Dr.S.Venkatesan MD

What are the   structures that  can get punctured and result in cardiac tamponade during PTMC ?

1. Aorta
2. LA  roof ( Many parts of LA are extra pericardial . Still ,  if you are good enough !  you can enter the pericardium )
3. LA free wall
4. IAS  /pericardial space Interface (Stitch effect )
5. LV free wall
6. Pulmonary vein
7. RA free wall

Traditionally  cardiologist’s major  fear is  confined to  accidental  aortic puncture . With growing  experience  &   inexperience   we  now know   PTMC  is vested with other  risks  for cardiac puncture other than Aorta .

• LA roof  puncture can occur if the septal puncture is high  and  the movement of sheath over IAS plane is not smooth . ( Animated  to and fro movement across IAS is largely unnecessary !)
• LA free wall when the guidewire is manipulated.
• The  right atrial side of IAS  often  over shoots the LA side of IAS . This brings a unique situation where  Brocken-burrogh needle may  enter the LA through pericardial space .One may not be aware of this until you pull back the needle when pericardial
• LV free wall  rupture is  rare with Inoue technique .Over the wire  balloon technique with a guide wire tip can cause LV injury
• Accidental  pulmonary vein inflation with the balloon is  always  possible. One has to verify the balloon position in lateral view.
• RA free wall should not happen  today . Still  a distorted RA anatomy due to associated  tricuspid regurgitation or stenosis . This can bring a surprise element to our understanding of IAS septal alignment .

Reference

http://interventions.onlinejacc.org/data/Journals/JCIN/22697/04019.pdf

Joseph G, Chandy ST, Krishnaswami S, et al. Mechanisms of cardiac perforation leading to tamponade in balloon mitral valvuloplasty.
Cathet Cardiovasc Diagn 1997;42:138–46.