Catheterization and Cardiovascular Diagnosis 26:31&318 (1992)
Modified lnoue Technique for Difficult Mitral Balloon Commissurotomy Bernhard Meier, MD INTROOUCTlON
The introduction of percutaneous balloon commissurotomy of mitral valve stenosis in 1985 by Lock et al. [ 11 has created tremendous interest among interventional cardiologists, in particular those practicing in countries with a high prevalence of rheumatic heart disease. The methods used initially were technically intricate and far from perfect. They necessitated predilatation of the atrial septum with a smaller balloon [ 1-31 and were only moderately effective unless 2 large balloons were used simultaneously (41. They lacked the possibility to assess left atrial pressure between balloon inflations, hindered echocardiographic evaluation until removal of the hardware across the valve, and carried the risk of inadvertent balloon inflation across the atrial septum. In addition, the placement and stabilization of these large and rigid balloons across the stenosed mitral valve frequently required tedious exchange maneuvers with guidewires of various degrees of stiffness and special flow-directed balloon catheters. These fragile balloons could leak and had to be inflated with CO, for fear of systemic or coronary air embolism. Methods to introduce the dilating balloon retrogradely over a wire loop created transseptally from a femoral vein to a femoral artery [5] or with direct retrograde canulation of the left atrium from the left ventricle [6] met only limited interest because of their technical complexity and the large size of the arterial puncture hole. The long sheath technique, finally, permitting the introduction of the commissurotomy balloon from the venous side without predilation of the septum, providing continuous monitoring of the left atrial septum through the sheath and precluding inadvertent dilatation of the atrial septum [7] suffered from the bulkiness of the 16F sheaths necessary to accept sufficiently large balloons for adults. The introduction of the percutaneous Inoue balloon (Toray) resolved most of these problems [8]. It has become the common technique across the globe. It had been invented by the Japanese heart surgeon Kanji Inoue prior to all percutaneous techniques but it could only be inserted in the beginning Of its use [91. In its CUITent perCUtane0US form, it features a Complete Set 0 1992 Wlley-Liss, Inc.
consisting of a stiff 0.025 in. guidewire with a large pigtail tip to be introduced into the left atrium after a conventional transeptal puncture and a long 14F dilator for predilatation of the venous entry site and the atrial septum. The key component is a sophisticated balloon catheter that expands first in its distal half. A well dosed distal filling allows for flow directed crossing of the mitral valve with little risk of passing through a small loophole between the chordae tendineae. Then the distal filling can be increased to seat the now pear-shaped balloon in the mitral valve by pulling gently on the catheter. With further filling, the balloon assumes an hourglass shape, with the waist saddling the stenotic valve. Filled completely finally, the waist disappears, indicating successful commissurotomy. The diameter of the completely filled balloon can be preselected by gauging the liquid in the inflation syringe (included in the set) to the mark indicating the desired diameter. A single balloon encompasses, for example, a range selection from 24 to 30 mm, which is sufficient for the great majority of adult patients. The set is completed by a tube to stretch the balloon for introduction and removal, and by a preshaped steerable support wire (stylet) to be inserted close to the catheter tip to point it into the desired direction while searching for the mitral orifice. The Inoue technique only has 2 shortcomings. First, the balloon is limited to about 2 bar of filling pressure. This disadvantage may prevent commissurotomy in resistant valves. On the other hand, it may represent a built-in safety feature, reducing the risk of rupturing leaflets of valves with commissures to tightly fused to be split [lo]. It may, in fact, be the key to the amazingly low complication rate with this technique [ 1 1-13]. Second, the balloon has to be withdrawn into the left atrium after deflation to measure the left atrial pressure through
From the Cardiology Center, University Hospital, Geneva, Switzerland.
Received March 28, 1992; accepted March 30, 1992 Address reprint requests to Bernhard Meier, MD, Cardiology Center. University Hospital, 1211 Geneva 4. Switzerland.
Modified lnoue Commissurotomy
317
its tip. On the one hand, this provides for undisturbed echocardiographic assessment of valve opening and regurgitation to decide about the need for additional inflations. On the other hand, it implies renegotiating the mitral valve for each individual inflation. This may be time consuming or even impossible in patients with a large left atrium and with adversely placed septa1 punctures. The following case report describes a technique to overcome this problem. MODIFIED INOUE TECHNIQUE
In a 60-year-old woman with symptomatic rheumatic mitral stenosis (valve area 1.0 cm2) and a large left atrium in chronic fibrillation, it proved impossible to traverse the mitral valve with the Inoue balloon despite the maneuvers recommended for these situations [ 121, such as reshaping the support stylet, filling the tip of the balloon with CO, for enhanced flow guidance, and changing the transseptal puncture site. Over the 0.025 inch pigtail guidewire in the left atrium, the balloon was exchanged for a diagnostic coronary catheter with a number 4 right Judkins curve. In spite of careful placement of the Judkins catheter with its tip pointing into the mitral orifice, it was impossible to pass the valve with the Inoue wire because of its pigtail tip. A 0.020 in. backup wire for valvuloplasty with a steerable J tip (Schneider) [7] was substituted, easily crossed the valve (Fig. l ) , and helped the diagnostic coronary catheter into the left ventricle. The distal end of the rigid shaft of the Inoue 0.025 in. pigtail wire was preshaped with a curve congruous to the path from the inferior vena cava to the left ventricle before it was inserted into the left ventricle through this catheter. It provided a stable rail for the Inoue balloon to be placed in the left ventricle, inflated, pulled back into the left atrium for echocardiographic assessment of the result, and readvanced for additional inflations. The resulting valve area was 2.2 cm2, and there were no complications. In a similar case, the placement of the Inoue pigtail wire was tried through a flow-guided balloon catheter. However, the balloon catheter just floated about the huge left atrium like the Inoue balloon tried beforehand, but it would not find the mitral orifice until a long sheath [7] was used to deploy it immediately in front of the mitral valve. DISCUSSION The described technique can be reserved for the rare cases (about 5% in our experience) where direct placement of the Inoue balloon fails in spite of flow guidance and assistance with the preshaped support stylet. It
Fig. 1. Modified lnoue technique for percutaneous mitral balloon commissurotomy in a 61-year-old woman with a large, fibrillating left atrium impeding conventional placement of the lnoue balloon. Top: Steerable 0.020 in. backup guidewire introduced into the left ventricle through a diagnostic right Judkins coronary catheter. There is also a retrogradely introduced 4F pigtail catheter in the left ventricle for transvalvular pressure gradient assessment and ventriculography. Center: lnoue balloon positioned across the stenosed mitral valve on the lnoue 0.025 in. pigtail wire placed in the left ventricle through the Judkins catheter previously advanced into the left ventricle over the 0.020 in. backup wire. Bottom: Balloon commissurotomy with the lnoue balloon supported by the lnoue 0.025 in. pigtail wire. allowing for easy withdrawal and advancement of the balloon between inflations.
should add even more perfection to the intriguing Inoue technique that has revolutionized the second most important procedure of interventional cardiology, namely, balloon commissurotomy of mitral valve stenosis. REFERENCES I . Lock JE, Khalilullah M, Shrivasta S, Bahl V, Keane JF: Percutaneous catheter commissurotomy in rheumatic mitral stenosis. N Engl J Med 313:1515-1518, 1985.
318
Meier
2. Vahanian A, Michel PL, Cormier B, Vitoux B, Michel X, Slama AD: Results of percutaneous mitral commissurotomy in 200 patients. Am J Cardiol 63:847-852, 1989. 3. Palacios IF, Block PC,Wilkins GT, Weyman AE: Follow-up of patients undergoing percutaneous mitral balloon valvotomy. Circulation 79573-579. 1989. 4. Zaibag MA, Kassab SA, Ribeiro P, Fagih MR: Percutaneous double balloon mitral valvotomy for rheumatic mitral valve stenosis. Lancet 1:757-761. 1986. 5 . Babic UU, Pejcic P, Djurisic Z, Vucinic I, Gmjcic SM: Percutaneous transarterial balloon valvuloplasty for mitral valve stenosis. Am J Cardiol 57:1101-1104, 1986. 6. Stefanidis C. Kourouklis C, Stratos C, Pisavos C, Tentolouris C, Toutouzas P: Percutaneous balloon mitral valvuloplasty by retrograde left atrial catheterization. Am J Cardiol 65:650-654, 1990. 7. Meier B, Friedli B, von Segesser L: Valvuloplasty with trefoil and bifoil balloons and the long sheath technique. Herz 13:l-13, 1988. 8. Inoue K , Nobuyoshi M, Chen C, Hung JS: Advantages of Inoueballoon (self-positioning balloon) in percutaneous transvenous
9.
10.
11.
12.
13.
mitral commissurotomy (PTMC) and aortic valvuloplasty (PTAV) (abstract). J Am Coll Cardiol 13:16, 1989. Inoue K, Owaki T, Nakamura T: Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 87:394-402, 1984. Ramondo A, Chirillo F, Dan M, Sorbara C, Fracasso A, Mazzucco A, Rampazzo C, Isabella G, Chioin R: Mitral valve disruption following balloon valvuloplasty. Cathet Cardiovasc Diagn 22:21-24, 1991. Nobuyoshi H, Hamasaki N, Kimura T, Nosaka H, Yokoi H, Yasumoto H, Horiuchi H, Nakashima H, Shindo T. Mori T, Miyamoto AT, Inoue K: Indications, complications, and shortterm clinical outcome of percutaneous transvenous mitral commissurotomy. Circulation 80:782-792, 1989. lnoue K, Hung JS: Percutaneous transvenous mitral commissurotomy (PTMC) In Topol El (ed): “Textbook of Interventional Cardiology.” Philadelphia: WB Saunders, 1990, pp 887-899. Chen CR. Huang ZD, Lo ZX, Cheng TO: Comparison of single rubber-nylon balloon and double polyethylene balloon valvuloplasty in 94 patients with rheumatic mitral stenosis. Am Heart J 119:102-111, 1990.
Modified lnoue Technique for Difficult Mitral Balloon Commissurotomy Bernhard Meier, MD INTROOUCTlON
The introduction of percutaneous balloon commissurotomy of mitral valve stenosis in 1985 by Lock et al. [ 11 has created tremendous interest among interventional cardiologists, in particular those practicing in countries with a high prevalence of rheumatic heart disease. The methods used initially were technically intricate and far from perfect. They necessitated predilatation of the atrial septum with a smaller balloon [ 1-31 and were only moderately effective unless 2 large balloons were used simultaneously (41. They lacked the possibility to assess left atrial pressure between balloon inflations, hindered echocardiographic evaluation until removal of the hardware across the valve, and carried the risk of inadvertent balloon inflation across the atrial septum. In addition, the placement and stabilization of these large and rigid balloons across the stenosed mitral valve frequently required tedious exchange maneuvers with guidewires of various degrees of stiffness and special flow-directed balloon catheters. These fragile balloons could leak and had to be inflated with CO, for fear of systemic or coronary air embolism. Methods to introduce the dilating balloon retrogradely over a wire loop created transseptally from a femoral vein to a femoral artery [5] or with direct retrograde canulation of the left atrium from the left ventricle [6] met only limited interest because of their technical complexity and the large size of the arterial puncture hole. The long sheath technique, finally, permitting the introduction of the commissurotomy balloon from the venous side without predilation of the septum, providing continuous monitoring of the left atrial septum through the sheath and precluding inadvertent dilatation of the atrial septum [7] suffered from the bulkiness of the 16F sheaths necessary to accept sufficiently large balloons for adults. The introduction of the percutaneous Inoue balloon (Toray) resolved most of these problems [8]. It has become the common technique across the globe. It had been invented by the Japanese heart surgeon Kanji Inoue prior to all percutaneous techniques but it could only be inserted in the beginning Of its use [91. In its CUITent perCUtane0US form, it features a Complete Set 0 1992 Wlley-Liss, Inc.
consisting of a stiff 0.025 in. guidewire with a large pigtail tip to be introduced into the left atrium after a conventional transeptal puncture and a long 14F dilator for predilatation of the venous entry site and the atrial septum. The key component is a sophisticated balloon catheter that expands first in its distal half. A well dosed distal filling allows for flow directed crossing of the mitral valve with little risk of passing through a small loophole between the chordae tendineae. Then the distal filling can be increased to seat the now pear-shaped balloon in the mitral valve by pulling gently on the catheter. With further filling, the balloon assumes an hourglass shape, with the waist saddling the stenotic valve. Filled completely finally, the waist disappears, indicating successful commissurotomy. The diameter of the completely filled balloon can be preselected by gauging the liquid in the inflation syringe (included in the set) to the mark indicating the desired diameter. A single balloon encompasses, for example, a range selection from 24 to 30 mm, which is sufficient for the great majority of adult patients. The set is completed by a tube to stretch the balloon for introduction and removal, and by a preshaped steerable support wire (stylet) to be inserted close to the catheter tip to point it into the desired direction while searching for the mitral orifice. The Inoue technique only has 2 shortcomings. First, the balloon is limited to about 2 bar of filling pressure. This disadvantage may prevent commissurotomy in resistant valves. On the other hand, it may represent a built-in safety feature, reducing the risk of rupturing leaflets of valves with commissures to tightly fused to be split [lo]. It may, in fact, be the key to the amazingly low complication rate with this technique [ 1 1-13]. Second, the balloon has to be withdrawn into the left atrium after deflation to measure the left atrial pressure through
From the Cardiology Center, University Hospital, Geneva, Switzerland.
Received March 28, 1992; accepted March 30, 1992 Address reprint requests to Bernhard Meier, MD, Cardiology Center. University Hospital, 1211 Geneva 4. Switzerland.
Modified lnoue Commissurotomy
317
its tip. On the one hand, this provides for undisturbed echocardiographic assessment of valve opening and regurgitation to decide about the need for additional inflations. On the other hand, it implies renegotiating the mitral valve for each individual inflation. This may be time consuming or even impossible in patients with a large left atrium and with adversely placed septa1 punctures. The following case report describes a technique to overcome this problem. MODIFIED INOUE TECHNIQUE
In a 60-year-old woman with symptomatic rheumatic mitral stenosis (valve area 1.0 cm2) and a large left atrium in chronic fibrillation, it proved impossible to traverse the mitral valve with the Inoue balloon despite the maneuvers recommended for these situations [ 121, such as reshaping the support stylet, filling the tip of the balloon with CO, for enhanced flow guidance, and changing the transseptal puncture site. Over the 0.025 inch pigtail guidewire in the left atrium, the balloon was exchanged for a diagnostic coronary catheter with a number 4 right Judkins curve. In spite of careful placement of the Judkins catheter with its tip pointing into the mitral orifice, it was impossible to pass the valve with the Inoue wire because of its pigtail tip. A 0.020 in. backup wire for valvuloplasty with a steerable J tip (Schneider) [7] was substituted, easily crossed the valve (Fig. l ) , and helped the diagnostic coronary catheter into the left ventricle. The distal end of the rigid shaft of the Inoue 0.025 in. pigtail wire was preshaped with a curve congruous to the path from the inferior vena cava to the left ventricle before it was inserted into the left ventricle through this catheter. It provided a stable rail for the Inoue balloon to be placed in the left ventricle, inflated, pulled back into the left atrium for echocardiographic assessment of the result, and readvanced for additional inflations. The resulting valve area was 2.2 cm2, and there were no complications. In a similar case, the placement of the Inoue pigtail wire was tried through a flow-guided balloon catheter. However, the balloon catheter just floated about the huge left atrium like the Inoue balloon tried beforehand, but it would not find the mitral orifice until a long sheath [7] was used to deploy it immediately in front of the mitral valve. DISCUSSION The described technique can be reserved for the rare cases (about 5% in our experience) where direct placement of the Inoue balloon fails in spite of flow guidance and assistance with the preshaped support stylet. It
Fig. 1. Modified lnoue technique for percutaneous mitral balloon commissurotomy in a 61-year-old woman with a large, fibrillating left atrium impeding conventional placement of the lnoue balloon. Top: Steerable 0.020 in. backup guidewire introduced into the left ventricle through a diagnostic right Judkins coronary catheter. There is also a retrogradely introduced 4F pigtail catheter in the left ventricle for transvalvular pressure gradient assessment and ventriculography. Center: lnoue balloon positioned across the stenosed mitral valve on the lnoue 0.025 in. pigtail wire placed in the left ventricle through the Judkins catheter previously advanced into the left ventricle over the 0.020 in. backup wire. Bottom: Balloon commissurotomy with the lnoue balloon supported by the lnoue 0.025 in. pigtail wire. allowing for easy withdrawal and advancement of the balloon between inflations.
should add even more perfection to the intriguing Inoue technique that has revolutionized the second most important procedure of interventional cardiology, namely, balloon commissurotomy of mitral valve stenosis. REFERENCES I . Lock JE, Khalilullah M, Shrivasta S, Bahl V, Keane JF: Percutaneous catheter commissurotomy in rheumatic mitral stenosis. N Engl J Med 313:1515-1518, 1985.
318
Meier
2. Vahanian A, Michel PL, Cormier B, Vitoux B, Michel X, Slama AD: Results of percutaneous mitral commissurotomy in 200 patients. Am J Cardiol 63:847-852, 1989. 3. Palacios IF, Block PC,Wilkins GT, Weyman AE: Follow-up of patients undergoing percutaneous mitral balloon valvotomy. Circulation 79573-579. 1989. 4. Zaibag MA, Kassab SA, Ribeiro P, Fagih MR: Percutaneous double balloon mitral valvotomy for rheumatic mitral valve stenosis. Lancet 1:757-761. 1986. 5 . Babic UU, Pejcic P, Djurisic Z, Vucinic I, Gmjcic SM: Percutaneous transarterial balloon valvuloplasty for mitral valve stenosis. Am J Cardiol 57:1101-1104, 1986. 6. Stefanidis C. Kourouklis C, Stratos C, Pisavos C, Tentolouris C, Toutouzas P: Percutaneous balloon mitral valvuloplasty by retrograde left atrial catheterization. Am J Cardiol 65:650-654, 1990. 7. Meier B, Friedli B, von Segesser L: Valvuloplasty with trefoil and bifoil balloons and the long sheath technique. Herz 13:l-13, 1988. 8. Inoue K , Nobuyoshi M, Chen C, Hung JS: Advantages of Inoueballoon (self-positioning balloon) in percutaneous transvenous
9.
10.
11.
12.
13.
mitral commissurotomy (PTMC) and aortic valvuloplasty (PTAV) (abstract). J Am Coll Cardiol 13:16, 1989. Inoue K, Owaki T, Nakamura T: Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 87:394-402, 1984. Ramondo A, Chirillo F, Dan M, Sorbara C, Fracasso A, Mazzucco A, Rampazzo C, Isabella G, Chioin R: Mitral valve disruption following balloon valvuloplasty. Cathet Cardiovasc Diagn 22:21-24, 1991. Nobuyoshi H, Hamasaki N, Kimura T, Nosaka H, Yokoi H, Yasumoto H, Horiuchi H, Nakashima H, Shindo T. Mori T, Miyamoto AT, Inoue K: Indications, complications, and shortterm clinical outcome of percutaneous transvenous mitral commissurotomy. Circulation 80:782-792, 1989. lnoue K, Hung JS: Percutaneous transvenous mitral commissurotomy (PTMC) In Topol El (ed): “Textbook of Interventional Cardiology.” Philadelphia: WB Saunders, 1990, pp 887-899. Chen CR. Huang ZD, Lo ZX, Cheng TO: Comparison of single rubber-nylon balloon and double polyethylene balloon valvuloplasty in 94 patients with rheumatic mitral stenosis. Am Heart J 119:102-111, 1990.
