Transjugular approach to balloon mitral valvuloplasty helps overcome impediments caused by anatomical alterations

Abstract

Ten patients who had anatomic alterations that cause impediments to successful completion of conventional transfemoral balloon mitral valvuloplasty (BMV) underwent transjugular BMV. They included six patients in whom conventional BMV could not be completed due to cardiac anatomic distortion; two patients with dextrocardia (one with visceroatrial situs solitus and the other with situs inversus); two patients with venous abnormalities (one with azygous continuation of the inferior vena cava and the other with bilateral iliac/femoral vein occlusion). Transjugular BMV was successful in all 10 patients (mean mitral valve area increasing from 0.68 +/- 0.17 to 1.92 +/- 0.40 cm(2); range, 1.56-2.76 cm(2)); it was quick (mean total fluoroscopy time, 10.5 +/- 2.7 min; range, 7.3-15.2 min); and it was safe (no major or minor complications except one patient who developed severe mitral regurgitation that only required medical therapy). The jugular approach to BMV overcomes many of the technical problems caused by anatomic changes that are encountered in transfemoral BMV and complements the latter approach.

Transjugular balloon mitral valvotomy in a patient with severe kyphoscoliosis

“…In addition to technical feasibility in anatomically difficult cases, transjugular BMV offers some other advantages 1, 3. Septal puncture for transjugular BMV is performed above the fossa ovalis and the limbic ledge; this results in a smaller residual left-to-right shunt as in this location the septal tissue is thicker and tends to recoil more than the thin fossa ovalis septum.…”

“…However, in situations such as grossly distorted cardiac anatomy, abnormalities of the inferior vena cava and severe kyphoscoliosis, successful completion of the BMV procedure using the conventional transfemoral approach may not be possible due to technical difficulties, especially when performing transseptal puncture and during delivery of the valvuloplasty balloon across the mitral valve. A jugular venous transseptal approach provides a more direct approach to the mitral valve and can help in overcoming many of the anatomical impediments encountered when using a transfemoral approach 1 . We report a case where transfemoral BMV could not be performed because of severe thoracolumbar kyphoscoliosis; however, the transjugular approach allowed successful completion of the procedure.…”

“…It was then decided to attempt BMV using jugular venous approach. As described previously,1, 3 the right internal jugular vein was cannulated percutaneously and a Berman angiographic catheter (Arrow, Reading, PA, USA) was positioned in the right pulmonary artery. A 5-French pigtail catheter introduced from right radial access was positioned in the non-coronary aortic sinus to serve as a landmark during transjugular septal puncture.…”

Percutaneous Mitral Valvotomy in a Case of Situs Inversus Totalis and Juvenile Rheumatic Critical Mitral Stenosis: Case Report

“…7 - 9 o’clock position of the external indicator of the needle instead of its usual 4 - 6 o’clock position [8]. After septal puncture, entry into the LA and its depth can be confirmed by pressure measurement and contrast staining of the left atrium [5, 6, 8]. Septal dilatation is to be done in usual fashion.…”

Retrograde non trans‐septal balloon mitral valvotomy in mitral stenosis with interrupted inferior vena cava, left superior vena cava, and hugely dilated coronary sinus

“…Interrupted inferior vena cava makes fluoroscopy‐guided transcatheter procedures challenging, specially percutaneous transvenous mitral commissurotomy (PTMC), where the unusual cardiac anatomy considerably increases the risk of complications during trans‐septal puncture and entry into left ventricular cavity. Although, PTMC has become the standard of care for selected patients with rheumatic mitral stenosis, there are only a few reports on successful PTMC in patients with atypical cardiac anatomy . This particular case was peculiar in that there was a hugely dilated right atrium and coronary sinus with interrupted inferior vena cava which makes both femoral and trans‐jugular approaches unsuccessful and retrograde approach was used for successful valvotomy and relief of symptoms.…”