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Impasse Sign in Balloon Mitral Valvotomy
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A 33-year-old woman presented to our out-patient department with worsening shortness of breath over the past 2 years. The physical examination revealed loud S1 and a low pitch, long mid-diastolic murmur with presystolic accentuation at the apex. Two-dimensional transthoracic echocardiogram showed severe mitral stenosis with mitral valve area of 0.6 cm2 (normal, 4-6 cm2) and moderate pulmonary artery hypertension. The Wilkins score was 7/16 (subvalvular = 3, mobility = 2, calcification = 1, leaflet thickening = 1).
After informed consent, the patient was taken up for balloon mitral valvotomy (BMV). The calculated balloon size (height/10+10) was 25 mm; a 26-mm SYM balloon (Translumina) was prepared at 23 mm in view of severe subvalvular disease. After septal dilation, the balloon was crossed to the left ventricle with the reverse loop technique. During balloon inflation, the proximal balloon inflated before the distal balloon, which suggested the Impasse sign (Figure, Video). The balloon was deflated immediately, the mitral valve was recrossed again, and successful balloon dilation was done. The left atrial pressure decreased from 24 to 16 mm Hg, and mild mitral regurgitation was noted; henceforth, no further dilations were given. In this case, the operator felt that the impasse sign occurred due to entanglement of the distal balloon in the chordal apparatus.
The impasse sign portends severe mitral regurgitation in BMV. The operator should be aware of this possibility and, if the impasse sign is noticed, the operator should deflate the balloon immediately to avoid severe mitral regurgitation.
Affiliations and Disclosures
From the Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Address for correspondence: Sourabh Agstam, MD, DM, MRCP(UK), FACC, Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India. Email: sourabhagstam@gmail.com; X: @agstamsourabh
