Live from Jaideva Institute Of Cardiology Bangalore, Dr. CN Manjunath performs a balloon mitral valvotomy on a 35 year old female with rheumatic mitral valve stenosis who is in atrial fibrillation.

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Complete Transcript:

Dr. Manjunath Reporter: Yeah, Dr. Manjunath, Dr. Hidremath is here, with me we have Dr. Mukhre, Dr. Ashok and Dr. Dikshit and Sameer Dani I ask that Manjunath to finish two cases. Dr. Manjunath: Little different from the morning, we are moving from coronary to valve here. This is a 37-year-old lady of rheumatic mitral stenosis. I can see here, she is in atrial fibrillation and left atrial appendage clot type 1 A based on our classification. She was anti-coagulated for three months. So she is in functional class III atrial fibrillation and heart rate on the table is about 120 (01:00). Blood pressure is 120/80 and we will show the other pictures. This is next atrial fibrillation. This is typical x-ray of rheumatic mitral stenosis, pulmonary hypertension and you can see here the parasternal long axis shows doming of mitral valve and a bit of calcium on the posterior mitral leaflet. Then in the left lower panel you can see the short axis of the mitral valve that RSI is less than 1 and there is TR and there is pulmonary artery hypertension is around 70. Pulmonary artery systolic pressure is 70. If you look at the short axis of the mitral valve, the anterolateral commissure is free from calcium while the posteromedial there is some amount of calcium. This is very very important because if both the commissures are calcified (02:00), then there is always a risk of leaflet tear. So at least if one of the commissure is free from calcium it can still have a balloon mitral valvuloplasty. This is transesophageal echo for you, you can see a clot confined to the LA appendage protruding a little bit into the body and of course there is spontaneous echo contrast. Since the clot is confined to the appendage body and anti-coagulated for about 3 months we are going ahead with the balloon mitral valvuloplasty because our hardwares will not be into the appendage at all and clot is also organized. Yeah, this is the story of this patient, Dr. Hiremath. Dr. Hiremath: Yeah, I am surprised they kept half hour for you Dr. Manjunath. I am sure you will finish in a few minutes (03:00). Dr. Manjunath: The only thing we have to use a 3.2 wire for threading the Mullin sheath because the Mullin sheath does not go over 3.5 because most of our labs do have only 3.5. So unless you have a 3.2 wire Mullin sheath does not slide. So you can always see that this sparks, I mean you can maneuver, so that it is in the left innominate vein so that when you are coming down it gets an angle onto the atrial septum. This patient actually was on anti-coagulation stopped 5 days back, INR yesterday was 1.3. Dr. Hiremath: Was she anti-coagulated for a length of time earlier or no (04:00)? Dr. Manjunath: Yeah, yeah, she was anti-coagulated for about 3 months. The whole objective of anticoagulation is let the clot became more adherent and more distinct. So I am just one space below in AP view, then I am going to LA view 40. LA 40 we have to pick up a point between Pigtail anteriorly, vertebral column posteriorly, so you can see I am just injecting, we are into left, we are in the left atrium now. So now I will just advance the Mullin sheath over the Brockenbrough needle because (05:00) we should not advance with the needle projecting beyond the Mullin sheath because there is always a chance of perforation. So can you show the pressure, we are into the left atrium actually, now we are in LA. So let me take simultaneous LV as well as LA pressure. Can you show that? So there is a big diastolic gradient okay. LA pressure is 53/24, mean of 38. Dr. Hiremath. Yeah, we can see that very well. Dr. Manjunath: So we will go with the Spring guide wire now (06:00). I always keep pigtail in descending aorta, any flushes and all you can always do it. See now to know whether you have gone to the softest portion of the septum, just the Mullin sheath itself you can advance and see. Yes. Mullin sheath is going smoothly. So probably it has gone through the softest portion there. Many people say, I have always punctured at fossa ovalis which I do not believe, many a times you are across fossa ovalis, some times it is above fossa ovalis sometimes it is below fossa ovalis. Dr. Hiremath: Your are a vary honest interventionalist, Dr. Manjunath (07:00). Dr. Manjunath: So this is, I mean her 165, so we are going to, because as per the formula we have to take 25 balloon, but I will down size by 2. See many a time rather than doing multiple runs of the septal dilator, you can just dilate, keep it for 30 seconds it stretches the septum nicely, because septal puncture is not just for balloon mitral valvuloplasty, we have other procedures, LA appendage closure, left heart catheterization , mitraClip device, so many things (08:00). Dr. Hiremath So what are going to be the special steps to avoid the clot? Dr. Manjunath: Other important thing is you have to always keep an eye on the clot. Yeah, I think since it is an appendage clot, I am just doing routinely, otherwise, if the clot were to be in the roof of the thing we would have done over the wire technique. That is rare. We introduce the Spring guide wire instead of LA into the LV itself. See here when once two thirds of the stretched balloon crosses this thing you release this balloon stretching tube so that it does not get into that zone (09:00). Dr. Hiremath: Yeah. Dr. Manjunath Always I never flush into the left atrium, always we keep aspirating because. Dr. Hiremath: What about the Heparin? Have you already given the heparin. Dr. Manjunath: So we have to come and look for this. Heparin 3000 units we have given. Before septal puncture only I had given because sometimes you can give after septal puncture. See you can always watch for this bobbing movement, that means you are on the top of the mitral valve (10:00). So one thing, you always make sure that the balloon reaches the apex, otherwise it can get stuck in the sub-valvular apparatus 50%. So we will just check with the gradient as well as the mitral valve area. Dr. Hiremath So because you are slightly under sized you could go full on the inflation, right?(11:00) Dr. Manjunath: Yeah, we will superimpose, I think always you should inflate the pyramid at a high pressure soon. See here, our required balloon diameter was 24, so I have taken 26 balloon. So if you inflate a 24 in a 26 balloon you generate a great pressure. Suppose, if you take 28 balloon and inflate 24 then you will not generate that great pressure. So we have to inflate balloon at a high pressure zone. So if your required diameter is 24, you take 26 balloon or if your require diameter is 22, you take 24 balloon. Dr. Hiremath: So, is there something like soft dilatation like if there is mitral regurge people under to the dilatation. Is that acceptable or no (12:00). Dr. Manjunath: No, if there is calcium or if there is MR you can down size the balloon by 2 mm. I think with the heart rate of 144 a gradient of around almost diastole it is touching, it is a wide jet actually, in fact LA pressure mean has dropped from 35 to 17 (13:00). And see here a wide jet. Because of atrial fibrillation, fast heart rate, you can go on the short axis and show. Yeah, zoom that. Freeze, freeze, freeze.. You can see here both anterolateral as well as posterior medial commissure is well split and there is no MR. Dr. Hiremath: Yeah, we can see that. Yeah, we can see it very well on echo. How much the area now? (14:00) Dr. Hiremath: So Dr. Manjunath. You are 5 minutes ahead of time. Dr. Dikshit any comments from you, interesting that you are here. Dr Dikshit: I do not do much of valvuloplasty. Dr. Manjunath: What is happening with the audio, I mean, I mean audio visual. Dr. Dikshit: Mitral valve replacement and they both are very well, aortic valve, mitral position. Dr. Hiremath: Yeah, yeah Dr. Manjunath, we can hear you. Dr. Dikshit: Back in US, we do not get pretty much of this mitral valves (15:00), but every now and then, there is prosthetic mitral valve stenosis. Dr. Hiremath: Where do you think the septal puncture technique would be useful for you in US: Dr. Dikshit: Pardon. Dr. Hiremath: Septal puncture techniques, where do you think it will be useful for you in United States. Dr. Dikshit: For this mitral valve, for atrial appendage occludes, very important. Dr. Hiremath: Alright, Ms. Padma, can we speak to Dr. Khanna. Dr. Manjunath: Hello, actually, you can see here the short axis of the mitral valve both the commissures are split (16:00) So both the commissures are split and I think the end diastolic, I think I do not want to dilate any further here because we have achieved a good area is around 1.8 and LA pressure has dropped and end diastolic gradient is hardly 2-3. See, when we are removing the balloon from the left atrium to right atrium normally we have to put back the Spring guide wire and this thing. If it comes smoothly it is fine. Here it is coming smoothly, that is okay. And let me check the RV pressure rather than going for an exchange with the endol catheter let me check the RV pressure with the mitral balloon itself. So because otherwise it takes lot of other exchange and all. Dr. Hiremath Dr. Hiremath: eah, we are watching that. Dr. Manjunath: You are with us? Dr. Hiremath: Yeah, this is RV, right? Dr. Manjunath: See RV pressure before the procedure was 75 systolic and now it is around 55 and 59. So this is one. I think with the same mitral balloon you can check the RV pressure which indirectly always gives pulmonary artery systolic pressure (18:00), otherwise, you have to exchange for this again Spring guide wire, then you have to introduce, I mean endol or those catheters. So this will shorten the fluoroscopic time, so definitely PA pressure has dropped from 75 to 50, now. See when we are stretching the balloon one point here we have to keep the Spring guide wire loop well in the, at least two loops should be there in the right atrium beyond this balloon tip. See, otherwise what happens, if only tip of the wire is projecting then you try to stretch the balloon that wire can get cut, so best is have two looks beyond the balloon then you can lock and stretch the balloon and remove it (19:00). So I think this is for you. Any questions from the panel. Dr. Hiremath: Dr. Manjunath, that was an excellent demonstration, actually EMVs by and large now a days, sort of not done by many people. So I think this was an excellent case


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