From Transseptal Puncture to Mitral Commissurotomy: A Zero-Wire-Exchange Approach Using Inoue Balloon

Figures

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  Visual Summary. Procedural Steps of Zero-Wire Exchange PMC Using an Inoue Balloon Over the VersaCross Wire LA = left atrium; LV = left ventricle; MS = mitral stenosis; MV = mitral valve; PMC = percutaneous mitral commissurotomy; RF = radiofrequency; TOE = transesophageal echocardiography; TSP = transseptal puncture.

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  Figure 1. Transesophageal Echocardiography Showing Significant Mitral Stenosis, Patient 1 (A) Mean transmitral gradient of 11 mm Hg. (B) Mitral valve area (MVA) of 1.25 cm2 measured by 3-dimensional planimetry.

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  Figure 2. Procedural Steps, Patient 1 (A) Transseptal puncture using an 8.5-F VersaCross system with advancement of the preshaped VersaCross wire into the left atrium. (B) The VersaCross wire was further advanced into the left ventricle, directed by the VersaCross steerable sheath. (C) Septostomy is dilated using a 14-F septal dilator that is advanced over the VersaCross wire. (D) Delivery of a slenderized 26-mm Inoue balloon via the modified over-the-wire technique to cross the diseased mitral valve. (E) Sequential balloon inflations to a final diameter of 26 mm. (F) Direct withdrawal of the balloon and guidewire from the left ventricle under fluoroscopic guidance.

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  Figure 3. Standard Inoue Balloon Preparation (A to D) Slenderized position is obtained through locking the stretching tube (red arrow) to the inner lumen tube (yellow arrow), then locking the inner tube to the hub (green arrow) of the balloon catheter. The slenderized balloon is then advanced over the Inoue guidewire across the septostomy. Once in the left atrium, the above steps are reversed, and balloon is floated across the mitral valve with the help of a shapeable stylet.

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  Figure 4. Modification of Inoue Balloon Preparation (A) The stretching silver tube (not compatible with 0.035-inch VersaCross wire) is removed (red arrow). (B) The front end of the Inoue balloon is loaded over the back end of the VersaCross guidewire (after transseptal puncture). (C and D) Resting unslenderized position. (E and F) Slenderized position is obtained outside the body through locking the inner tube to the hub of the balloon catheter back end (yellow arrow), causing balloon elongation while on the wire. The balloon is then advanced smoothly over the VersaCross guidewire across the septostomy. Once correctly positioned in the left atrium, the balloon is unslenderized again by retracting the inner tube, then advanced to the left ventricular cavity and directly inflated over the VersaCross guidewire. No need for Inoue guidewire or the shapeable stylet.

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  Figure 5. Postinterventional Transesophageal Echocardiography, Patient 1 (A) A drop in the mean transmitral gradient to 4 mm Hg. (B) An increase in mitral valve area (MVA) to 1.96 cm2 measured by 3-dimensional planimetry.

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  Figure 6. Transesophageal Echocardiography Demonstrating Severe Mitral Stenosis, Patient 2 (A) Mean transmitral gradient of 7 mm Hg. (B) Mitral valve area (MVA) of 0.98 cm2 measured by 3-dimensional planimetry.

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  Figure 7. Procedural Steps, Patient 2 (A) Transseptal puncture performed with an 8.5-F VersaCross system, with advancement of the preshaped guidewire into the left atrium. (B) Further advancement of the VersaCross wire into the left ventricle, guided by the steerable VersaCross sheath. (C) Septostomy dilation using a 14-F septal dilator. (D) Delivery of a slenderized 28-mm Inoue balloon across the diseased mitral valve using a modified over-the-wire technique. (E) Three sequential balloon inflations. (F) Direct withdrawal of the balloon and guidewire from the left ventricle.

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  Figure 8. Postinterventional Transesophageal Echocardiography, Patient 2 (A) Reduction in the mean transmitral gradient to 3 mm Hg. (B) Increase in mitral valve area (MVA) to 1.5 cm2 as assessed by 3-dimensional planimetry.