European Heart Journal (1991) 12 {Supplement B), 99-108
Percutaneous transvenous mitral commissurotomy using the Inoue balloon K.
INOUE
Department of Cardiovascular Surgery, Takeda Hospital, Kyoto, Japan
KEY WORDS: Right atrial angiography, stepwise dilatation.
Introduction Percutaneous transvenous mitral commissurotomy (PTMC) is now widely used and its effectiveness and safety have been demonstrated'1"131. However, because the history of PTMC is still short, new findings to improve the procedure, select cases and counter measures against complications have increasingly been reported as its clinical application has increased. The purpose of this paper is to present recent findings regarding this procedure, to ensure the safe, easy and effective application of PTMC. ATRIAL SEPTAL PUNCTURE
Designation of optimum site for septal puncture on X-ray fluoroscopy (Fig. 1). Right atrial angiography is very useful to determine the appropriate point of septal puncture on the fluoroscopic image (Fig. 1). Right atrial angiography is performed in the antero-posterior projection under normal respiration until the aorta can be visualized. On the right atrial image, the position of the upper end of the tricuspid valve at systole is held in relation to the vertebral body; this is Point A. On a left atrial phase, a horizontal line is drawn from Point A, and the intersection of this line with the right edge of the left atrium is Point B. A line vertical to the line AB is drawn at the mid point between A and B, and its intersection with the lower edge of the left atrium is "Correspondence: Kanji Inoue, MD, 98-13 Miyazaki-Cho, Simogamo, Sakyo-Ku, Kyoto, 606, Japan.
0195-668X/91/OB0099 + 10 $03.00/0
Point C. The site for puncture is designated on this vertical line at a point about one vertebral body length above Point C. This position is held in relation to the vertebral body. This means of designating the puncture site is also applicable to cases of giant left atrium (Fig. 1). In such cases, the puncture site is closer to the lower part of the cardiac shadow. Procedure for PTMC and site of puncture. If the puncture site is markedly deviated in the upper direction from the point designated on the right atrial angiogram, the thick muscular wall of the upper edge of the fossa ovalis will be punctured (Fig. 2). If this occurs, strong resistance is faced during the passage of the balloon catheter through the muscular wall, and subsequent manipulation of the catheter will be limited. Because the tip of the balloon catheter tends to be directed towards the posterior wall of the left atrium, its insertion into the mitral orifice on the ventral side is difficult. If the puncture site is greatly deviated to the left from the designated point (Fig. 3), the catheter is curved in steps at the punctured region, resulting in marked restriction of catheter movement and difficult insertion of the catheter into the orifice. TOOLS AND DEVICES FOR PTMC (FIG. 4)
The following tools and devices are needed for PTMC. Inoue balloon catheter (Fig. 4, 1); metallic stiffening cannula (18-guage, 80 cm long, Fig. 4, 2) for stretching and stiffening the Inoue balloon catheter; guide wire for PTMC (0025 inch in diameter, 180cm © 1991 The European Society of Cardiology
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
The Inoue balloon catheter is unique in function as well as shape, and can be especially adapted for each patient to ensure a high success rate and low morbidity during percutaneous transvenous mitral commissurotomy (PTMC). Before transseptal puncture, right atrial angiography is performed to image the proper point of puncture to avoid not only accidental perforation but also the difficulty of balloon insertion into the mitral orifice. There are two main techniques for inserting the balloon into the mitral orifice. One is a direct method, and the other is loop formation in the left atrium. Balloon selection is basically standardized by patient height; 30mm for a height of > 180cm, 28 for >160, 26 for >147, 24 for 180 >160
M S
ss
>147 =5147
(2) Other influential conditions: sex; age; working conditions; severity of valve pathology; surgical height risk. (3) Stepwise dilatation technique: Diameter at initial dilatation 4 ram less than maximum diameter; diameter at subsequent dilatations increased by 1 or 2 mm. (4) Decision making for further dilatation: Resultant mitral regurgitation; increased mitral valve area; degree of commissure separation; disappearance of balloon waist.
Rigid and/or severely calcified values Size of valve orifice Severe stenosis (0-7 cm2 > ) Mild stenosis (1-5 cm2 < ) Thrombus in the left atrium Fresh thrombus Thrombus at the atrial septum History of thromboembolism Combined mitral regurgitation Mild (Sellers Classification 1/4) Moderate (Sellers Classification 2/4) Severe (Sellers Classification 3/4) End-stage of mitral stenosis Combined other valvular diseases Combined other organ diseases
B A
B B C
C A A B C A A A
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
Figure 7 In cases of mild stenosis. Top: the balloon has slipped into the left atrium during inflation; bottom: countermeasure for slippage of balloon.
PTMC using the Inoue balloon
107
(B)
compared with those with pliable valves, post-PTMC improvement in symptoms is more marked with severe stenosis. In the past, these cases were treated with valve replacement, but the artificial valves developed so far have problems as regards durability and thrombosis in long-term use. Bearing this in mind, cases for PTMC should not be selected on the basis of valvular pathology. However, this may change in the future. The safety of PTMC is supported by developments in cardiovascular surgery. Although PTMC is significant as the only available life-saving procedure for patients not indicated for surgical operation, it involves some risk if there is no support from heart surgeons. In applying PTMC to inoperable cases, procedures should be performed carefully, with the emphasis on safety.
References [1] Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissuro-
tomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984; 87: 394-402. [2] Inoue K, et al. Transvenous mitral commissurotomy by a new balloon catheter. Eur Heart J 1984; 5 (Suppl I): 111 (abst). [3] Inoue K, et al. Transvenous Mitral Commissurotomy: Long-term Follow-up and Recent Modification. Circulation 1986; 74 (Suppl II): 208. [4] Inoue K, et al. Advantage of Inoue-Balloon (selfpositioning balloon) in percutaneous transvenous mitral commissurotomy and aortic valvuloplasty. Eur Heart J 1988; 9 (Suppl I): 606, (abst). [5] Chen C. Single rubber-nylon balloon (Inoue balloon) percutaneous mitral valvuloplasty: long term results. Circulation 1989; 80: 73 (abst). [6] Hung JS et al. Rapid fall in elevated plasma atrial natriuretic peptide levels after successful catheter balloon valvuloplasty of mitral stenosis. Am Heart J 1989; 117 381-5. [7] Nakatani S, Nagata S, et al. Diastolic suction in human ventricle: a study during balloon inflation of percutaneous transvenous mitral commissurotoray. Circulation 1989; 80: 74. [8] Yoshida K, Yoshikawa J, Ajasaja T et al. Assessment of left-to-right atrial shunting after percutaneous mitral valvuloplasty by transoesophageal color Doppler flowmapping. Circulation 1989; 80: 1521-26.
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
Figure 8 Confirmation of proper balloon position in the left ventricle under X-ray fluoroscopy in the right anterior ablique projection. Top: the balloon is entangled among the chordae; bottom: the balloon is placed properly in the left ventricle.
108
K. Inoue
[9] Inoue K, et al. Advantages of Inoue-Balloon (selfpositioning balloon) in Percutaneous Transvenous Mitral Commissurotomy (PTMC) and Aortic Valvuloplasty (PTAV). JACC 1989; 13: 18A (abst). [10] Inoue K, Chen C. Percutaneous Transvenous mitral commissurotomy guided and assessed by echocardiography. In: Cikes I, ed. Echocardiography in cardiac interventions. Dordrecht: Kluwer Academic Publishers, 1989: 67-76. [11] Nobuyoshi M, et al. Indications, complications, and short-term clinical outcome of percutaneous transvenous mitral Commissurotomy. Circulation, 1989; 80: 782-92.
[12] Chen C, Huang Z, Lo Z, Cheng TO. Comparison of single rubber-nylon balloon and double polyethylene balloon valvuloplasty in 94 patients with rheumatic mitral stenosis. Am Heart J 1990; 119: 102-10. [13] Inoue K J S. Hung: percutaneous transvenous mitral commissurotomy (PTMC): the Far East experience. In: Topol E, ed. Textbook of Interventional Cardiology. Philadelphia: W. B. Saunders, 1990: 887-99. [14] Hosokawa H, Suzuki T, et al. Insertion of Inoue balloon catheter in percutaneous transvenous mitral commissurotomy. Shin Kekkan 1990; 5: 118-23 (Jpn).
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
The Bjflrk-Shiley Monostrut™ Cardiac Valve Prosthesis has a unique, one-piece design with a freefloating disc, which eliminates the need for hinges. In addition, the disc moves away from the orifice ring in the open between the disc and ring. This allows Wood to flow through freely. As a result, after eight years with more than 75,000 BjOrk-Shiley Monostmt Valves implanted, studies worldwide bring to light a low rate of thrombosis.133 For example, in one recent computerized multicenter study consisting of
Doesn't Rest On A Hinge
2,726 patients, there were no cases of valve thrombosis found over a two-year period.1 For a copy of this study or others demonstrating the BjOrk-Shiley Monostrut Valves low rate of thrombosis, please contact your local Monostrut Valve distributor. .«id. Five * O T Eifcrtcox rti UK B)0rt-S*r UooosrM VD»e to 2720 PKfca* A SfWfeti ItaUcma Stndr. Sato?torHrsn Abe DiKOc Id Prtbtm LoodOQ. 09QP 208. 2. nofti. a n AX. not SB»
pofcr I* tte taanakaa prorided » U m% Otrto. a ta[fteU*edSula.CfilertacnpomolSOL Al rt«Ki ramcri.
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
position, creating a clearance area
Percutaneous transvenous mitral commissurotomy using the Inoue balloon K.
INOUE
Department of Cardiovascular Surgery, Takeda Hospital, Kyoto, Japan
KEY WORDS: Right atrial angiography, stepwise dilatation.
Introduction Percutaneous transvenous mitral commissurotomy (PTMC) is now widely used and its effectiveness and safety have been demonstrated'1"131. However, because the history of PTMC is still short, new findings to improve the procedure, select cases and counter measures against complications have increasingly been reported as its clinical application has increased. The purpose of this paper is to present recent findings regarding this procedure, to ensure the safe, easy and effective application of PTMC. ATRIAL SEPTAL PUNCTURE
Designation of optimum site for septal puncture on X-ray fluoroscopy (Fig. 1). Right atrial angiography is very useful to determine the appropriate point of septal puncture on the fluoroscopic image (Fig. 1). Right atrial angiography is performed in the antero-posterior projection under normal respiration until the aorta can be visualized. On the right atrial image, the position of the upper end of the tricuspid valve at systole is held in relation to the vertebral body; this is Point A. On a left atrial phase, a horizontal line is drawn from Point A, and the intersection of this line with the right edge of the left atrium is Point B. A line vertical to the line AB is drawn at the mid point between A and B, and its intersection with the lower edge of the left atrium is "Correspondence: Kanji Inoue, MD, 98-13 Miyazaki-Cho, Simogamo, Sakyo-Ku, Kyoto, 606, Japan.
0195-668X/91/OB0099 + 10 $03.00/0
Point C. The site for puncture is designated on this vertical line at a point about one vertebral body length above Point C. This position is held in relation to the vertebral body. This means of designating the puncture site is also applicable to cases of giant left atrium (Fig. 1). In such cases, the puncture site is closer to the lower part of the cardiac shadow. Procedure for PTMC and site of puncture. If the puncture site is markedly deviated in the upper direction from the point designated on the right atrial angiogram, the thick muscular wall of the upper edge of the fossa ovalis will be punctured (Fig. 2). If this occurs, strong resistance is faced during the passage of the balloon catheter through the muscular wall, and subsequent manipulation of the catheter will be limited. Because the tip of the balloon catheter tends to be directed towards the posterior wall of the left atrium, its insertion into the mitral orifice on the ventral side is difficult. If the puncture site is greatly deviated to the left from the designated point (Fig. 3), the catheter is curved in steps at the punctured region, resulting in marked restriction of catheter movement and difficult insertion of the catheter into the orifice. TOOLS AND DEVICES FOR PTMC (FIG. 4)
The following tools and devices are needed for PTMC. Inoue balloon catheter (Fig. 4, 1); metallic stiffening cannula (18-guage, 80 cm long, Fig. 4, 2) for stretching and stiffening the Inoue balloon catheter; guide wire for PTMC (0025 inch in diameter, 180cm © 1991 The European Society of Cardiology
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
The Inoue balloon catheter is unique in function as well as shape, and can be especially adapted for each patient to ensure a high success rate and low morbidity during percutaneous transvenous mitral commissurotomy (PTMC). Before transseptal puncture, right atrial angiography is performed to image the proper point of puncture to avoid not only accidental perforation but also the difficulty of balloon insertion into the mitral orifice. There are two main techniques for inserting the balloon into the mitral orifice. One is a direct method, and the other is loop formation in the left atrium. Balloon selection is basically standardized by patient height; 30mm for a height of > 180cm, 28 for >160, 26 for >147, 24 for 180 >160
M S
ss
>147 =5147
(2) Other influential conditions: sex; age; working conditions; severity of valve pathology; surgical height risk. (3) Stepwise dilatation technique: Diameter at initial dilatation 4 ram less than maximum diameter; diameter at subsequent dilatations increased by 1 or 2 mm. (4) Decision making for further dilatation: Resultant mitral regurgitation; increased mitral valve area; degree of commissure separation; disappearance of balloon waist.
Rigid and/or severely calcified values Size of valve orifice Severe stenosis (0-7 cm2 > ) Mild stenosis (1-5 cm2 < ) Thrombus in the left atrium Fresh thrombus Thrombus at the atrial septum History of thromboembolism Combined mitral regurgitation Mild (Sellers Classification 1/4) Moderate (Sellers Classification 2/4) Severe (Sellers Classification 3/4) End-stage of mitral stenosis Combined other valvular diseases Combined other organ diseases
B A
B B C
C A A B C A A A
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
Figure 7 In cases of mild stenosis. Top: the balloon has slipped into the left atrium during inflation; bottom: countermeasure for slippage of balloon.
PTMC using the Inoue balloon
107
(B)
compared with those with pliable valves, post-PTMC improvement in symptoms is more marked with severe stenosis. In the past, these cases were treated with valve replacement, but the artificial valves developed so far have problems as regards durability and thrombosis in long-term use. Bearing this in mind, cases for PTMC should not be selected on the basis of valvular pathology. However, this may change in the future. The safety of PTMC is supported by developments in cardiovascular surgery. Although PTMC is significant as the only available life-saving procedure for patients not indicated for surgical operation, it involves some risk if there is no support from heart surgeons. In applying PTMC to inoperable cases, procedures should be performed carefully, with the emphasis on safety.
References [1] Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissuro-
tomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984; 87: 394-402. [2] Inoue K, et al. Transvenous mitral commissurotomy by a new balloon catheter. Eur Heart J 1984; 5 (Suppl I): 111 (abst). [3] Inoue K, et al. Transvenous Mitral Commissurotomy: Long-term Follow-up and Recent Modification. Circulation 1986; 74 (Suppl II): 208. [4] Inoue K, et al. Advantage of Inoue-Balloon (selfpositioning balloon) in percutaneous transvenous mitral commissurotomy and aortic valvuloplasty. Eur Heart J 1988; 9 (Suppl I): 606, (abst). [5] Chen C. Single rubber-nylon balloon (Inoue balloon) percutaneous mitral valvuloplasty: long term results. Circulation 1989; 80: 73 (abst). [6] Hung JS et al. Rapid fall in elevated plasma atrial natriuretic peptide levels after successful catheter balloon valvuloplasty of mitral stenosis. Am Heart J 1989; 117 381-5. [7] Nakatani S, Nagata S, et al. Diastolic suction in human ventricle: a study during balloon inflation of percutaneous transvenous mitral commissurotoray. Circulation 1989; 80: 74. [8] Yoshida K, Yoshikawa J, Ajasaja T et al. Assessment of left-to-right atrial shunting after percutaneous mitral valvuloplasty by transoesophageal color Doppler flowmapping. Circulation 1989; 80: 1521-26.
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
Figure 8 Confirmation of proper balloon position in the left ventricle under X-ray fluoroscopy in the right anterior ablique projection. Top: the balloon is entangled among the chordae; bottom: the balloon is placed properly in the left ventricle.
108
K. Inoue
[9] Inoue K, et al. Advantages of Inoue-Balloon (selfpositioning balloon) in Percutaneous Transvenous Mitral Commissurotomy (PTMC) and Aortic Valvuloplasty (PTAV). JACC 1989; 13: 18A (abst). [10] Inoue K, Chen C. Percutaneous Transvenous mitral commissurotomy guided and assessed by echocardiography. In: Cikes I, ed. Echocardiography in cardiac interventions. Dordrecht: Kluwer Academic Publishers, 1989: 67-76. [11] Nobuyoshi M, et al. Indications, complications, and short-term clinical outcome of percutaneous transvenous mitral Commissurotomy. Circulation, 1989; 80: 782-92.
[12] Chen C, Huang Z, Lo Z, Cheng TO. Comparison of single rubber-nylon balloon and double polyethylene balloon valvuloplasty in 94 patients with rheumatic mitral stenosis. Am Heart J 1990; 119: 102-10. [13] Inoue K J S. Hung: percutaneous transvenous mitral commissurotomy (PTMC): the Far East experience. In: Topol E, ed. Textbook of Interventional Cardiology. Philadelphia: W. B. Saunders, 1990: 887-99. [14] Hosokawa H, Suzuki T, et al. Insertion of Inoue balloon catheter in percutaneous transvenous mitral commissurotomy. Shin Kekkan 1990; 5: 118-23 (Jpn).
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
The Bjflrk-Shiley Monostrut™ Cardiac Valve Prosthesis has a unique, one-piece design with a freefloating disc, which eliminates the need for hinges. In addition, the disc moves away from the orifice ring in the open between the disc and ring. This allows Wood to flow through freely. As a result, after eight years with more than 75,000 BjOrk-Shiley Monostmt Valves implanted, studies worldwide bring to light a low rate of thrombosis.133 For example, in one recent computerized multicenter study consisting of
Doesn't Rest On A Hinge
2,726 patients, there were no cases of valve thrombosis found over a two-year period.1 For a copy of this study or others demonstrating the BjOrk-Shiley Monostrut Valves low rate of thrombosis, please contact your local Monostrut Valve distributor. .«id. Five * O T Eifcrtcox rti UK B)0rt-S*r UooosrM VD»e to 2720 PKfca* A SfWfeti ItaUcma Stndr. Sato?torHrsn Abe DiKOc Id Prtbtm LoodOQ. 09QP 208. 2. nofti. a n AX. not SB»
pofcr I* tte taanakaa prorided » U m% Otrto. a ta[fteU*edSula.CfilertacnpomolSOL Al rt«Ki ramcri.
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 9, 2016
position, creating a clearance area
