Balloon Rupture During Balloon Mitral Valvotomy

J INVASIVE CARDIOL 2021;33(11):E916.

Key words: cardiac imaging, Inoue balloon rupture

A 38-year-old pregnant female with a 30-week non-viable fetus presented with worsening dyspnea from New York Heart Association (NYHA) class II to NYHA class IV during pregnancy. She was married for 10 years and had previous recurrent miscarriages. The physical examination revealed a high pitch opening snap (OS), along with low-pitched long diastolic rumble at the apex with wide A2-OS gap. Transthoracic echocardiography revealed very severe mitral stenosis (calculated valve area by planimetry, 0.9 cm²; normal valve area, 4-6 cm²), with a Wilkins score of 5/16 (subvalvular=2, mobility=2, calcification=0, leaflet thickening=1).

After informed consent, she was taken for percutaneous balloon mitral valvotomy. The 26 mm reused Inoue balloon (Toray Industries) was prepared for 25 mm using the formula height (in cm)/10 + 10. During full inflation of the Inoue balloon, the balloon got ruptured and deflated (Figure 1 and Video 1). There were no complications and the procedure was completed with a new 26 mm Inoue balloon. The mitral valve area was increased to 1.5 cm² and the mean left atrial pressure decreased from 40 mm Hg to 12 mm Hg (normal is 8 mm Hg).

The Inoue balloon catheter is made from polyvinyl chloride, and has a 3-layered balloon with a polyester micromesh layer between the 2 latex layers. The blood can enter the space between the latex layers and become embedded in the mesh layer, which is difficult to clean during resterilization. This is a common cause of rupture. The reuse of sterilized Inoue catheters is practiced widely in developing countries to bring down the procedure cost. Proper meticulous inspection of reused Inoue balloons for deformity or leakage through the small holes is necessary to prevent such complications.