Kỹ thuật nong van hai lá bằng bóng inoue

Challenging to the procedure  Unfavorable clinical situation  Emergency cases: APO, cardiogenic shock…  Pregnant patients  Procedure-related complications  Acute tamponade or Acute

Mitral Valvuloplasty by

Inoue Balloon: How to

Make It Fast and Effective

A/Prof Phạm Mạnh Hùng, MD PhD FACC FESC

Vice Director, Vietnam National Heart Institute

Director, Cardiac Cath Lab., Vietnam National Heart Institute Secretary General, Vietnam National Heart Association

Vietnam National Heart Institute

(VNHI)

300 Beds; 4 Cath Labs; 4 Op rooms

• 354 CSI (170 ASD,118 PDA, 44 VSD)

• 30 TEVAR, 16 stem cells, 2 RND

• 266 EPS+ 819 Ablation, 475 PPM

Challenging to the procedure

 Unfavorable clinical situation

 Emergency cases: APO, cardiogenic shock…

 Pregnant patients

 Procedure-related complications

 Acute tamponade or Acute stroke (LAA thrombus)

 Unfavorable or deformed anatomy

 Abnormalities of chest, heart, venous system…

 Left atrial: too small or too big (giant LA)

 Mitral valve: very severe stenosis or unequal calcification

 Septal position abnormal: previous heart surgery

 Trapped balloon at septum or femoral artery access site

 …

How to Make it Easy and

• Cross Mitral Valve

• Selection Balloon Size

• Avoid MR

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…

Predictors for success rate of

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

Technical

Considerations

Septal puncture

 Vital component of PTMC

 Not only avoid tamponade, but also made an appropriate septal site to facilitate balloon crossing valve

Simplified Septal Puncture Method:

Puncture site must inside LA border

“Landmark” only base on LA border

• No artery access

• New Landmark: # sign

• Clarify Left Atria (PA angiography if

needed)

• Catheter/Needle manipulation

LA border and # landmark

• Pull back from SVC with needle/catheter fix

system at 4 – 5 o’clock

• When needle tip jump, stop and turn

posterior (to 6 o’clock) (septal in MS usally like

• Release finger, make puncture

• Test with small contrast injection

Catheter/Needle Manipulation

Catheter/needle fitting exercise

Catheter/Needle Manipulation

Anterior-Posterior (4-6 O’clock)

Movement of the transseptal sheath

Staining technique: thick septal

Puncture site for vertical LV axis (lower)

Puncture site for horizon LV axis (higher)

Optimal puncture site for optimal

Mitral valve crossing and Valvuloplasty

Crossing Mitral Stenotic Valve

Crossing Mitral Stenotic Valve

How to cross the mitral valve

How to open the mitral valve

Physiological techniques

Stylet reshaping

Stylet reshaping

Assuring free movement of balloon

in the LV: “accordion” maneuver to

avoid severe MR by chordea rupture

Pushing balloon when full

inflation for well coaxial with Mitral valve orifice

Not Pushing balloon when full inflation for well coaxial with Mitral valve orifice plan can lead to severe MR

PMV in Some

Special Scenarios

PMV in patient with LAA thrombus

PMV in patient with giant LA

PMV in Patient with giant RA

Always clarify LA border

PMV in Kyphoscoliosis

• LA clarify

• # sign is still useful

PTMC from the Left Femoral Site (1)

• Gentle turn and go

throught pelvis area

• Make more angle

needle tip

Septal Puncture from the Left Femoral Site (2)

Before (needle tip less

angle)

After (needle tip more angle)

• PMV using Inoue balloon is still

considered as first long-lasting temporary treatment of choice for rheumatic mitral