Figure 2: Size 20 mm Inoue balloon was found to be appropriate for this case. Less compliant waist portion effectively dilates mitral valve orifice. Figure 3: Properly inflated middle portion of Inoue balloon after full inflation is seen to securely dilate mitral valve at the level of commissures.
Each dilatation was followed by measurement of mitral valve area by planimetry on transthoracic echocardiography. Any worsening of mitral regurgitation was also observed closely. The entire procedure was uneventful. The stay in ICU was uneventful and the patient was discharged at the end of 4 days. The patient came for a follow up at the end of 3 months and 1 year. Juvenile rheumatic mitral stenosis has a fulminant course, especially in developing countries. This has been attributed to persistence of predisposing factors to acute rheumatic fever and inadequate penicillin therapy. Moreover, many patients lack access to secondary prophylaxis and most of them fail to adhere to it [ 12 ].
Echocardiographic evaluation is gold standard for differentiating between congenital and rheumatic mitral stenosis. Commissural fusion is hallmark of rheumatic process. Congenital mitral stenosis may be associated with other abnormalities.
After administration of U of heparin, right heart catheterization was performed. Egypt Heart J 71, 19 doi Article Text. This could be explained by the underestimation of MV score especially the degree of calcification and subvalvular apparatus affection by 2DE, while 3DE allowed for better visualization of MV and subvalvular apparatus from the ventricular perspective, which gave a respective quantification of leaflet motion and calcification, chordate shortening and fusion, commissural union, and papillary muscle fibrosis [ 6 ]. Living myocardial slices: a novel multicellular model for cardiac translational research. Rheumatic fever RF develops as the consequence of autoimmune reaction to group A beta-hemolytic streptococcal pharyngeal infection [ 1 ]. Therefore, percutaneous transvenous mitral commissurotomy PTMC should only be recommended in patients with high risk factors.
There may be complete or incomplete supravalvular mitral ring, annular hypoplasia, leaflet abnormalities, chordae abnormalities or single papillary muscle parachute mitral valve. PBMV produce better results in rheumatic rather than in congenital mitral stenosis [ 13 ].
Percutaneous balloon mitral valvuloplasty offers definite advantages by obviating the need for lifelong anticoagulation which is mandatory in case of prosthetic valves.
In young patients PBMV is the procedure of choice circumventing disadvantages of patient prosthesis mismatch as the child grows. Percutaneous balloon mitral valvuloplasty by different routes are possible, namely antegrade and retrograde technique. Antegrade technique using the Inoue balloon is most commonly used. The advantages of double balloon method is a smaller sheath can be used [ 14 ] Figure 4. Percutaneous balloon mitral valvuloplasty in paediatric patients needs special considerations. Firstly, the procedure has to be carried out under general anaesthesia because complete immobility is required during the procedure.
The patients are usually sick with severe pulmonary arterial hypertension and very sensitive to effects of anaesthetic agents [ 16 ].
Occult blood loss is very common during these procedures especially during vascular puncture. All the paraphernalia designed for PMBV is mostly for adult patients. Inadvertent injury to vessels may occur because of the rigidity of the Inoue balloon catheter. Packed cells should be kept in reserve and it is desirable that the procedure is carried out in a hybrid OR where cardiac surgery back up is available. Serious intraoperative complications may occur during transeptal puncture with Brockenbrough needle.
If done too anteriorly, it might cause damage to ascending aorta and when done too posteriorly, the needle might enter post-atrial space. There may be perforation of left atrial appendage, pulmonary veins and left ventricular apex with guide wires or balloon catheter leading to cardiac tamponade [ 18 , 19 ].
The balloon may get entrapped in the subvalvular apparatus and this will be evident by distortion in shape of balloon. In that case proper positioning is required before balloon inflation. Overzealous balloon inflation may cause severe mitral regurgitation [ 20 , 21 ]. Other considerations include limiting the size of sheath because of small caliber of blood vessels in paediatric patients.
Percutaneous balloon mitral valvotomy with the Inoue single-balloon catheter: commissural morphology as a determinant of outcome. J Am Coll Cardiol. However, the development of percutaneous mitral balloon valvotomy (PMBV) by Inoue in and Lock in for the treatment of selected.
Also, risk of air embolism due to air entrapped in the sheath. During follow up at the end of 3 months, the functional capacity showed to be improved drastically but there was evidence of mild mitral regurgitation. At the end of 1 year the child was in NYHA grade 1, with mild mitral regurgitation. The pulmonary arterial pressures had regressed and the patient had no evidence of pulmonary hypertension. Kapoor et al. Till date there is only one single report of successful balloon mitral valvuloplasty in such a small child in India. Adel Zaki followed 46 children and adolescents in the age group years for a period of 5 years and they found out that BMV produced excellent intermediate term results in patients with relatively low mitral valve scores [ 23 ].
Percutaneous balloon mitral valvuloplasty is now considered the procedure of choice in paediatric patients with rheumatic mitral stenosis with favourable valve morphology. This technique forms a cost effective alternative which is minimally invasive and thus suits to the need of the children in developing countries where rheumatic fever is prevalent. Author Guidelines Submit Manuscript. Visit for more related articles at Translational Biomedicine.
Keywords Rheumatic mitral stenosis; Rheumatic fever; Pulmonary venous congestion Introduction Rheumatic fever is still the commonest cause of mitral stenosis in developing countries.
Case Report A 4 year 3month old patient presented to the Department of Cardiology of our institution in February with complaints of dyspnea since past 18 months. Two balloons 15—20 mm in diameter are introduced over the wires and positioned across the mitral valve and inflated simultaneously [ 21 ].
In theory, two balloons side-by-side can exert a more focused pressure on the commissures than a single balloon. This technique is relatively safe and effective but is not widely used because of being more time-consuming than the Inoue technique and more hazardous because of the risk of wire-induced LV perforation.
The multi-track system is a newer variant of double-balloon valvuloplasty that provides effectiveness of double-balloon inflation using a single wire. The Inoue balloon catheter is a dumbbell-shaped balloon that self-positions in the mitral valve because of its unique physical properties and mode of inflation.
It has been made from two latex layers and a middle nylon layer, giving the balloon its specialized shape and inflation characteristics. The balloon inflates in three sequential stages.
The distal end of the balloon inflates at the first stage, followed by the proximal half, to facilitate positioning across the mitral valve. Finally, inflation of the waist portion of the balloon separates commissures [ 22 ]. Several balloon sizes are available 24, 26, 28, and 30 mm in diameter , and each can be inflated in a 4-mm diameter zone. A spring pigtail-like stiff wire is placed in the LA and a French dilator is used to dilate both the femoral subcutaneous track and the atrial septum.
A previously vented, de-aired, and calibrated slenderized balloon is sent to the LA over the wire and then reshaped to its original deflated configuration by removing the stretching tube and the wire and pulling back the gold tube. If there is any resistance when crossing the inguinal area, redilating the area using a larger dilator definitely helps.
To overcome the resistance across the septum, the operator turns the balloon catheter in one or other directions or dilates the septum with a peripheral balloon 6—8 mm in diameter. By changing the projection from the anteroposterior AP to the right-anterior oblique RAO , the operator introduces the stylet and while the balloon is partially inflated at its distal end acting as a floating balloon, the operator directs the balloon catheter toward and across the mitral valve with a combination of rotating anticlockwise and pulling the stylet and pushing the balloon.
Free movement of the balloon in the LV toward the apex shows that the balloon has not been entrapped in the subvalvular apparatus and papillary muscles. If any kind of distortion in the contour of the balloon is seen, the inflation should not be continued because of the possibility of balloon entrapment and subsequent severe MR. The balloon should be inflated with a diluted contrast medium contrast-saline ratio of to minimize the inflation-deflation period 2—4 s. It is recommended that the balloon be inflated in a stepwise fashion started 2—4 mm below the calculated RS.
Inoue technique. Inflation of distal end of the balloon, retracted toward mitral valve A—B. Inflation of proximal half catching the commissures in between C. Full inflation of the balloon disappearing the waist D. Imaging modalities combined with fluoroscopy can help to guide the procedure, assess the results, and diagnose complications. Evaluation of the mean LA pressure, transmitral valve gradient, and the contours of LA pressure between the inflations might help but they are subjected to variations and are not reliable markers of the success or occurrence of the complications. TTE is integral to guiding the procedure and should be performed between the inflations and at the end of BMV.
TEE needs general anesthesia and is difficult to perform in the catheterization laboratory but is helpful in patients with poor echo window and in pregnant women in whom fluoroscopy is of concern. After the removal of the balloon catheter, the venous access site should be compressed to achieve hemostasis.