
redifocus”” guide wire (Terumo Corp., Japan) in the left ventricle, on which the 7F, 110 cm steerableleft atria1 catheter (Cordis Europa N.V.) was inserted and the tip of the catheter was manipulated until it pointed towards the mitral valve. Atria1 entry was achieved in 3 min by the previously described technique [7,8]. The 0.035” Terumo wire was then exchangedwith an extrastiff 0.038II heavy duty guidewire and the steerableleft atria1 catheter was removed. The mitral valve was dilated with a single 23-mm Mansfield balloon (effective balloon dilating area four times the body surface area) inserted through right femoral artery over the extrastiff guidewire. A tight waist disappearing with the inflation was clearly visualised (Fig. 2). The final hemodynamic data was collected at the end of both the dilatations (Table 1). Post dilatation tine-angiograms showed mild mitral regurgitation and no increase in the aortic regurgitation, The sheaths were removed and hemostasis achieved by manual compression. Total procedure time was 80 min with a fluoroscopy time of 20 min. The patient was observed in the coronary care unit for 24 h and discharged the next day. Follow-up echocardiogram at the end of 12 weeks revealed the gradient of 16 mmHg across the aortic valve and a mitral valve area of 1.9 cm’.
V.K. Bahl et al. /International
Sownal of C?rdiology 52 (1995) 13-15
15
tality of an open heart surgery, her small body size would have left a significant gradient across the aortic valve. We believe that the retrograde non-transseptal approach is a reasonable alternative to the breviously used techniques because of its relative simplicity, balloon insertion through a single vascular accessand inherent low risk, Acknowledgment
We are grateful to Christodoulos Stefanadis, MD, Department of Cardiology, Medical School of the University of Athens, Greece,who introduced the retrograde non-transseptal technique to us and provided the left atria1 catheters.
Fig. 2. Lateral projection showing an inflated balloon across the mitral valve. A tight waist is clearly visualized. A temporary pacing lead in the right ventricle and a Swan-Ganz catheter are also seen.
References
VI Kritzer GL, Block PC, Palacios I. Simultaneous percuta-
3. Discussion
. Currently, both aortic and mitral balloon dilatation can be performed either antergadely or retrogradely. The limited experience world-wide on simultaneous balloon valvuloplasty does not permit absolute guidelines of approach or sequence of dilatation. Although the antegrade approach for both the valves has the advantage of avoiding local arterial complications, it requires transseptal catheterisation and balloon placement across aortic valve via the antegrade approach at times may be difficult and hazardous. Retrograde dilatation of both valves is possible by Babic’s technique [6] but still requires a septal puncture and being technically demanding, remains limited to a few centres. The retrograde technique has the obvious advantage of avoiding a septal puncture and allowing both valve dilatation through a single vascular access. Also, it allows aortic valve dilatation to be performed first, which we believe should be preferable [2]. For our patient the usual surgical treatment modality would have been aortic valve replacement with open mitral commissurotomy. Apart from the morbidity and mor-
neousmitral and aortic balloon valvotomies in an elderly patient. Am Heart J 1987; 114:420-423. PI Cheng TO. Concurrent multivalve balloon valvulopasty. In: Cheng TO, editor. Percutaneousballoon valvuloplasty. New York: Igaku-Shoin, 1992;468-490. [31 McKay CR, Kawanishi DT, Chatterjee S, Reid CL, Rahimtoola SH. Stenotic aortic and mitral valves treated with catheter balloon valvuloplasty in a patient with I small valve annuli. Ann Intern Med 1988; 108:568-569. 141 Berman AD, Weinstein JS, Safain RD, Diver DJ, Grossman W, McKay RG. Combined aortic and mitral balloon valvuloplasty in patients with critical aortic and mitral valve stenosis. J Am Coil Cardiol 1988; 11: 1213-1218. [51 Medina A, Bethencurt A, Coello I, Hernandez E, Goicolea J, Laraudogoitia E, Mehan F, Jimenez F, Drumond A, Olalla E. Combined percutaneous mitral and aortic balloon valvuloplasty. Am J Cardiol 1989;a 620-624. El Babic UU, Pejcic P, Djurisic Z, Vucinic M, Grujicic SM. Percutaneous transarterial balloon valvuloplasty for mitral valve stenosis.Am J Cardiol 1986;57: 1101-l 104. [71 Stefanadis C, Stratos C, Pitsavos C, Kallikazaros I, Triposkiadis F, Trikas A, Vlachopoulos C, Gavaliatsis I, Toutouzas P. Retrograde non-transseptal balloon mitral valvuloplasty - immediate results and long term followup. Circulation 1992; 85: 1760-1767. PI Bahl VK, Juneja R, Thatai D, Kaul U, Sharma S, Wasir HS. Retrograde non-transseptal balloon mitral valvuloplsty for rheumatic mitral stenosis. Cath Cardiovasc Diagn 1994; 33: 331-335.
Concurrent aortic and mitral balloon valvuloplasty by the retrograde non-transseptal technique Vinay K. Bahl*, Subhash Chandra, Rajnish Juneja Department of Cardiology, Cardiothoracic
Sciences Centre, Ail India Institute of Medical Science, New Delhi 110029, India
Received 5 June 1995; revision accepted 26 July 1995
Abstract Balloon valvuloplasty for combined aortic and mitral stenosis is now being increasingly practised. Transseptal catheterisation forms an integral part of this procedure. We describe a casewhere the retrograde non-transseptal approach was used for dilating both valves in a single intervention. Keywords:
Retrograde; Transseptal
1. Introduction
Patients with combined aortic and mitral stenosis can be managed either by surgery or balloon dilatation. However, concurrent aortic and mitral valve balloon dilatation, tirst reported by Kritzer et al. [l] in 1987, has several potential advantages over the surgical treatment modalities [2]. In most reported casesof simultaneous mitral and aortic balloon valvuloplasty, mitral dilatation was performed by transvenous transseptal techniques. Aortic valve was either dilated antegradely [l], retrogradely [3,4] and, in one large seriesof 10 cases[5], both valves were dilated retrogradely by Babic’s technique [6]. In an effort to avoid the mandatory septal puncture, Stefanadis et al. [7] designed a steerable catheter with which l
Corresponding author.
retrograde left atria1 entry is easy and predictable. Results of mitral valve dilatation with their retrograde non-transseptal technique have been similar to the conventional transseptal techniques. We describe its application for the first time in a case of concurrent mitral and aortic stenosis. 2. Case report
A 30-year-old female, with complaint of exertional dyspnoea (New York Heart Association class III) of 5 years duration, was clinically diagnosed to have non-calcific severe mitral and significant aortic stenosis. Chest X-ray revealed a cardiothoracic ratio of 54%, left atria1 enlargement, severepulmonary venous and arterial hypertension. The QRS axis was + 120”, PR interval was 0.22 with evidence of left atria1 enlargement and incomplete right bundle branch block on the elec-
0167-5273/95/$09.50 0 1995Elsevier Science Ireland Ltd. All rights reserved SSDI 0167-5273(95)02449-7
14
V.K. Bahl et al. /International
Journal of Cardiology 52 (1995) 13-15
trocardiogram. Shewas in sinus rhythm. Echocardiography showed an enlarged left atrium (40 mm) without any evidence of clot and normal sized left ventricle with mildly diminished ejection fraction. Mitral valve area was 0.8 cm* with an echo score of 6. Aortic valve was thick with a peak systolic gradient of 51 mmHg across it, and the annulus measured 19 mm. There was no significant aortic or mitral regurgitation. Cinefluoroscopy did not reveal any valvular calcification. Shewas receiving digoxin, diuretics and penicillin prophylaxis. After obtaining an informed consent, diagnostic catheterization was performed via the left femoral vessels. Basal hemodynamic data was recorded (Table 1). Cardiac output was obtained using Fick’s principle and mitral valve area was calculated by Gorlin’s formula. Left ventriculography showed no mitral regurgitation and aortic root angiography revealed trivial aortic regurgitation. A 14F arterial sheath was placed in the right femoral artery. The pigtail catheter was removed over a 0.038” heavy duty guide wire and the aortic valve was dilated initially with a 17-mm balloon (Mansfield Inc.) and tinally with a 19-mmballoon (Fig. 1). The balloon was removed over the exchange guide wire and a 8F pigtail catheter put into the left ventricle. After repeat hemodynamic measurements the pigtail catheter was removed, leaving a 0.035” exchange Table1 Hemodynamic data
-69 LV Aorta CI (Vmin/mz) PsG WV) MDG (MV) EDG (MV) MVA (em’)
Basal
Post AVBD Post BMV
20 120/S-10 IO/40 2 50 13 12-13 0.7
30 120/10-14 100156 20 14 -
10 lOO/lO 88/50 3.8 12 6 0 1.9
AVBD, aortic valve balloon dilatation; BMV, balloon mitral valvuloplasty; PCW (M), mean pulmonary capillary wedge pressure;LV, left ventricle; CI, cardiac index; PSG (AV), peak systolii gradient across aortic valve; MDG (MV), mean diastolic gradient acrossmitral valve; EDG (MV), end diastolic gradient across mitral valve; MVA, mitral valve area (all pressures are in mmHg).
Fig. 1. Right anterior oblique view showing an inflated balloon across the aortic valve.
redifocus”” guide wire (Terumo Corp., Japan) in the left ventricle, on which the 7F, 110 cm steerableleft atria1 catheter (Cordis Europa N.V.) was inserted and the tip of the catheter was manipulated until it pointed towards the mitral valve. Atria1 entry was achieved in 3 min by the previously described technique [7,8]. The 0.035” Terumo wire was then exchangedwith an extrastiff 0.038II heavy duty guidewire and the steerableleft atria1 catheter was removed. The mitral valve was dilated with a single 23-mm Mansfield balloon (effective balloon dilating area four times the body surface area) inserted through right femoral artery over the extrastiff guidewire. A tight waist disappearing with the inflation was clearly visualised (Fig. 2). The final hemodynamic data was collected at the end of both the dilatations (Table 1). Post dilatation tine-angiograms showed mild mitral regurgitation and no increase in the aortic regurgitation, The sheaths were removed and hemostasis achieved by manual compression. Total procedure time was 80 min with a fluoroscopy time of 20 min. The patient was observed in the coronary care unit for 24 h and discharged the next day. Follow-up echocardiogram at the end of 12 weeks revealed the gradient of 16 mmHg across the aortic valve and a mitral valve area of 1.9 cm’.
V.K. Bahl et al. /International
Sownal of C?rdiology 52 (1995) 13-15
15
tality of an open heart surgery, her small body size would have left a significant gradient across the aortic valve. We believe that the retrograde non-transseptal approach is a reasonable alternative to the breviously used techniques because of its relative simplicity, balloon insertion through a single vascular accessand inherent low risk, Acknowledgment
We are grateful to Christodoulos Stefanadis, MD, Department of Cardiology, Medical School of the University of Athens, Greece,who introduced the retrograde non-transseptal technique to us and provided the left atria1 catheters.
Fig. 2. Lateral projection showing an inflated balloon across the mitral valve. A tight waist is clearly visualized. A temporary pacing lead in the right ventricle and a Swan-Ganz catheter are also seen.
References
VI Kritzer GL, Block PC, Palacios I. Simultaneous percuta-
3. Discussion
. Currently, both aortic and mitral balloon dilatation can be performed either antergadely or retrogradely. The limited experience world-wide on simultaneous balloon valvuloplasty does not permit absolute guidelines of approach or sequence of dilatation. Although the antegrade approach for both the valves has the advantage of avoiding local arterial complications, it requires transseptal catheterisation and balloon placement across aortic valve via the antegrade approach at times may be difficult and hazardous. Retrograde dilatation of both valves is possible by Babic’s technique [6] but still requires a septal puncture and being technically demanding, remains limited to a few centres. The retrograde technique has the obvious advantage of avoiding a septal puncture and allowing both valve dilatation through a single vascular access. Also, it allows aortic valve dilatation to be performed first, which we believe should be preferable [2]. For our patient the usual surgical treatment modality would have been aortic valve replacement with open mitral commissurotomy. Apart from the morbidity and mor-
neousmitral and aortic balloon valvotomies in an elderly patient. Am Heart J 1987; 114:420-423. PI Cheng TO. Concurrent multivalve balloon valvulopasty. In: Cheng TO, editor. Percutaneousballoon valvuloplasty. New York: Igaku-Shoin, 1992;468-490. [31 McKay CR, Kawanishi DT, Chatterjee S, Reid CL, Rahimtoola SH. Stenotic aortic and mitral valves treated with catheter balloon valvuloplasty in a patient with I small valve annuli. Ann Intern Med 1988; 108:568-569. 141 Berman AD, Weinstein JS, Safain RD, Diver DJ, Grossman W, McKay RG. Combined aortic and mitral balloon valvuloplasty in patients with critical aortic and mitral valve stenosis. J Am Coil Cardiol 1988; 11: 1213-1218. [51 Medina A, Bethencurt A, Coello I, Hernandez E, Goicolea J, Laraudogoitia E, Mehan F, Jimenez F, Drumond A, Olalla E. Combined percutaneous mitral and aortic balloon valvuloplasty. Am J Cardiol 1989;a 620-624. El Babic UU, Pejcic P, Djurisic Z, Vucinic M, Grujicic SM. Percutaneous transarterial balloon valvuloplasty for mitral valve stenosis.Am J Cardiol 1986;57: 1101-l 104. [71 Stefanadis C, Stratos C, Pitsavos C, Kallikazaros I, Triposkiadis F, Trikas A, Vlachopoulos C, Gavaliatsis I, Toutouzas P. Retrograde non-transseptal balloon mitral valvuloplasty - immediate results and long term followup. Circulation 1992; 85: 1760-1767. PI Bahl VK, Juneja R, Thatai D, Kaul U, Sharma S, Wasir HS. Retrograde non-transseptal balloon mitral valvuloplsty for rheumatic mitral stenosis. Cath Cardiovasc Diagn 1994; 33: 331-335.