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Percutaneous mitral balloon valvotomy in a case of situs inversus dextrocardia with severe rheumatic mitral stenosis
Cardiovascular Revascularization Medicine 13 (2012) 246–248
Contents lists available at SciVerse ScienceDirect
Cardiovascular Revascularization Medicine
Percutaneous mitral balloon valvotomy in a case of situs inversus dextrocardia with severe rheumatic mitral stenosis Prashanth Kulkarni ⁎, Prabhu Halkati, Suresh Patted, Sameer Ambar, Suresh Yavagal Department of Cardiology, J.N. Medical College, KLE University, Belgaum, Karnataka, India
a r t i c l e
i n f o
Article history: Received 24 January 2012 Accepted 16 March 2012 Keywords: Situs inversus dextrocardia Rheumatic mitral stenosis Balloon mitral valvotomy
a b s t r a c t 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. © 2012 Elsevier Inc. All rights reserved.
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
⁎ Corresponding author. E-mail address: [email protected] (P. Kulkarni). 1553-8389/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.carrev.2012.03.003
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
Table 1 Pre and Post BMV parameters. Parameters
PRE- BMV
POST- BMV
LA Pressure
45/35(30)
LV Pressure Mean Gradient Across the Mitral Valve MVO / 2D Echo MR Aorta
100/5 30 mmHg 0.8–0.9 cm2 No MR __ 101/57(78) __ 74/27(47)
__ 13/6(8) 110/8 4 mmHg 1.7–1.8 cm2 No MR __ 110/67(80) __ 45/12(27)
PA
P. Kulkarni et al. / Cardiovascular Revascularization Medicine 13 (2012) 246–248
247
Fig. 1. Echocardiography showing severe rheumatic MS.
4 mmHg, across the mitral valve. Echocardiography showed a welldivided bilateral commissure with an MVA of 1.8 cm 2 and no mitral regurgitation (Table 1; Figs. 1–4). 2. Discussion Mirror-image dextrocardia, has been estimated to occur with a prevalence of 1:10,000 patients. In geographical areas with a high prevalence of rheumatic heart disease such as the Indian subcontinent, the coincidence of rheumatic MS and dextrocardia is a chance occurrence. However, there are only a few case reports in the literature on BMV in such patients [1–6]. This might be due to
Fig. 2. Angiographic pseudo-AP view showing pigtail in aortic root.
the fact that many of these patients undergo surgical commissurotomy due to the technical difficulties involved in a percutaneous procedure [7–10]. However, we decided to proceed with this technically demanding procedure in view of the substantial experience we had with BMV in the past.
3. Summary BMV is safe and feasible in the rare patient with situs inversus and dextrocardia with additional modifications of the Inoue technique to delineate the IAS.
Fig. 3. Angiography showing septal descent.
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P. Kulkarni et al. / Cardiovascular Revascularization Medicine 13 (2012) 246–248
References
Fig. 4. Angiographic pseudo-RAO view showing successful inflation of Inoue balloon across the mitral valve.
[1] Raju R, Singh S, Kumar P, et al. Percutaneous balloon valvuloplasty in mirror-image dextrocardia and rheumatic mitral stenosis. Cathet Cardiovasc Diagn 1993;30: 138–40. [2] Patel TM, Dani SI, Thakore SB, et al. Balloon mitral and aortic valvuloplasty in mirror-image dextrocardia. J Invasive Cardiol 1996;8:164–8. [3] Chow WH, Fan K, Chow TC. Balloon mitral commissurotomy in a patient with situs inversus and dextrocardia. J Heart Valve Dis 1996;5:307–8. [4] Nallet O, Lung B, Cormier B, et al. Specifics of technique in percutaneous mitral commissurotomy in a case of dextrocardia and situs inversus with mitral stenosis. Cathet Cardiovasc Diagn 1996;39:85–8. [5] Joseph G, George OK, Mandalay A, Sathe S. Transjugular approach to balloon mitral valvuloplasty helps overcome impediments caused by anatomical alterations. Catheter Cardiovasc Interv 2002;57:353–62. [6] Verma PK, Bali HK, Suresh PV, Varma JS. Balloon mitral valvotomy using Inoue technique in a patient of isolated dextrocardia with rheumatic mitral stenosis. Indian Heart J 1999;51:315–7. [7] Said SA, Veerbeek A, van der Wieken LR. Dextrocardia, situs inversus and severe mitral stenosis in a pregnant woman: successful closed commissurotomy. Eur Heart J 1991;12:825–8. [8] Ramasamy D, Zambahari R, Fu M, et al. Percutaneous transvenous mitral commissurotomy in patients with severe kyphoscoliosis. Cathet Cardiovasc Diagn 1993;30:40–4. [9] Shalganov TN, Paprika D, Borbas S, et al. Preventing complicated transseptal puncture with intracardiac echocardiography: case report. Cardiovasc Ultrasound 2005;1:3–5. [10] Inoue K. Percutaneous transvenous mitral commissurotomy using the Inoue balloon. Eur Heart J 1991;12(Suppl. B):99–108.
Contents lists available at SciVerse ScienceDirect
Cardiovascular Revascularization Medicine
Percutaneous mitral balloon valvotomy in a case of situs inversus dextrocardia with severe rheumatic mitral stenosis Prashanth Kulkarni ⁎, Prabhu Halkati, Suresh Patted, Sameer Ambar, Suresh Yavagal Department of Cardiology, J.N. Medical College, KLE University, Belgaum, Karnataka, India
a r t i c l e
i n f o
Article history: Received 24 January 2012 Accepted 16 March 2012 Keywords: Situs inversus dextrocardia Rheumatic mitral stenosis Balloon mitral valvotomy
a b s t r a c t 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. © 2012 Elsevier Inc. All rights reserved.
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
⁎ Corresponding author. E-mail address: [email protected] (P. Kulkarni). 1553-8389/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.carrev.2012.03.003
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
Table 1 Pre and Post BMV parameters. Parameters
PRE- BMV
POST- BMV
LA Pressure
45/35(30)
LV Pressure Mean Gradient Across the Mitral Valve MVO / 2D Echo MR Aorta
100/5 30 mmHg 0.8–0.9 cm2 No MR __ 101/57(78) __ 74/27(47)
__ 13/6(8) 110/8 4 mmHg 1.7–1.8 cm2 No MR __ 110/67(80) __ 45/12(27)
PA
P. Kulkarni et al. / Cardiovascular Revascularization Medicine 13 (2012) 246–248
247
Fig. 1. Echocardiography showing severe rheumatic MS.
4 mmHg, across the mitral valve. Echocardiography showed a welldivided bilateral commissure with an MVA of 1.8 cm 2 and no mitral regurgitation (Table 1; Figs. 1–4). 2. Discussion Mirror-image dextrocardia, has been estimated to occur with a prevalence of 1:10,000 patients. In geographical areas with a high prevalence of rheumatic heart disease such as the Indian subcontinent, the coincidence of rheumatic MS and dextrocardia is a chance occurrence. However, there are only a few case reports in the literature on BMV in such patients [1–6]. This might be due to
Fig. 2. Angiographic pseudo-AP view showing pigtail in aortic root.
the fact that many of these patients undergo surgical commissurotomy due to the technical difficulties involved in a percutaneous procedure [7–10]. However, we decided to proceed with this technically demanding procedure in view of the substantial experience we had with BMV in the past.
3. Summary BMV is safe and feasible in the rare patient with situs inversus and dextrocardia with additional modifications of the Inoue technique to delineate the IAS.
Fig. 3. Angiography showing septal descent.
248
P. Kulkarni et al. / Cardiovascular Revascularization Medicine 13 (2012) 246–248
References
Fig. 4. Angiographic pseudo-RAO view showing successful inflation of Inoue balloon across the mitral valve.
[1] Raju R, Singh S, Kumar P, et al. Percutaneous balloon valvuloplasty in mirror-image dextrocardia and rheumatic mitral stenosis. Cathet Cardiovasc Diagn 1993;30: 138–40. [2] Patel TM, Dani SI, Thakore SB, et al. Balloon mitral and aortic valvuloplasty in mirror-image dextrocardia. J Invasive Cardiol 1996;8:164–8. [3] Chow WH, Fan K, Chow TC. Balloon mitral commissurotomy in a patient with situs inversus and dextrocardia. J Heart Valve Dis 1996;5:307–8. [4] Nallet O, Lung B, Cormier B, et al. Specifics of technique in percutaneous mitral commissurotomy in a case of dextrocardia and situs inversus with mitral stenosis. Cathet Cardiovasc Diagn 1996;39:85–8. [5] Joseph G, George OK, Mandalay A, Sathe S. Transjugular approach to balloon mitral valvuloplasty helps overcome impediments caused by anatomical alterations. Catheter Cardiovasc Interv 2002;57:353–62. [6] Verma PK, Bali HK, Suresh PV, Varma JS. Balloon mitral valvotomy using Inoue technique in a patient of isolated dextrocardia with rheumatic mitral stenosis. Indian Heart J 1999;51:315–7. [7] Said SA, Veerbeek A, van der Wieken LR. Dextrocardia, situs inversus and severe mitral stenosis in a pregnant woman: successful closed commissurotomy. Eur Heart J 1991;12:825–8. [8] Ramasamy D, Zambahari R, Fu M, et al. Percutaneous transvenous mitral commissurotomy in patients with severe kyphoscoliosis. Cathet Cardiovasc Diagn 1993;30:40–4. [9] Shalganov TN, Paprika D, Borbas S, et al. Preventing complicated transseptal puncture with intracardiac echocardiography: case report. Cardiovasc Ultrasound 2005;1:3–5. [10] Inoue K. Percutaneous transvenous mitral commissurotomy using the Inoue balloon. Eur Heart J 1991;12(Suppl. B):99–108.