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      Percutaneous transmitral balloon commissurotomy using a single balloon with arteriovenous loop stabilisation: an alternative when there is no Inoue balloon

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          Summary

          Background

          The Inoue balloon technique is the standard technique for mitral valve balloon commissurotomy at this stage. However, the hardware for this technique is expensive and may not always be available in resource-limited settings.

          Objectives

          This article reports our experience with percutaneous transmitral balloon commissurotomy using a single balloon (Nucleus) with arteriovenous loop stabilisation.

          Methods

          Eleven young patients, aged 12–26 years and weighing 23–48 kg, underwent transmitral balloon commissurotomy using the described technique at our centre from April to May 2014.

          Results

          Mean fluoroscopy time was 22.6 ± 6.4 min (18.5– 30.0). Mean transmitral gradient decreased from 24.1 ± 5.9 (16–35) to 6.6 ± 3.8 (3–14) mmHg, as measured on transoesophageal echocardiography. Mean mitral valve area increased from 0.69 ± 0.13 cm 2 (range 0.5–0.9) before dilation to 1.44 ± 0.25 cm 2 (1.1–1.9) after dilation (p < 0.001). Mean estimated pulmonary artery systolic pressure decreased from 110.0 ± 35 mmHg (75–170) before dilation to 28.0 ± 14.4 mmHg (range 10–60) after dilation.

          Conclusion

          Our modified Nucleus balloon technique for mitral valve dilation in young patients with mitral stenosis is effective and safe. The technique differs from other over-thewire techniques in that it avoids placing stiff wire in the left ventricle. It also offers better balloon stability and control owing to the arteriovenous loop. This technique may be easier for use by paediatric interventionists who might not be familiar with the Inoue balloon technique.

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          Most cited references22

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          Clinical application of transvenous mitral commissurotomy by a new balloon catheter.

          A new balloon catheter was developed which allows mitral commissurotomy without thoracotomy. The procedure has been successful in five of the six patients with mitral stenosis so treated. In the remaining patient, the procedure could not be performed because of technical difficulties. The balloon is reinforced with a nylon micromesh and its shape changes in three stages, depending on the extent of inflation. It is inserted from the saphenous vein into the mitral orifice transseptally, fixed across the mitral orifice with partial inflation, and finally inflated to full its extent, separating the fused commissures by its expansile force. After the procedure, catheterization revealed a significant reduction in the mean diastolic pressure gradient across the mitral valve without resultant mitral regurgitation in each patient. Two-dimensional echocardiograms showed a marked to moderate degree of dilatation of the mitral orifice in each patient. All five patients are well with remarkable clinical improvements 2 to 16 months after the procedure.
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            Percutaneous balloon versus surgical closed and open mitral commissurotomy: seven-year follow-up results of a randomized trial.

            Percutaneous balloon mitral commissurotomy (BMC) has been proposed as an alternative to surgical closed mitral commissurotomy (CMC) and open mitral commissurotomy (OMC) for the management of rheumatic mitral valve stenosis (MS). We conducted a prospective, randomized trial comparing the results of the 3 procedures in 90 patients (30 patients in each group) with severe pliable MS. Cardiac catheterization was performed in all patients before and at 6 months after each procedure. All patients had clinical and echocardiographic evaluation initially and throughout the 7-year follow-up period. Gorlin mitral valve area (MVA) increased much more after BMC (from 0.9+/-0.16 to 2.2+/-0.4 cm2) and OMC (from 0.9+/-0.2 to 2.2+/-0.4 cm2) than after CMC (from 0.9+/-0.2 to 1.6+/-0.4 cm2). Residual MS (MVA <1.5 cm2) was 0% after BMC or OMC and 27% after CMC. There was no early or late mortality or thromboembolism among the three groups. At 7-year follow-up, echocardiographic MVA was similar and greater after BMC and OMC (1.8+/-0.4 cm2) than after CMC (1.3+/-0.3 cm2; P<.00l). Restenosis (MVA <1.5 cm2) rate was 6.6% after BMC or OMC versus 37% after CMC. Residual atrial septal defect was present in 2 patients and severe grade 3 mitral regurgitation was present in 1 patient in the BMC group. Eighty-seven percent of patients after BMC and 90% of patients after OMC were in New York Heart Association functional class I versus 33% (P<.0001) after CMC. Freedom from reintervention was 90% after BMC, 93% after OMC, and 50% after CMC. In contrast to surgical CMC, BMC and OMC produce excellent and comparable early hemodynamic improvement and are associated with a lower rate of residual stenosis and restenosis and need for reintervention. However, the good results, lower cost, and elimination of drawbacks of thoracotomy and cardiopulmonary bypass indicate that BMC should be the treatment of choice for patients with tight pliable rheumatic MS.
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              Percutaneous catheter commissurotomy in rheumatic mitral stenosis.

              We attempted percutaneous transcatheter-balloon mitral commissurotomy in eight children and young adults (9 to 23 years of age) with rheumatic mitral stenosis. The atrial septum was traversed by needle puncture, and an 8-mm angioplasty balloon was advanced over a guide wire. The atrial septal perforation was then dilated to allow passage of the valvuloplasty balloon catheter (18 to 25 mm) across the mitral annulus. Inflation of the transmitral balloon decreased the end-diastolic transmitral gradient temporarily in all patients (from 21.2 +/- 4.0 mm Hg [mean +/- S.D.] to 10.1 +/- 5.5 mm Hg; P less than 0.001). The immediate decrease in the gradient was associated with increases in cardiac output (from 3.8 +/- 1.0 to 4.9 +/- 1.3 liters per minute per square meter of body-surface area; P less than 0.01) and in the calculated mitral-valve-area index (from 0.73 +/- 0.29 to 1.34 +/- 0.32 cm2 per square meter; P less than 0.001). Murmur intensity diminished immediately after commissurotomy in all patients. The greatest reduction in pressure gradient (76 to 95 per cent) occurred when the largest balloon (inflated diameter, 25 mm) was used in the smallest patients (0.9 to 1.2 m2). The balloon commissurotomy produced minimal mitral regurgitation in only one child. Follow-up catheterization (at two to eight weeks) demonstrated persistence of hemodynamic improvement with evidence of partial restenosis in one patient. These early results indicate that balloon mitral commissurotomy can be a safe and effective treatment for children and young adults with rheumatic mitral stenosis.
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                Author and article information

                Contributors
                Journal
                Cardiovasc J Afr
                Cardiovasc J Afr
                TBC
                Cardiovascular Journal of Africa
                Clinics Cardive Publishing
                1995-1892
                1680-0745
                May-Jun 2018
                : 29
                : 3
                : 167-171
                Affiliations
                Department of Paediatrics and Child Health, Cardiology Division, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
                Division of Paediatric Cardiology, CHU Sainte-Justine, Université de Montréal, QC, Canada
                Division of Paediatric Cardiology, CHU Sainte-Justine, Université de Montréal, QC, Canada
                Department of Medicine, Montréal Heart Institute, Université de Montréal, QC, Canada
                Division of Cardiovascular Surgery, Montreal Institute of Cardiology, Université de Montréal, QC, Canada
                Article
                10.5830/CVJA-2018-010
                6107808
                29457827
                e623bec6-62af-435d-8663-4c9c51226ec6
                Copyright © 2015 Clinics Cardive Publishing

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 9 December 2016
                : 29 January 2018
                Categories
                Cardiovascular Topics

                arteriovenous loop stabilisation,balloon mitral commissurotomy,modified nucleus balloon technique,mitral valvotomy in resource-limited settings

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