Percutaneous balloon valvuloplasty for mitral stenosis complicated by fatal pericardial tamponade in a patient with extreme pulmonary hypertension

Near-fatal cardiac arrest due to cardiac tamponade during percutaneous mitral valvuloplasty

The incidence of hemopericardium following percutaneous mitral valvuloplasty is reported at 1–3%, being related to either trans-septal puncture, or left ventricular perforation with guide wires or balloons. We report a case of percutaneous mitral valvuloplasty for a middle-aged man with moderately severe rheumatic mitral stenosis. The procedure was performed through a right femoral vein approach, employing the multitrack technique, utilizing 2 balloons (20 and 18 mm). Inadvertently, the procedure was complicated by cardiac tamponade. Despite immediate diagnosis and prompt pericardiocentesis, hemodynamic stability was not maintained. Echocardiography revealed a mass in the posterior pericardial sac. The patient was arrested in asystole, and rigorously resuscitated during transfer to the operating room. Exploration revealed a tear in the left ventricular apex that was adequately sutured. In a few days, the patient gradually regained adequate consciousness, and was ultimately discharged. Post-procedural echocardiography revealed a mitral valve area of 1.9 cm², with no mitral regurgitation.

Mitral valvuloplasty with the Inoue balloon tracked over an arteriovenous wire

Mitral stenosis is associated with significant morbidity and mortality. Percutaneous balloon mitral valvuloplasty is a standard treatment option for severe mitral stenosis, and in some patients may be the only feasible option. In patients with suitable valve anatomy and morphology, and with requisite physician expertise the procedure has a high success rate and good long-term outcomes. Nonetheless, even in appropriately selected patients the procedure can pose significant technical challenges. The transeptal antegrade approach using the Inoue Balloon system may be associated with difficulty and rarely with failure to cross the stenotic mitral valve. We report a case of initial Inoue balloon failure to cross followed by successful Inoue mitral valvuloplasty tracked over an arteriovenous wire loop.

Mechanisms of cardiac perforation leading to tamponade in balloon mitral valvuloplasty

Mechanisms of cardiac perforation in 10 cases of cardiac tamponade encountered in a single-center series of 903 balloon mitral valvuloplasty procedures were elucidated by precise localization of the site of perforation at subsequent surgery. These mechanisms were perforation of the aortic root and adjacent right atrium by sliding up of the transseptal set (2), apical tears by straight-tip balloon catheters driven distally during mitral valve dilatation (3), apical perforations by guidewires introduced through catheters wedged in the apex (2), tear of the posterior right atrial wall by dilatation of the track produced by very low septal punctures (2), and right ventricular perforation by a pacing catheter (1). Multivariate analysis showed cardiac perforation to be significantly related to the total experience at the center (inversely) and to patient age (directly). Left ventricular perforation occurred exclusively in patients > 40 yr of age. Understanding these mechanisms has enabled formulation of effective strategies to prevent cardiac perforation.

Inoue balloon usefulness in case of failure to stabilize bifoil catheter balloons during percutaneous mitral valvotomy

A new bifoil balloon catheter has been used in the last 120 percutaneous mitral valvotomies carried out in our institution. The shaft segment between the two balloons of the bifoil catheter has been adjusted to the guide-wire diameter, allowing its introduction through a 14F sheath. This thinner shaft does not always offer enough back up to the balloons during inflation. An Inoue balloon replaced an unstable bifoil balloon in 5 cases of mitral dilatation failure due to balloon instability, regularly providing firm stability until full balloon inflation.

Left ventricular perforation during percutaneous balloon mitral valvuloplasty

Percutaneous balloon mitral valvuloplasty has been reported to be complicated by left ventricular perforation with fatal results. We report two cases of left ventricular perforation following balloon mitral valvuloplasty. In one patient left ventricular perforation occurred silently without any hemodynamic sequelae and was only detected at left ventricular angiography after valvuloplasty. In the second patient left ventricular perforation was caused by the mitral dilating balloon catheter. The subsequent tamponade was relieved by immediate aspiration with hemodynamic stabilization thereafter. Neither patient required surgery. Both patients are well 6 mon after the procedure. We discuss the mechanism of this serious complication in these two patients.

Left ventricular rupture complicating percutaneous mitral commissurotomy: salvage using percutaneous cardiopulmonary bypass support

Left ventricular rupture resulting in death has been reported to be a complication of percutaneous mitral commissurotomy. We report a 71-year-old man in whom a left ventricular rupture occurred during percutaneous mitral commissurotomy and resulted in hemodynamic collapse due to acute cardiac tamponade. The patient was stabilized using percutaneously instituted cardiopulmonary bypass support with subsequent repair of the left ventricle and successful mitral valve replacement. Three months later this patient remains in New York Heart Class I.