Modified technique of Joseph balloon mitral valvuloplasty
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CASE REPORT
Modified technique of Joseph balloon mitral valvuloplasty Arunkumar Panneerselvam • Ramasamy Palanimuthu
Received: 31 July 2012 / Accepted: 18 October 2012 / Published online: 27 October 2012 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2012
Abstract Joseph balloon mitral valvuloplasty is a single balloon procedure for severe symptomatic mitral stenosis. We present a case where difficulty was encountered in advancing the balloon catheter across the mitral valve by standard technique. As the left atrium was grossly dilated, every time the balloon was tracked over the 0.03500 extra support wire placed in left ventricle, the wire prolapsed into left atrium. A modified method wherein the balloon was maneuvered into left ventricle with the support of 14F long introducer sheath is presented. This step is useful to complete balloon mitral valvuloplasty successfully in subset of patients with giant left atrium. Keywords
BMV Technique Single balloon
Introduction Balloon mitral valvuloplasty (BMV) is the treatment of choice in patients with symptomatic moderate to severe mitral stenosis. The Joseph balloon is a single balloon technique utilized for BMV in selected centers with good result [1]. Technically BMV is challenging in the presence of valve morphology with high Wilkins score, bulging interatrial septum and large left atrium (LA). We describe a case where difficulty was encountered during BMV and the steps taken to complete the procedure.
A. Panneerselvam (&) R. Palanimuthu Department of Cardiology, PSG Institute of Medical Sciences and Research, Peelamedu, Coimbatore 641004, India e-mail: [email protected]
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Case report A 32-year-old female presented with NYHA class 3 dyspnea of 6 months duration. Her echocardiography revealed severe mitral stenosis with valve orifice area of 0.8 cm2. The peak and mean mitral valve gradients were 29 and 14 mmHg, respectively. The Wilkins score was 11 and there was no mitral regurgitation. The anteroposterior LA diameter was 5.8 cm. She had history of paroxysmal episodes of atrial fibrillation and was on oral anticoagulant. BMV was attempted by the Joseph BMV technique [2]. In this technique following septal puncture, the Brokenbrough needle is exchanged for Swan–Ganz catheter which is advanced into left ventricle (LV). Subsequently a 0.03500 back up Meiers wire (Boston Scientific, Natick, MA, USA) is introduced into LV and the balloon floatation catheter and Mullins sheath are exchanged for 14F introducer sheath (75 cm) (Cook medical, Bloomington, IN, USA). The Joseph balloon (Numed, Hopkinton, NY, USA) is advanced through this sheath and BMV is completed. Because the left atrium was grossly dilated and the plane of mitral valve was more horizontal (Figs. 1, 2) the Meiers wire did not provide support for advancement of balloon catheter across mitral valve and it prolapsed into left atrium (Fig. 3). Several attempts to enter LV by conventional technique turned futile. The balloon floatation catheter was again introduced into LV a
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