What are the structures that can get punctured and result in cardiac tamponade during PTMC ?
- LA roof ( Many parts of LA are extra pericardial . Still , if you are good enough ! you can enter the pericardium )
- LA free wall
- IAS /pericardial space Interface (Stitch effect )
- LV free wall
- Pulmonary vein
- 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 .
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.