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Posts Tagged ‘inoue balloon’

Unusual tips in PTMC : How to cross a critically narrowed mitral orifice ?

Posted in Cardiology - Animations, Cardiology -Non coronary Interventions -PTMC, cath lab tips and tricks, PTMC -Tips and tricks, tagged , , , , , , , , , on October 12, 2013| Leave a Comment »

Click over the Image  for animation

ptca balloon for PTMC inoue 002

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April fooled with PTMC balloon !

Posted in Cardiology -Non coronary Interventions -PTMC, tagged , , , , , , on August 12, 2013| Leave a Comment »

PTMC is a revolutionary    interventional cardiology procedure .A fibrosed obstructed  mitral valve is  opened up just like that , with few wires and a balloon  .The procedure  performed within 30 minutes .No  anaesthesia . No surgery .No scar.

Thousands of procedures are done world-wide (Rich countries excluded    they do not have RHD) .We in our institute , have gained considerable experience in PTMC ,  and  have  completed  nearly  200 procedures  in the last  few years .

As we gain experience surprises also galore ! .Suddenly I realised this  funny (At least for me !) phenomenon  from the unique PTMC balloon design.

The other day  , there was an intense argument between two of my  fellows , who were in a dispute  .One was arguing  , the PTMC  balloon  had dilated the tricuspid valve erroneously  while  other was adamant , and  wholesomely convinced  , since the waist  had disappeared it must be the stenotic mitral valve.

The issue came to me  . . .  ended after a nice  debate !

PTMC balloon accura Inoue waist mitral stenosis percutaneous mitral commissurotomy .

Both PTMC balloons  (Inoue ,Accura) are made with innovative design  conceptualized by Japanese genius Kanji Inoue . The balloon has two layers of latex with a nylon mesh sandwiched in between.The latex  is compliant while nylon limits  it  and generates the required pressure .

The balloon is glued in a such a way ,  central part is  constricted  like narrow band .This makes sure the distal part of balloon inflates first , followed by  the proximal and finally the central .This  also help us  to  geographically to fix  the balloon across the narrow mitral valve orifice .

While , we must agree  this a great  concept , there is an an inherent issue when handling a hour glass shaped balloon with a  natural waist .There would  be great deal of confusion when we take disappearing waist as an index of relief of mitral stenosis.

We know ,the key  requirement is that ,  balloon’s waist  should match anatomical MVO .But , it is estimated  exact match  happens in a minority.  The issue gets further complex  with  subvalvular disease , double mitral orifice, eccentric orifices . The efficacy of PTMC is also determined by the appropriate contact of the balloon’s various pressure points . ( It is a balance of intra balloon pressure(3-4 ATMs)  and  the surrounding tissue pressure !)

Disappearing waists is not synonymous with opening  MVOs .All PTMC balloon inflations will shrug of the waist at peak inflation wherever you inflate .(Intra chamber inflations included !)

Final message

Please realise ,  falling pressure gradients and echo  documentation of  MVO  rules supreme  in assessing successful PTMC. Often times , disappearing waist  is  meagerly an optical  Illusion or gratification.

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

Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, tagged , , , , , , , on September 29, 2012| Leave a Comment »

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.

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