Modified Technique of BMV for Severe Submitral Stenosis

ABSTRACT: We present a case where difficulty was encountered during balloon mitral valvotomy (BMV) because of severe submitral stenosis. As the orifice was 0.4 cm² at submitral level the BMV balloon catheter could not enter the left ventricle. We used a modified technique of liberating the submitral apparatus that facilitated successful BMV.

J INVASIVE CARDIOL 2011;23:387–388

Key words: balloon mitral valvotomy, technique, submitral stenosis

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A 45-year-old woman presented with severe symptomatic mitral stenosis with mitral valve orifice area of 1.0 cm² at cusp level and 0.4 cm² at chordal level (Figure 1). The submitral apparatus was extensively diseased with thickening and fusion (Figure 2). Initially balloon mitral valvotomy (BMV) was attempted by over-the-wire technique described by the authors.¹ In this technique, a deliberate low septal puncture is made and the 0.025-inch coiled guidewire is directly placed in the left ventricle (LV) (Figure 3). Subsequently, a BMV balloon is passed over this wire and inflated. Because of severe submitral disease, there was resistance to the entry of the balloon catheter into the  LV and the entire assembly backed out into the left atrium (Figure 4). Subsequently, we made several futile attempts to enter the LV.

The coiled guidewire was withdrawn and a 0.035-inch Terumo wire (Terumo Corporation) was introduced into LV with the support of a Judkins right catheter (Figure 5) and the distal end was parked in the right subclavian artery. An 8 x 20 mm Opta-Pro PTA balloon (Cordis Corporation) was passed over the Terumo wire and the submitral apparatus was serially dilated (Figure 6). The Terumo wire was then exchanged for a coiled guidewire and the procedure was completed with a BMV balloon catheter (Figure 7). The medial commissure was split (Figure 8) and the submitral stenosis was released (Figure 9).

Conclusion. In severe submitral stenosis, crossing the mitral valve with a Terumo wire and releasing the submitral stenosis with peripheral angioplasty balloon facilitates entry of BMV balloon catheter and this procedure can be completed successfully.    

Reference

1. Manjunath CN, Srinivasa KH, Ravindranath KS, et al. Balloon mitral valvotomy in patients with mitral stenosis and left atrial thrombus. Catheter Cardiovasc Interv. 2009;1(4):653-661.

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From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. No authors reported conflicts regarding the content herein.
Manuscript submitted April 19, 2011, provisional acceptance given May 23, 2011, final version accepted July 1, 2011.
Address for correspondence: Dr. Arunkumar Panneerselvam MD, DM, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Jaya Nagar 9th Block, BG Road, Bangalore 560069, India. Email:  drparun1976@gmail.com