Interventional cardiology has grown leaps and bounds. We are in the era of percutaneous replacement of cardiac valves. Mitral valvotomy for mitral stenosis is one the stupendous success stories of interventional cardiology.
In PTMC, we have a major cardiac valve disease , treated without anesthesia in a procedure lasting about 30 minutes and patients can walk home within hours of the procedure.
The maximum such procedures are done in developing countries like India, Brazil, and many south Asian , African countries.
It is a procedure requiring continuous fluroscopy in cath lab. This has been our traditional way of thinking. But now we learn , what we require is an imaging modality for the entry of balloon into IAS and the stenotic mitral valve .This can be Echo, MRI , CT scan etc not necessarily fluroscopy.
Why not echocardiography to guide the balloon in PTMC ?
This question was answered successfully . Both TTE and TEE are used .Surprisingly transthoracic echo , by itself was sufficient in many patients to complete a PTMC.
The following article in JASE (American society of Echocardiography ) opens new avenues for echocardiography .The work was done in New Delhi India
http://www.onlinejase.com/article/S0894-7317(05)00073-8/abstract
The most surprising conclusion from this study is , it is suggested complications like cardiac tamponade is less likely in echo guided PTMC ! as we are sure where we re puncturing and entering .
Advantages
- Huge cost advantage.
- Can be practiced in a wider clinical set up
- Radiation free (Very important advantage )
- Live 3D /Echo and MRI are expected to improve the feasibility of this modality .
Caution about TTE/TEE guided PTMC.
- Not every one can do this procedure.
- Cardiologists who have mastered catheter based PTMC can only understand the intricacies of PTMC
- While catheters can be easily imaged , when the procedure requires finer guidewire manipulations fluro is a must .
- Currently this procedure should be done with a cath lab standby
- Tackling complications may be an issue , but the most dreaded complication cardiac tamponade is more easily recognised by echocardigraphy
- Special training on this modality is to be strongly encouraged.Such thing is possible only in country like ours where RHD continues to be rampant.
Final message
Cath guided PTMC is considered the gold standard .But , often we create gold standards with impure gold ! The IAS puncture and mitral valve crossing is the most blinded procedure in cath lab.
The same job can be done better , with good “ocular orientation” by simple echocardiography
Often in medicine , a simple alternate technique rarely can compete with a proven technique .Thus , these techniques are denied wider application and hence fail to prove it’s worthiness.
Echo guided pericardial aspiration , MRI guided deep thoracic biopsy are already established non invasive assisted intervention , soon we can expect many cardiac intervention will be done in radiation free environment.
Unpopular treatment modalities need not be synonymous with ineffective and dangerous forms of treatment.
Dr.S.Venkatesan MD 