Acute Cardiac Care, September 2014; 16(3): 110–111 Copyright © 2014 Informa UK, Ltd ISSN 1748-2941 print/ISSN 1748-295X online
LETTER TO THE EDITOR
Successful retrieval of broken coiled guidewire from left atrium during balloon mitral valvotomy: A rare complication DOI: 10.3109/17482941.2014.921311 Surender Deora, Dheeraj More, Sanjay Shah & Tejas Patel Department of Cardiovascular Sciences, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College, Gujarat University, Ahmedabad, Gujarat, India
in LA through the Mullin's dilator and septum was dilated with 14F septal dilator (Figure 1C). Then, septal dilator was exchanged for10F Amplatzer long delivery sheath used for atrial septal defect (ASD) closure. The snare unit (10 mm gooseneck snare (Microneva Corporation, MN, USA)) was introduced in LA through Amplatzer delivery sheath and the broken guidewire was captured at its proximal end and pulled into the sheath without any trauma to atrial septum and any other vascular structure (Figure 1D–F; Videos 2, 3). The BMV was completed successfully by using Accura balloon (Vascular Concepts, Halstead, Essex, UK) achieving the final mitral valve orifice area of 2.1cm2. The patient remained hemodynamically stable during the procedure and was symptomatically better at one-month follow-up. Percutaneous retrieval of broken hardware or foreign body from LA is although challenging but preferred to surgical removal. Various catheter based techniques using Mullin's sheath, indigenously made snare, loop snares, forceps catheter, helical basket catheter, etc. have been described in the past (1–3). Hardware related complications during BMV are very rare and exact incidence is not known. It may cause local groin complications, damage to various cardiovascular structures ranging from femoral vein, inferior vena cava, right atrium, interatrial septum to left atrial or ventricular perforation and systemic embolization. Fracture of 0.025 inch LA guidewire is very rare and to the best of our knowledge reported only twice in literature (4,5). The 0.025 inch LA guidewire is 180 cm long and is made of stainless steel with coiled floppy tip soldered to stiff straighter wire. This junction between the floppy tip and stiffer portion is prone for fracture during the procedure. The various factors which may cause this complication are utilization of reused hardware, improper placement of LA wire with soldered portion of the wire at the septum, abnormal angulation between guidewire and dilator with forceful septal dilation and rarely manufacturing defect. Shankarappa et al. reported fracture
Balloon mitral valvotomy (BMV) is the procedure of choice for rheumatic mitral stenosis with favorable valve morphology. Fracture of 0.025 inch coiled guidewire during BMV is a very rare complication. The various factors which may cause this complication are utilization of reused hardware, improper placement of guidewire, abnormal angulation between guidewire and dilator with forceful septal dilation and rarely manufacturing defect. Here, we report successful retrieval of broken 0.025 inch coiled guidewire from left atrium during BMV using 10F Amplatzer long sheath without any complication. Keywords: Guidewire retrieval, BMV, Amplatzer sheath
A 48-year-old male was admitted to our department with complaints of gradually progressive dyspnea on exertion of two-year duration. 12-lead electrocardiogram showed sinus rhythm. Transthoracic echocardiography (TTE) and color Doppler revealed thickened mitral valve with restricted posterior leaflet mobility, moderate mitral stenosis (mitral valve orifice area by planimetry was 1.1 cm2) and no significant mitral regurgitation. The estimated pulmonary artery systolic pressure by tricuspid regurgitation (TR) jet gradient was 64 mm Hg. The calculated Wilkins score was 5. After informed consent, elective BMV was planned. Right and left heart catheterization was done through right femoral vessels and baseline pressure data was obtained. Transseptal puncture was performed and Mullin's dilator was advanced in LA (Figure 1A). Systemic anticoagulation was achieved with 100 units per kilogram of body weight of heparin. A long stainless steel 0.025-inch coiled floppy tip guidewire (Toray Industries, Japan) was passed through Mullin's dilator in the LA and during its positioning, the guidewire became kinked. At this moment, while pulling it back into the Mullin's dilator, the wire broke (Figure 1B, Video 1). To retrieve it safely, another 0.025 inch coiled guidewire was introduced
Correspondence: Surender Deora, Department of Cardiovascular Sciences, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College, Gujarat University, Ahmedabad, India–380006. Fax: ⫹ 91 79 26842288. E-mail: [email protected] (Received 14 March 2014; accepted 29 April 2014)
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Guidewire retrieval during BMV
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Figure 1. Transseptal puncture using Brokenbrough needle and Mullin's dilator (A). Broken 0.025 inch coiled tip guidewire in left atrium (B). Septal dilation with 14F septal dilator after introduction of another 0.025 inch coiled tip guidewire through 8F Mullin's dilator (C). Introduction of gooseneck snare in left atrium through 10F Amplatzer long delivery sheath to capture broken guidewire (D) and pulling it into sheath (E). Severed proximal end of broken guidewire after successful retrieval (arrow, F).
of 0.025 inch coiled guidewire during septal dilatation which was successfully retrieved with indigenous snare made of 300 cm floppy tip percutaneous transluminal coronary angioplasty (PTCA) 0.014 inch wire as retrieval with 10 mm gooseneck snare was failed (5). In their report, 6F Multipurpose guidecatheter and the snare unit with captured 0.025 inch broken guidewire could not be pulled back in Mullins sheath, therefore, the whole unit was pulled en bloc and removed from the femoral vein. Although in their case, there was no damage to the interatrial septum or femoral vein but there is always finite risk of interatrial septal tear and damage to inferior vena cava or femoral vein. In another case by Patil et al. the proximal portion of the broken 0.025 inch LA wire was in Mullins sheath so that by using 0.014 inch floppy wire and PTCA balloon it was retrieved successfully (6). But in their case also, the whole assembly, including Mullin's sheath, was removed and to complete the BMV, repeat femoral vein and interatrial septal puncture was required. In our case, we have used 10F Amplatzer long delivery sheath used for atrial septal defect (ASD) closure. It has three advantages over the Mullins sheath. First, the Mullins sheath is 8F whereas we have used 10F long sheath so that it is relatively easy to retrieve whole unit inside the sheath without any damage to interatrial septum and other cardiovascular structures. Second, ASD delivery sheath is relatively stiffer compared to Mullins sheath which makes it easy to retrieve the broken guidewire and snare unit into the sheath without
much difficulty. Third, by our technique access to LA is retained which allows to complete the procedure without the need to regain the access to femoral vein and LA.
Funding None. Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Massin M, Lombet J, Rigo J. Percutaneous retrieval of broken silastic catheter from the left atrium in a critically Ill premature infant. Cathet Cardiovasc Diagn. 1997;42:409–11. 2. Casserly IP, Goldstein JA, Rogers JH, Lasala JM. Paradoxical embolization of a fractured guidewire: Successful retrieval from left atrium using a snare device. Catheter Cardiovasc Interv. 2002;57:34–8. 3. Ramondo AB, Favero L, Chioin R. Percutaneous retrieval of a broken catheter from the left atrium in an adult. J Interv Cardiol. 2002;15:417–9. 4. Shankarappa RK, Panneerselvam A, Dwarakaprasad R, Nayak MH, Nanjappa MC. Removal of broken balloon mitral valvotomy coiled guidewire from giant left atrium using indigenous snare. Cardiovasc Interv Ther. 2011;26:60–3. 5. Patil S, Agarwal A, Ramalingam R, Kumar T, Agarwal N, Manjunath CN. Successful percutaneous removal of broken mitral valvuloplasty coiled tip guidewire. Cardiovasc Interv Ther. 2013;28:398–402.
Supplementary material available online Online Video 1. Attempt to retrieve kinked 0.025 inch coiled tip guidewire into Mullin's dilator lead to its fracture. Online Video 2. Capture of broken 0.025 inch coiled tip guidewire at its proximal end using 10 mm gooseneck snare. Online Video 3. Retrieval of 0.025 inch coiled tip guidewire through 10F Amplatzer long sheath. Online Video 4. Introduction of Accura balloon into left ventricle and its inflation across stenosed mitral valve during BMV. Available at http://informahealthcare.com/doi/abs/10.3109/17482941.2014.921311. © 2014 Informa UK, Ltd.
Copyright of Acute Cardiac Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
LETTER TO THE EDITOR
Successful retrieval of broken coiled guidewire from left atrium during balloon mitral valvotomy: A rare complication DOI: 10.3109/17482941.2014.921311 Surender Deora, Dheeraj More, Sanjay Shah & Tejas Patel Department of Cardiovascular Sciences, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College, Gujarat University, Ahmedabad, Gujarat, India
in LA through the Mullin's dilator and septum was dilated with 14F septal dilator (Figure 1C). Then, septal dilator was exchanged for10F Amplatzer long delivery sheath used for atrial septal defect (ASD) closure. The snare unit (10 mm gooseneck snare (Microneva Corporation, MN, USA)) was introduced in LA through Amplatzer delivery sheath and the broken guidewire was captured at its proximal end and pulled into the sheath without any trauma to atrial septum and any other vascular structure (Figure 1D–F; Videos 2, 3). The BMV was completed successfully by using Accura balloon (Vascular Concepts, Halstead, Essex, UK) achieving the final mitral valve orifice area of 2.1cm2. The patient remained hemodynamically stable during the procedure and was symptomatically better at one-month follow-up. Percutaneous retrieval of broken hardware or foreign body from LA is although challenging but preferred to surgical removal. Various catheter based techniques using Mullin's sheath, indigenously made snare, loop snares, forceps catheter, helical basket catheter, etc. have been described in the past (1–3). Hardware related complications during BMV are very rare and exact incidence is not known. It may cause local groin complications, damage to various cardiovascular structures ranging from femoral vein, inferior vena cava, right atrium, interatrial septum to left atrial or ventricular perforation and systemic embolization. Fracture of 0.025 inch LA guidewire is very rare and to the best of our knowledge reported only twice in literature (4,5). The 0.025 inch LA guidewire is 180 cm long and is made of stainless steel with coiled floppy tip soldered to stiff straighter wire. This junction between the floppy tip and stiffer portion is prone for fracture during the procedure. The various factors which may cause this complication are utilization of reused hardware, improper placement of LA wire with soldered portion of the wire at the septum, abnormal angulation between guidewire and dilator with forceful septal dilation and rarely manufacturing defect. Shankarappa et al. reported fracture
Balloon mitral valvotomy (BMV) is the procedure of choice for rheumatic mitral stenosis with favorable valve morphology. Fracture of 0.025 inch coiled guidewire during BMV is a very rare complication. The various factors which may cause this complication are utilization of reused hardware, improper placement of guidewire, abnormal angulation between guidewire and dilator with forceful septal dilation and rarely manufacturing defect. Here, we report successful retrieval of broken 0.025 inch coiled guidewire from left atrium during BMV using 10F Amplatzer long sheath without any complication. Keywords: Guidewire retrieval, BMV, Amplatzer sheath
A 48-year-old male was admitted to our department with complaints of gradually progressive dyspnea on exertion of two-year duration. 12-lead electrocardiogram showed sinus rhythm. Transthoracic echocardiography (TTE) and color Doppler revealed thickened mitral valve with restricted posterior leaflet mobility, moderate mitral stenosis (mitral valve orifice area by planimetry was 1.1 cm2) and no significant mitral regurgitation. The estimated pulmonary artery systolic pressure by tricuspid regurgitation (TR) jet gradient was 64 mm Hg. The calculated Wilkins score was 5. After informed consent, elective BMV was planned. Right and left heart catheterization was done through right femoral vessels and baseline pressure data was obtained. Transseptal puncture was performed and Mullin's dilator was advanced in LA (Figure 1A). Systemic anticoagulation was achieved with 100 units per kilogram of body weight of heparin. A long stainless steel 0.025-inch coiled floppy tip guidewire (Toray Industries, Japan) was passed through Mullin's dilator in the LA and during its positioning, the guidewire became kinked. At this moment, while pulling it back into the Mullin's dilator, the wire broke (Figure 1B, Video 1). To retrieve it safely, another 0.025 inch coiled guidewire was introduced
Correspondence: Surender Deora, Department of Cardiovascular Sciences, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College, Gujarat University, Ahmedabad, India–380006. Fax: ⫹ 91 79 26842288. E-mail: [email protected] (Received 14 March 2014; accepted 29 April 2014)
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Guidewire retrieval during BMV
111
Figure 1. Transseptal puncture using Brokenbrough needle and Mullin's dilator (A). Broken 0.025 inch coiled tip guidewire in left atrium (B). Septal dilation with 14F septal dilator after introduction of another 0.025 inch coiled tip guidewire through 8F Mullin's dilator (C). Introduction of gooseneck snare in left atrium through 10F Amplatzer long delivery sheath to capture broken guidewire (D) and pulling it into sheath (E). Severed proximal end of broken guidewire after successful retrieval (arrow, F).
of 0.025 inch coiled guidewire during septal dilatation which was successfully retrieved with indigenous snare made of 300 cm floppy tip percutaneous transluminal coronary angioplasty (PTCA) 0.014 inch wire as retrieval with 10 mm gooseneck snare was failed (5). In their report, 6F Multipurpose guidecatheter and the snare unit with captured 0.025 inch broken guidewire could not be pulled back in Mullins sheath, therefore, the whole unit was pulled en bloc and removed from the femoral vein. Although in their case, there was no damage to the interatrial septum or femoral vein but there is always finite risk of interatrial septal tear and damage to inferior vena cava or femoral vein. In another case by Patil et al. the proximal portion of the broken 0.025 inch LA wire was in Mullins sheath so that by using 0.014 inch floppy wire and PTCA balloon it was retrieved successfully (6). But in their case also, the whole assembly, including Mullin's sheath, was removed and to complete the BMV, repeat femoral vein and interatrial septal puncture was required. In our case, we have used 10F Amplatzer long delivery sheath used for atrial septal defect (ASD) closure. It has three advantages over the Mullins sheath. First, the Mullins sheath is 8F whereas we have used 10F long sheath so that it is relatively easy to retrieve whole unit inside the sheath without any damage to interatrial septum and other cardiovascular structures. Second, ASD delivery sheath is relatively stiffer compared to Mullins sheath which makes it easy to retrieve the broken guidewire and snare unit into the sheath without
much difficulty. Third, by our technique access to LA is retained which allows to complete the procedure without the need to regain the access to femoral vein and LA.
Funding None. Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Massin M, Lombet J, Rigo J. Percutaneous retrieval of broken silastic catheter from the left atrium in a critically Ill premature infant. Cathet Cardiovasc Diagn. 1997;42:409–11. 2. Casserly IP, Goldstein JA, Rogers JH, Lasala JM. Paradoxical embolization of a fractured guidewire: Successful retrieval from left atrium using a snare device. Catheter Cardiovasc Interv. 2002;57:34–8. 3. Ramondo AB, Favero L, Chioin R. Percutaneous retrieval of a broken catheter from the left atrium in an adult. J Interv Cardiol. 2002;15:417–9. 4. Shankarappa RK, Panneerselvam A, Dwarakaprasad R, Nayak MH, Nanjappa MC. Removal of broken balloon mitral valvotomy coiled guidewire from giant left atrium using indigenous snare. Cardiovasc Interv Ther. 2011;26:60–3. 5. Patil S, Agarwal A, Ramalingam R, Kumar T, Agarwal N, Manjunath CN. Successful percutaneous removal of broken mitral valvuloplasty coiled tip guidewire. Cardiovasc Interv Ther. 2013;28:398–402.
Supplementary material available online Online Video 1. Attempt to retrieve kinked 0.025 inch coiled tip guidewire into Mullin's dilator lead to its fracture. Online Video 2. Capture of broken 0.025 inch coiled tip guidewire at its proximal end using 10 mm gooseneck snare. Online Video 3. Retrieval of 0.025 inch coiled tip guidewire through 10F Amplatzer long sheath. Online Video 4. Introduction of Accura balloon into left ventricle and its inflation across stenosed mitral valve during BMV. Available at http://informahealthcare.com/doi/abs/10.3109/17482941.2014.921311. © 2014 Informa UK, Ltd.
Copyright of Acute Cardiac Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
