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Transesophageal Echocardiography During Percutaneous Balloon Mitral Valvuloplasty
Transesophageal Echocardiography During Percutaneous Balloon Mitral Valvuloplasty Wybren Jaarsma, MD, Cees A. Visser, MD, Maarten J. Suttorp, MD, Frans D. H. Haagen, MD, and Sjef M. P. G. Ernst, MD, Nieuwegein and Utrecht) The Netherlands
To ascertain the value of transesophageal echocardiography during percutaneous balloon mitral valvuloplasty, the present study was undertaken in 26 anesthesized patients (21 women and 5 men; mean age, 47 years) with symptomatic rheumatic mitral valve stenosis. In all but one patient the balloon dilation of the mitral valve was successful and Doppler-derived valve area increased (0.9 ± 0.3 to 1.9 ± 0.4 cm2 ). Transesophageal echocardiography provides continuous monitoring, as well as guidance of the procedure. Crossing the arterial septum, as well as delivery of the sheath through the mitral valve orifice and correct positioning of the balloon, was highly facilitated and reduced x-ray exposure time. The degree of mitral regurgitation and the presence of interatrial shunting at the end of the procedure could be readily assessed, making cineangiography not necessary. Complications of the procedure, such as pericardial effusion, could be detected before hemodynamic deterioration had occurred (one patient). The advantages of trans esophageal echocardiography for routine monitoring of percutaneous mitral valvuloplasty, however, should be weighted against the added risk and expense of this support. (J AM Soc ECHO 1990;3:384-91.)
Balloon dilation of a stenotic valve by way of the transcutaneous approach was firstly performed by Kan et aU as early as 1982 in patients with a congenitally stenotic pulmonary valve. Recently, it has been demonstrated that this approach was also applicable for mitral valve stenosis attributable to rheumatic heart disease2-6 and that the outcome of this procedure was largely dependent on mitral valve morphology, such as leafiet thickness and mobility, subvalvular thickening, and extent of calcifications. 7 Because two-dimensional echocardiography is capable of assessing morphologic abnormalities at both valvular and subvalvular mitral valve level, the immediate results could be predicted. 8 Accordingly, two-dimensional echocardiography can also be applied for patient selection. Furthermore, Doppler echocardiography can be readily performed after valFrom the Department of Cardiology of the Sint Antonius Hospital, Nieuwegein, and the Interuniversity Cardiology Institute of the Netherlands, Utrecht. Presented in part at the Sixty-first Scientific Sessions of the American Heart Association, Washington, D.C., November 1988. Reprint requests: Wybren Jaarsma, MD, Sint Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands. 27/1/19876
384
vuloplasty and has shown that mitral valve area may increase to values as obtained after surgical commissurotomy.9 Echocardiography during mitral valvuloplasty has been used recently by Pandian et al. 10 for delivery of the valvular dilation catheter across the atrial septum and through the valve. orifice by use of the subcostal approach. Because transesophageal echocardiography provides high quality images of the interatrial septum, left atrial appendage, and mitral valve morphologyll and because it does not interfere with the valvuloplasty procedure, the present study was undertaken to ascertain the additional value of this imaging modality during valvuloplasty. PATIENTS AND METHODS
The study group conisted of 33 patients with a mean age of 48 years (range, 23 to 81 years). There were 27 women and 6 men. All had severe, symptomatic rheumatic mitral stenoses as determined by both hemodynamics and Doppler echocardiography. All patients gave informed consent to participate in this study, which had the approval of the local medical ethics commirtee (Sint Antonius Hospital, Nieu-
Volume 3 Number 5 September-October 1990
TEE during balloon mitral valvuloplasty
385
PROBE
Figure 1 Inflated two-foil balloon in the mitral valve orifice. Note the position of the echocardiographic probe in relation to the balloon and the indention (arrow) of the stenotic mitral valve (see also Figure 3).
wegein, The Netherlands). Electrocardiograms showed sinus rhythm in 23 patients and atrial fibrillation in 10 patients. Right and left heart catheterization, including selective coronary angiography and left ventriculography, was performed in all patients before the mitral valvuloplasty procedure. Echocardiography Transthoracic echocardiography was initially performed for patient selection; patients who had heavily calcified, immobile leaflets with subvalvular involvement were excluded (five patients). In addition, another two patients had to be excluded because transesophageal echocardiography showed the presence of a thrombus in the left atrium or left atrial appendage, which was an exclusion criterion. The study group was composed of four patients with mild and one patient with moderate calcifications of the mitral valve apparatus. Approximately 24 hours before and after mitral valvuloplasty the mitral valve orifice was calculated by continuous-wave Doppler as previously described. 12 During the mitral valvuloplasty procedure, a commercially available transesophageal transducer (Hewlett-Packard Company, Andover, Massachusetts) was introduced after in-
duction of general anesthesia. This device provided both two-dimensional and color-coded Doppler flow imaging capabilities. Presence and degree of mitral regurgitation was semiquantatively assessed before and after valvuloplasty.13 In addition, "maximal leaflet separation," (i.e., the maximal distance during diastole between the two tips of the mitral valve leaflets as assessed in the. trans esophageal echocardiographic four-chamber view). was calculated. During the procedure, continuous two-dimensional echocardiographic monitoring was used to facilitate positioning of the sheath and balloon. After termination of the procedure, the jet length of interatrial shunting was approximated, pending the extent into the right atrium. Mitral Valvuloplasty A Swan-Ganz catheter (Baxter Healthcare Corp., Santa Ana, California) was positioned in the pulmonary artery by way of the left femoral vein. A pigtail angiographic catheter was positioned in the aorta from the left femoral artery. Transseptal left heart catheterization was performed from the right common femoral vein with a No. 8F Mullens transseptal sheath and dilator (Bard, Inc., Billerica, Massachusetts) and a modified Brockenbrough needle (BectonDickinson, Rutherford, New Jersey). Systemic an-
386
Jaarsma et al.
Journal of the American Society of Echocardiography
Figure 2 "Biatrial" views with the right atrium (RA), left atrium (LA), and mteratnal septum, demonstrating a dome-shaped configuration caused by the transseptal device (A). Once the needle (arrow) had crossed the septum, this configuration disappeared (B).
ticoagulation was obtained by use of 10,000 U heparin. Mter the transseptal procedure, a long 16F Schneider sheath (Schneider Europe AG, Zurich, Switzerland) containing a septal dilator was positioned in the mitral orifice over a 0.38 "back-up" wire. Through this sheath a two-foil Schneider bal-
loon catheter was introduced into the mitral orifice during continuous fluoroscopic and echocardiographic monitoring. Then balloon inflations of 3 atm. during approximately 30 seconds were repeated until the indention of the balloon caused by the stenotic mitral valve was no longer present (Figure 1).
Volume 3 Number 5 September-October 1990
TEE during balloon mitral valvuloplasty
387
Figure 3 Transesophageal echocardiogram demonstrating the inflated balloon as "negative contrast" positioned within the mitral valve orifice. Note the "figure eight" configuration of the balloon caused by indention of the stenotic valve and the distance between the anulus and the proximal end of the balloon. The left atrium (LA) is filled with "spontaneous contrast" caused by stagnant blood. RA, Right atrium; AO, aorta; R V, right ventricle. RESULTS
In all but one patient, visualization of the interatrial septum, in particular of the oval fossa, was possible. The tip of the trans septal device could readily be localized, as well as the triangular configuration of the septum, if some pressure was applied on the needle (Figure 2). Once the needle had successfully crossed the interatrial septum, this typical triangular configuration disappeared. Transesophageal echocardiography was important for positioning of the septostomy device in only two patients. In these two patients, resistance was encountered because of a suboptimal position beyond the oval fossa in the muscular part of the interatrial septum. Positioning Through Mitral Valve Orifice
After it crossed the interatrial septum, the sheath was positioned through the mitral valve orifice after a combination of fluoroscopic and echocardiographic imaging was used. Then the two-foil balloon catheter was introduced and positioned with the proximal end approximately 2 cm above the mitral valve anulus (Figure 3). When the distance between the anulus and the proximal part of the balloon was more than
approximately 2 cm, the balloon, once fully inflated, usually slipped backwards into the left atrium. In one patient, however, it was not possible to cross the mitral valve orifice with the sheath and the procedure had to be discontinued. Mitral Valve Orifice and Maximal Leaflet Separation
Mitral valve orifice measurements obtained within 24 hours before valvuloplasty measured 0.9 ± 0.3 cm2 and within 24 hours after valvuloplasty 1.9 ± 0.4 cm2 (p < 0.01). During the valvuloplasty procedure, maximal leaflet separation was measured just before and at the end of the dilation procedure. Before valvuloplasty this variable was 0.6 ± 0.3 cm; after valvuloplasty it was 1.2 ± 0.6 cm (p < 0.01; Figure 4). However, the correlation between these two variables-mitral valve orifice and maximal leaflet separation-was poor both before and after valvuloplasty, with r values of 0.3 and 0.1, respectively. Mitral Regurgitation and Interatrial Shunting
During the procedure, presence and degree of mitral regurgitation was semiquantatively estimated before
388
Jaarsma et al.
Journal of the American Society of Echocardiography
Figure 4 Four-chamber transesophageal echocardiograms obtained during the mitral valvuloplasty procedure. The maximal leaflet separation (MLS) before dilation was 0.8 cm (A); after dilation it was 2.0 cm (B). The mitral valve orifice (MVD), as obtained by Doppler echocardiography the day before valvuloplasty, measured 0.7 cm 2 (A); 1 day after the procedure it measured 2.1 cm2 (B). LA, Left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.
and after valvuloplasty. Before valvuloplasty, there was no regurgitation present in 18 patients; the remaining 7 patients had a mild grade 114 regurgitation. Mter the procedure, no mitral regurgitation was present in 7 patients, 10 patients had a mild grade 1/4 regurgitation, 6 patients a moderate grade 2/4
regurgitation, and the other 2 a severe grade 3/4 regurgitation. In aU but two patients a jet, originating from the oval fossa, was present. The maximal jet length within the right atrium measured 1.66 ± 0.9 cm (Figure 5).
Volume 3 Number 5 September-October 1990
TEE during balloon mitral valvuloplasty 389
Figure 5 T ransesophageal two-dimensional and color flow image at the level of the interatrial septum, obtained at the end of the dilation procedure_ Because of the atrial septal perforation (ASP) of the oval fossa (A), a moderate jet (B) is present. LA, Left atrium; L V , left ventricle; RA, right atrium.
DISCUSSION
In both clinical and outpatient settings, the use of transesophageal echocardiography has become more and more popular. l l However, the use of this imaging technique, especially in the setting of inter-
vention such as valvuloplasty and coronary angioplasty, is as yet unknown. Transesophageal echocardiography performed during valvuloplasty permits the unique possibility of continuous monitoring, as well as guidance of the procedure. A disadvantage, however, is that transesophageal echocardiography
390 Jaarsma et al.
Journal of the American Society o f Echocardiography
Figure 6 During balloon inflation (A) a significant regurgitant jet (MR) within the left atrium is demonstrated with color flow imaging (B). LA, Left atrium; BALL, balloon; RV, right ventricle; LV, left ventricle.
in this particular setting, can only be applied in patients who have received anesthesia. Both the atrial septum and the stenotic mitral valve orifice constitute potential sites of resistance to advancement of the valvular dilation catheter. Echocardiographic monitoring was necessary to guide the catheter across the oval fossa in only two patients. In one patient the balloon catheter could not cross the severely stenotic mitral valve orifice, although echocardiographic im-
aging revealed that the sheath was correctly positioned. The short distance and sharp bend from the fossa ovalis to the mitral valve orifice may also provide difficulties when only fluoroscopy is used; Guidance at this stage by transesophageal echocardiography facilitates delivery of the sheath through the initial mitral valve orifice, and hence may reduce the x-ray exposure time. It is important that the degree of mitral regurgi-
Volume 3 Number 5 September-October 1990
tation and the interatrial shunting can be readily assessed at the end of the procedure, which makes cineangiography of the left ventricle and left atrium unnecessary. As could be expected with use of a bifoil balloon, a significant regurgitant jet could be detected during each inflation of the balloon, which means that no complete obstruction of the orifice during inflation of the balloon was achieved (Figure 6). Finally, in one patient the left ventricle was perforated by the dilation device; in this patient pericardial effusion leading to right atrial collapse could be readily seen before hemodynamic deterioration had occurred. Because a continuous-wave modality was not present in the transesophageal transducer used in this study, evaluation of mitral valvuloplasty during the procedure had to be performed by two-dimensional imaging and color Doppler flow. The maximal leaflet separation, however, appeared to be highly specific but insensitive for assessment of the mitral orifice increase. The widening of the flow jet through the mitral valve orifice and the change of color spectrum as a result of a lesser degree of disturbed flow was not systematically used in this study. Even in the absence of a control group, we think that the application of transesophageal echocardiography greatly reduced x-ray exposure. The advantages of this echocardiographic support should be weighed against the added risk and expense. Although the intervention cardiologists at our institution highly appreciate transesophageal echocardiography in this respect, we cannot fully recommend this imaging technique for routine monitoring of percutaneous mitral valvuloplasty.
REFERENCES
1. Kan JE, White RI Jr, Mitchell SE, Gardner TJ. Percutaneous balloon valvuloplasty; a new method for treating congenital pulmonary valve stenosis. N Engl J Med 1982;307:540-2.
TEE during balloon mitral valvuloplasty
391
2. Lock JE, Khalilullah M, Shrivasta S, Bahl V, Keane JF. Percutaneous catheter commissurotomy in rheumatic mitral stenosis. N Engl J Med 1985;313:1515-8. 3. McKay RG, Lock JE, Keane JF, Safian RD, Aroesty JM, Grossman W. Percutaneous mitral valvotomy in an adult patient with calcific rheumatic mitral stenosis. J Am ColI Cardiol 1986;7: 1410-5. 4. Al-Zaibag M, Ribeiro PA, Al-Kasab S, Al-Fagih MR. Percutaneous double balloon mitral valvotomy for rheumatic mitral valve stenosis. Lancet 1986;1:757-61. 5. Babic UU, Pejcic P, Djurisic Z, Vucinic M, Grujicic S. Percutaneous transarterial balloon valvuloplasty for mitral valve stenosis. Am J Cardiol 1986;57:IIOI-4. 6. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984;87:399-402. 7. Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios 1. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J 1988;60L299-308. 8. Reid CL, McKay C, Chandraratna AN, Kawamishi DT, Rahimtoola SH. Prediction of immediate results of double balloon catheter balloon valvuloplasty by echocardiographic analysis of mitral valve morphology. Circulation 1987; 74(supplll):11-209. 9. Hegar JJ, Wann LS, Weyman AE, Dillon JC, Feigenbaum H. Long-term changes in mitral valve area after successful mitral commissurotomy. Circulation 1979;59:443-8. 10. Pandian NG, Isuer JM, Hougen TJ, Desnoyers MR, McInerney K, Salem DV. Percutaneous balloon valvuloplasty of mitral stenosis aided by cardiac ultrasound. Am J Cardiol 1987;59:380-2. II. Visser CA, Koolen JJ, van Wezel HB, Dunning AJ. Transesophageal echocardiography: technique and clinical applications. J Cardiothorac Anesth 1988;2:74-91. 12. Hattie L, Angelsen B, Tromsdal A. Non-invasive assessment of atrioventricular pressure half-time by Doppler ultrasound. Circulation 1979;60:1096-105. 13. Czer LSC, Maurer G, Bolger AF, et al. Intraoperative evaluation of mitral regurgitation· by Doppler color flow mapping. Circulation 1987;76(suppl III): 108-16.
To ascertain the value of transesophageal echocardiography during percutaneous balloon mitral valvuloplasty, the present study was undertaken in 26 anesthesized patients (21 women and 5 men; mean age, 47 years) with symptomatic rheumatic mitral valve stenosis. In all but one patient the balloon dilation of the mitral valve was successful and Doppler-derived valve area increased (0.9 ± 0.3 to 1.9 ± 0.4 cm2 ). Transesophageal echocardiography provides continuous monitoring, as well as guidance of the procedure. Crossing the arterial septum, as well as delivery of the sheath through the mitral valve orifice and correct positioning of the balloon, was highly facilitated and reduced x-ray exposure time. The degree of mitral regurgitation and the presence of interatrial shunting at the end of the procedure could be readily assessed, making cineangiography not necessary. Complications of the procedure, such as pericardial effusion, could be detected before hemodynamic deterioration had occurred (one patient). The advantages of trans esophageal echocardiography for routine monitoring of percutaneous mitral valvuloplasty, however, should be weighted against the added risk and expense of this support. (J AM Soc ECHO 1990;3:384-91.)
Balloon dilation of a stenotic valve by way of the transcutaneous approach was firstly performed by Kan et aU as early as 1982 in patients with a congenitally stenotic pulmonary valve. Recently, it has been demonstrated that this approach was also applicable for mitral valve stenosis attributable to rheumatic heart disease2-6 and that the outcome of this procedure was largely dependent on mitral valve morphology, such as leafiet thickness and mobility, subvalvular thickening, and extent of calcifications. 7 Because two-dimensional echocardiography is capable of assessing morphologic abnormalities at both valvular and subvalvular mitral valve level, the immediate results could be predicted. 8 Accordingly, two-dimensional echocardiography can also be applied for patient selection. Furthermore, Doppler echocardiography can be readily performed after valFrom the Department of Cardiology of the Sint Antonius Hospital, Nieuwegein, and the Interuniversity Cardiology Institute of the Netherlands, Utrecht. Presented in part at the Sixty-first Scientific Sessions of the American Heart Association, Washington, D.C., November 1988. Reprint requests: Wybren Jaarsma, MD, Sint Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands. 27/1/19876
384
vuloplasty and has shown that mitral valve area may increase to values as obtained after surgical commissurotomy.9 Echocardiography during mitral valvuloplasty has been used recently by Pandian et al. 10 for delivery of the valvular dilation catheter across the atrial septum and through the valve. orifice by use of the subcostal approach. Because transesophageal echocardiography provides high quality images of the interatrial septum, left atrial appendage, and mitral valve morphologyll and because it does not interfere with the valvuloplasty procedure, the present study was undertaken to ascertain the additional value of this imaging modality during valvuloplasty. PATIENTS AND METHODS
The study group conisted of 33 patients with a mean age of 48 years (range, 23 to 81 years). There were 27 women and 6 men. All had severe, symptomatic rheumatic mitral stenoses as determined by both hemodynamics and Doppler echocardiography. All patients gave informed consent to participate in this study, which had the approval of the local medical ethics commirtee (Sint Antonius Hospital, Nieu-
Volume 3 Number 5 September-October 1990
TEE during balloon mitral valvuloplasty
385
PROBE
Figure 1 Inflated two-foil balloon in the mitral valve orifice. Note the position of the echocardiographic probe in relation to the balloon and the indention (arrow) of the stenotic mitral valve (see also Figure 3).
wegein, The Netherlands). Electrocardiograms showed sinus rhythm in 23 patients and atrial fibrillation in 10 patients. Right and left heart catheterization, including selective coronary angiography and left ventriculography, was performed in all patients before the mitral valvuloplasty procedure. Echocardiography Transthoracic echocardiography was initially performed for patient selection; patients who had heavily calcified, immobile leaflets with subvalvular involvement were excluded (five patients). In addition, another two patients had to be excluded because transesophageal echocardiography showed the presence of a thrombus in the left atrium or left atrial appendage, which was an exclusion criterion. The study group was composed of four patients with mild and one patient with moderate calcifications of the mitral valve apparatus. Approximately 24 hours before and after mitral valvuloplasty the mitral valve orifice was calculated by continuous-wave Doppler as previously described. 12 During the mitral valvuloplasty procedure, a commercially available transesophageal transducer (Hewlett-Packard Company, Andover, Massachusetts) was introduced after in-
duction of general anesthesia. This device provided both two-dimensional and color-coded Doppler flow imaging capabilities. Presence and degree of mitral regurgitation was semiquantatively assessed before and after valvuloplasty.13 In addition, "maximal leaflet separation," (i.e., the maximal distance during diastole between the two tips of the mitral valve leaflets as assessed in the. trans esophageal echocardiographic four-chamber view). was calculated. During the procedure, continuous two-dimensional echocardiographic monitoring was used to facilitate positioning of the sheath and balloon. After termination of the procedure, the jet length of interatrial shunting was approximated, pending the extent into the right atrium. Mitral Valvuloplasty A Swan-Ganz catheter (Baxter Healthcare Corp., Santa Ana, California) was positioned in the pulmonary artery by way of the left femoral vein. A pigtail angiographic catheter was positioned in the aorta from the left femoral artery. Transseptal left heart catheterization was performed from the right common femoral vein with a No. 8F Mullens transseptal sheath and dilator (Bard, Inc., Billerica, Massachusetts) and a modified Brockenbrough needle (BectonDickinson, Rutherford, New Jersey). Systemic an-
386
Jaarsma et al.
Journal of the American Society of Echocardiography
Figure 2 "Biatrial" views with the right atrium (RA), left atrium (LA), and mteratnal septum, demonstrating a dome-shaped configuration caused by the transseptal device (A). Once the needle (arrow) had crossed the septum, this configuration disappeared (B).
ticoagulation was obtained by use of 10,000 U heparin. Mter the transseptal procedure, a long 16F Schneider sheath (Schneider Europe AG, Zurich, Switzerland) containing a septal dilator was positioned in the mitral orifice over a 0.38 "back-up" wire. Through this sheath a two-foil Schneider bal-
loon catheter was introduced into the mitral orifice during continuous fluoroscopic and echocardiographic monitoring. Then balloon inflations of 3 atm. during approximately 30 seconds were repeated until the indention of the balloon caused by the stenotic mitral valve was no longer present (Figure 1).
Volume 3 Number 5 September-October 1990
TEE during balloon mitral valvuloplasty
387
Figure 3 Transesophageal echocardiogram demonstrating the inflated balloon as "negative contrast" positioned within the mitral valve orifice. Note the "figure eight" configuration of the balloon caused by indention of the stenotic valve and the distance between the anulus and the proximal end of the balloon. The left atrium (LA) is filled with "spontaneous contrast" caused by stagnant blood. RA, Right atrium; AO, aorta; R V, right ventricle. RESULTS
In all but one patient, visualization of the interatrial septum, in particular of the oval fossa, was possible. The tip of the trans septal device could readily be localized, as well as the triangular configuration of the septum, if some pressure was applied on the needle (Figure 2). Once the needle had successfully crossed the interatrial septum, this typical triangular configuration disappeared. Transesophageal echocardiography was important for positioning of the septostomy device in only two patients. In these two patients, resistance was encountered because of a suboptimal position beyond the oval fossa in the muscular part of the interatrial septum. Positioning Through Mitral Valve Orifice
After it crossed the interatrial septum, the sheath was positioned through the mitral valve orifice after a combination of fluoroscopic and echocardiographic imaging was used. Then the two-foil balloon catheter was introduced and positioned with the proximal end approximately 2 cm above the mitral valve anulus (Figure 3). When the distance between the anulus and the proximal part of the balloon was more than
approximately 2 cm, the balloon, once fully inflated, usually slipped backwards into the left atrium. In one patient, however, it was not possible to cross the mitral valve orifice with the sheath and the procedure had to be discontinued. Mitral Valve Orifice and Maximal Leaflet Separation
Mitral valve orifice measurements obtained within 24 hours before valvuloplasty measured 0.9 ± 0.3 cm2 and within 24 hours after valvuloplasty 1.9 ± 0.4 cm2 (p < 0.01). During the valvuloplasty procedure, maximal leaflet separation was measured just before and at the end of the dilation procedure. Before valvuloplasty this variable was 0.6 ± 0.3 cm; after valvuloplasty it was 1.2 ± 0.6 cm (p < 0.01; Figure 4). However, the correlation between these two variables-mitral valve orifice and maximal leaflet separation-was poor both before and after valvuloplasty, with r values of 0.3 and 0.1, respectively. Mitral Regurgitation and Interatrial Shunting
During the procedure, presence and degree of mitral regurgitation was semiquantatively estimated before
388
Jaarsma et al.
Journal of the American Society of Echocardiography
Figure 4 Four-chamber transesophageal echocardiograms obtained during the mitral valvuloplasty procedure. The maximal leaflet separation (MLS) before dilation was 0.8 cm (A); after dilation it was 2.0 cm (B). The mitral valve orifice (MVD), as obtained by Doppler echocardiography the day before valvuloplasty, measured 0.7 cm 2 (A); 1 day after the procedure it measured 2.1 cm2 (B). LA, Left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.
and after valvuloplasty. Before valvuloplasty, there was no regurgitation present in 18 patients; the remaining 7 patients had a mild grade 114 regurgitation. Mter the procedure, no mitral regurgitation was present in 7 patients, 10 patients had a mild grade 1/4 regurgitation, 6 patients a moderate grade 2/4
regurgitation, and the other 2 a severe grade 3/4 regurgitation. In aU but two patients a jet, originating from the oval fossa, was present. The maximal jet length within the right atrium measured 1.66 ± 0.9 cm (Figure 5).
Volume 3 Number 5 September-October 1990
TEE during balloon mitral valvuloplasty 389
Figure 5 T ransesophageal two-dimensional and color flow image at the level of the interatrial septum, obtained at the end of the dilation procedure_ Because of the atrial septal perforation (ASP) of the oval fossa (A), a moderate jet (B) is present. LA, Left atrium; L V , left ventricle; RA, right atrium.
DISCUSSION
In both clinical and outpatient settings, the use of transesophageal echocardiography has become more and more popular. l l However, the use of this imaging technique, especially in the setting of inter-
vention such as valvuloplasty and coronary angioplasty, is as yet unknown. Transesophageal echocardiography performed during valvuloplasty permits the unique possibility of continuous monitoring, as well as guidance of the procedure. A disadvantage, however, is that transesophageal echocardiography
390 Jaarsma et al.
Journal of the American Society o f Echocardiography
Figure 6 During balloon inflation (A) a significant regurgitant jet (MR) within the left atrium is demonstrated with color flow imaging (B). LA, Left atrium; BALL, balloon; RV, right ventricle; LV, left ventricle.
in this particular setting, can only be applied in patients who have received anesthesia. Both the atrial septum and the stenotic mitral valve orifice constitute potential sites of resistance to advancement of the valvular dilation catheter. Echocardiographic monitoring was necessary to guide the catheter across the oval fossa in only two patients. In one patient the balloon catheter could not cross the severely stenotic mitral valve orifice, although echocardiographic im-
aging revealed that the sheath was correctly positioned. The short distance and sharp bend from the fossa ovalis to the mitral valve orifice may also provide difficulties when only fluoroscopy is used; Guidance at this stage by transesophageal echocardiography facilitates delivery of the sheath through the initial mitral valve orifice, and hence may reduce the x-ray exposure time. It is important that the degree of mitral regurgi-
Volume 3 Number 5 September-October 1990
tation and the interatrial shunting can be readily assessed at the end of the procedure, which makes cineangiography of the left ventricle and left atrium unnecessary. As could be expected with use of a bifoil balloon, a significant regurgitant jet could be detected during each inflation of the balloon, which means that no complete obstruction of the orifice during inflation of the balloon was achieved (Figure 6). Finally, in one patient the left ventricle was perforated by the dilation device; in this patient pericardial effusion leading to right atrial collapse could be readily seen before hemodynamic deterioration had occurred. Because a continuous-wave modality was not present in the transesophageal transducer used in this study, evaluation of mitral valvuloplasty during the procedure had to be performed by two-dimensional imaging and color Doppler flow. The maximal leaflet separation, however, appeared to be highly specific but insensitive for assessment of the mitral orifice increase. The widening of the flow jet through the mitral valve orifice and the change of color spectrum as a result of a lesser degree of disturbed flow was not systematically used in this study. Even in the absence of a control group, we think that the application of transesophageal echocardiography greatly reduced x-ray exposure. The advantages of this echocardiographic support should be weighed against the added risk and expense. Although the intervention cardiologists at our institution highly appreciate transesophageal echocardiography in this respect, we cannot fully recommend this imaging technique for routine monitoring of percutaneous mitral valvuloplasty.
REFERENCES
1. Kan JE, White RI Jr, Mitchell SE, Gardner TJ. Percutaneous balloon valvuloplasty; a new method for treating congenital pulmonary valve stenosis. N Engl J Med 1982;307:540-2.
TEE during balloon mitral valvuloplasty
391
2. Lock JE, Khalilullah M, Shrivasta S, Bahl V, Keane JF. Percutaneous catheter commissurotomy in rheumatic mitral stenosis. N Engl J Med 1985;313:1515-8. 3. McKay RG, Lock JE, Keane JF, Safian RD, Aroesty JM, Grossman W. Percutaneous mitral valvotomy in an adult patient with calcific rheumatic mitral stenosis. J Am ColI Cardiol 1986;7: 1410-5. 4. Al-Zaibag M, Ribeiro PA, Al-Kasab S, Al-Fagih MR. Percutaneous double balloon mitral valvotomy for rheumatic mitral valve stenosis. Lancet 1986;1:757-61. 5. Babic UU, Pejcic P, Djurisic Z, Vucinic M, Grujicic S. Percutaneous transarterial balloon valvuloplasty for mitral valve stenosis. Am J Cardiol 1986;57:IIOI-4. 6. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984;87:399-402. 7. Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios 1. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J 1988;60L299-308. 8. Reid CL, McKay C, Chandraratna AN, Kawamishi DT, Rahimtoola SH. Prediction of immediate results of double balloon catheter balloon valvuloplasty by echocardiographic analysis of mitral valve morphology. Circulation 1987; 74(supplll):11-209. 9. Hegar JJ, Wann LS, Weyman AE, Dillon JC, Feigenbaum H. Long-term changes in mitral valve area after successful mitral commissurotomy. Circulation 1979;59:443-8. 10. Pandian NG, Isuer JM, Hougen TJ, Desnoyers MR, McInerney K, Salem DV. Percutaneous balloon valvuloplasty of mitral stenosis aided by cardiac ultrasound. Am J Cardiol 1987;59:380-2. II. Visser CA, Koolen JJ, van Wezel HB, Dunning AJ. Transesophageal echocardiography: technique and clinical applications. J Cardiothorac Anesth 1988;2:74-91. 12. Hattie L, Angelsen B, Tromsdal A. Non-invasive assessment of atrioventricular pressure half-time by Doppler ultrasound. Circulation 1979;60:1096-105. 13. Czer LSC, Maurer G, Bolger AF, et al. Intraoperative evaluation of mitral regurgitation· by Doppler color flow mapping. Circulation 1987;76(suppl III): 108-16.