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Efficacy of modified Technique for atrial Septal Puncture in Percutaneous Transvenous Mitral Commissurotomy... BACKGROUND • Mitral Stenosis is still a big burden especially in develop

Efficacy of modified Technique

for atrial Septal Puncture in

Percutaneous Transvenous

Mitral Commissurotomy

BACKGROUND

• Mitral Stenosis is still a big burden especially in

developing country

• The simplest technique (1st choice) for PTMC:

Using Inoue Balloon

• Effective: valid alternative to surgical therapy

in selected patients

Septal Puncture : Vital Step, not only to avoid

tamponade but also made an appropriate septal

site to facilitate balloon crossing valve

• At VNHI: Septal Puncture using modified technique since 2005

Landmark for Septal Punture

Classic Septal Puncture

Classic Septal Puncture (Ultrasound guided)

Gupta

Simplified Septal Puncture without

Atery Access:

- Puncture site must inside LA border

- Landmark only base on LA

• No artery access

• New Landmark: # sign

• Clarify Left Atrium (PA angiography if needed)

• Catheter/Needle manipulation

Catheter/needle fitting exercise

Catheter/Needle Manipulation

Simplified Technique

“# technique”

LA border and # landmark

PTMC procedure

OBJECTIVES

1 To Evaluate the efficacy of the modified

technique for Septal Puncture in

Percutanenous Transvenous Mitral

Commisurrotomy

2 To define some clinical factors affect the

result of this technique

Patient Selection

Severe MS with symptom

None combination of MR > 2/4 or/and

moderate/severe AS/AR

Echo Score: Wilkins; Padial; Comer

LA without thrombus

Some special scenarios: pregnancy; emergency; kyphoscoliosis; junior…

Consent

Patient Selection and Methods

Patient selection: 173 MS patients in Vietnam National Heart Institute undergone PTMC from 06/2013 to 09/2014

Method: Cross Sectional Study

Statistical analysis: SPSS 16.0

Balloon selection and sizing

Reference Size (RS)

(Patient’s height (cm) / 10) + 10

Inoue balloon selection

Valvular morphology Balloon

RS = 26) Calcified/SL One size < RS-matched

Balloon sizing

Valvular status Initial Increment

LA diameter (mm)

Pulmonary Artery pressure (mmHg)

MVA (2D and PHT) (cm2)

Wilkin Score

Research Parameter

 Result of Septal Puncture

 Success: Septal puncture and perform PTMC successfully

 Fail: (1) Complication that lead to stop

procedure, (2) can not advance needle into LA

or, or (3) can not advance balloon through valve

Research Parameter

and no complocation

 Pulmonary artery pressure, LA pressure (before

and after procedure) (mmHg)

Research Parameter

 Crossing Inoue balloon into mitral stenotic valve

Favourable : direct or vertical method

Difficulty : sliding or alternative loop method

Fail : balloon can not cross

 Operator Experience:

Group 1 : ≤ 100 cases

Group 2 : 101 – 200 cases

Group 3 : > 200 cases

RESULT AND DISCUSSION

General parameter of patients

102 (58,96%)

71 (41,04%)

History of PTMC or mitral valve surgery 27(15,43%)

Male/Female = 0.25, Võ Thành Nhân: (n=147) 0.25, Iung (1024) 0,2 Age: Võ Thành Nhân (n=147) 37,81 ± 9,46 Iung (n=1024) 49 ± 14

General technical aspects

R femoral vein: Most favourable vessel access for PTMC Although some

authors reported some cases with L femoral vein access

Angio Parameter

x ± SD (mm) / n (%)

Distance from lateral line of

right atrium and middle point of

Cross Inoue Balloon into Mitral Stenotic valve

Result of Septal Puncture

Nguyễn Quang Tuấn: (n=220) 96%

Jui Sung Hung: (n=219) 97%

Procedure time, radiation exposure time and days of

inpatient after procedure

X  SD (current study)

X  SD (Võ thành Nhân) P

Procedure time(n=58) 32,77 ± 13,13(mins) 75,67 ± 41,98(mins) < 0.001 Radiation exposure time

(n=61) 10,97 ± 10,96(mins) 14,3 ± 10,9(mins) < 0.001

Days of inpatient after

procedure(n=171) 3,27 ± 1,72(days)

LA pressure before and after PTMC (mmHg)

(p<0.001)

MVA before and after PTMC (cm 2 )

(p<0.001)

0 5 10 15 20 25 30 35 40 45 50

PAP max (Ultrasound)

PAP max (Angio)

PA pressure before and after PTMC (mmHg)

(p<0.001)

Complication

n (%)

Main Complication

Septal Puncture result

108

65

Septal Puncture

Favourable Difficult and fail

Septal Puncture: Technical aspects (regression

multifactor analysis) Group 1 (Favourable)

(n=108)

Group 2 (Difficult and fail)

(n=65)

OR (95%CI)

> 0,05

101 - 200 28 23

1,76 (0,70-4,46)

> 200 30 14 Age 45,6 ± 12,36 47,97±11,13

1,02 (0,99-1,04)

> 0,05 Sex

Male 19 16 1,53

(0,72-3,24) Female 89 49

MVA before procedure 1,02 ± 0,81 0,93 ± 0,18

0,59 (0,16-2,15)

Septal Puncture: Technical aspects

Group 1

(Favourable)

(n=33)

Group 1 (Difficult) (n=28)

OR (95%CI) P

Septal puncture in Pt with history of PTMC

or surgery compared to 1 st time PTMC

PTMC or Surgery history

CONCLUSION

1 Modified technique for Septal Puncture (# technique) :

 Decrease procedure time 32,77 ± 13,13(mins),

decrease radiation exposure time 10,97 ±

10,96(mins)

 PTMC result using this technique (PAP, LA pressure, MVA…), days of inpatients after PTMC

comparable to classic technique

 Only one venous access

 Experience operator (>100 cases).

Thank you for your attention!

Septal puncture:

Tips and Tricks

Always Clarify LA border

Good catheter/needle manipulation

Avoid puncture RA, Ao, Tricuspid valve and coronary sinus: inside LA border, # sign

landmark, at 4 – 6 o’clock

Needle tip reshaping

Confirmation of LA entry before advance

sheath to LA

Crossing Mitral Stenotic Valve

3.96 (1.28 <RR< 12.2)

Predictor of severe MR after PTMC

Our experience

VNHI’s Experience 1999-2010

• Single center experience 12 year (1/1999-12/2010)

• Total PTMC volume: 5930 pts (≈ 500 pts/yr)

• Using Inoue balloon: 99.1% (5870/5930 pts)

Restenosis and Clinical status on

50%; C = Clinical symptoms of restenosis; D = decreased MVA > 25%; E = decreased MVA > 50% or MVA< 1.5 cm2 or both

Clinical stability: NYHA I or II or no worsening on F/U later on

Predictors for success rate of