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Transjugular Balloon Mitral Valvotomy in a Patient With Inferior Vena-Caval Interruption
JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 5, NO. 2, 2012
© 2012 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER INC.
DOI: 10.1016/j.jcin.2011.09.025
Transjugular Balloon Mitral Valvotomy in a Patient With Inferior Vena-Caval Interruption John Jose, DM, MD, Vipin Kumar, MD, George Joseph, DM, MD Vellore, Tamil Nadu, India
Balloon mitral valvotomy (BMV) is an effective method of relieving severe rheumatic mitral valve stenosis in patients with suitable valve morphology. In the vast majority of patients, BMV can be successfully performed using femoral venous access; however, certain congenital or acquired anomalies of the inferior vena cava or iliofemoral veins may preclude this option and necessitate the use of alternative access routes. We present a 20-year-old woman with severe symptomatic rheumatic mitral valve stenosis who was referred to our center after an unsuccessful BMV attempt using femoral venous access. Venography revealed inferior vena caval interruption with azygous continuation (Fig. 1A) and onward drainage into the superior vena cava
(note the “candy cane” appearance) (Fig. 1B); the hepatic veins drained directly into the right atrium (Fig. 1C). Right internal jugular vein access was obtained, and pulmonary angiography was performed in right anterior oblique projection to obtain a levophase image of the left atrium. The atrial septum was punctured using a pediatric transseptal needle (asterisk demarcates the intended site of the interatrial septal puncture), about a vertebral body height below the roof of the left atrium, and midway between the aorta (identified fluoroscopically by a pigtail catheter introduced from the right radial artery) and the anterior border of the spine (Figs. 1D and 1E). (Note that contrast injection through the needle
Figure 1. Cine Images Demonstrating Inferior Vena Cava Interruption and Transjugular Balloon Mitral Valvotomy
From the Department of Cardiology, Christian Medical College Hospital, Vellore, Tamil Nadu, India. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received August 24, 2011; accepted September 3, 2011.
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Jose et al. Transjugular Balloon Mitral Valvotomy
delineates the floor of the left atrium.) A 14-F J-shaped sheath was advanced into the left atrium over a 0.025inch curved left atrial wire. A stiff 0.035-inch wire with a large, soft J-tip was then placed at the left ventricular apex and the mitral valve was dilated using an over-thewire cylindrical single balloon (Fig. 1F). (Note the almost straight-line access to the mitral valve afforded by the jugular approach.) The planimetric mitral valve area increased from 1.0 to 1.72 cm2. The entire procedure took 45 min and was performed without echocardio-
JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 5, NO. 2, 2012 FEBRUARY 2012:243– 4
graphic guidance. There were no complications. The transjugular approach to transseptal BMV is a useful alternative in patients with venous anomalies that preclude the conventional femoral venous approach. Reprint requests and correspondence: Dr. John Jose, Department of Cardiology, Christian Medical College Hospital, Vellore, Officer’s Lane, Vellore-632004, Tamil Nadu, India. E-mail: [email protected].
VOL. 5, NO. 2, 2012
© 2012 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER INC.
DOI: 10.1016/j.jcin.2011.09.025
Transjugular Balloon Mitral Valvotomy in a Patient With Inferior Vena-Caval Interruption John Jose, DM, MD, Vipin Kumar, MD, George Joseph, DM, MD Vellore, Tamil Nadu, India
Balloon mitral valvotomy (BMV) is an effective method of relieving severe rheumatic mitral valve stenosis in patients with suitable valve morphology. In the vast majority of patients, BMV can be successfully performed using femoral venous access; however, certain congenital or acquired anomalies of the inferior vena cava or iliofemoral veins may preclude this option and necessitate the use of alternative access routes. We present a 20-year-old woman with severe symptomatic rheumatic mitral valve stenosis who was referred to our center after an unsuccessful BMV attempt using femoral venous access. Venography revealed inferior vena caval interruption with azygous continuation (Fig. 1A) and onward drainage into the superior vena cava
(note the “candy cane” appearance) (Fig. 1B); the hepatic veins drained directly into the right atrium (Fig. 1C). Right internal jugular vein access was obtained, and pulmonary angiography was performed in right anterior oblique projection to obtain a levophase image of the left atrium. The atrial septum was punctured using a pediatric transseptal needle (asterisk demarcates the intended site of the interatrial septal puncture), about a vertebral body height below the roof of the left atrium, and midway between the aorta (identified fluoroscopically by a pigtail catheter introduced from the right radial artery) and the anterior border of the spine (Figs. 1D and 1E). (Note that contrast injection through the needle
Figure 1. Cine Images Demonstrating Inferior Vena Cava Interruption and Transjugular Balloon Mitral Valvotomy
From the Department of Cardiology, Christian Medical College Hospital, Vellore, Tamil Nadu, India. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received August 24, 2011; accepted September 3, 2011.
244
Jose et al. Transjugular Balloon Mitral Valvotomy
delineates the floor of the left atrium.) A 14-F J-shaped sheath was advanced into the left atrium over a 0.025inch curved left atrial wire. A stiff 0.035-inch wire with a large, soft J-tip was then placed at the left ventricular apex and the mitral valve was dilated using an over-thewire cylindrical single balloon (Fig. 1F). (Note the almost straight-line access to the mitral valve afforded by the jugular approach.) The planimetric mitral valve area increased from 1.0 to 1.72 cm2. The entire procedure took 45 min and was performed without echocardio-
JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 5, NO. 2, 2012 FEBRUARY 2012:243– 4
graphic guidance. There were no complications. The transjugular approach to transseptal BMV is a useful alternative in patients with venous anomalies that preclude the conventional femoral venous approach. Reprint requests and correspondence: Dr. John Jose, Department of Cardiology, Christian Medical College Hospital, Vellore, Officer’s Lane, Vellore-632004, Tamil Nadu, India. E-mail: [email protected].