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Brain & Heart Lutembacher’s percutaneous treatment

enter the left ventricle (LV) using the conventional method was then exchanged with the balloon catheter, which was
of anticlockwise turning of the catheter, aiming to position advanced across the MV into the LV over a spring coil
it across the MV (Inoue technique) in the right anterior wire, taking special care to remove the straightener only
oblique (RAO) view. when at least two-thirds of the balloon catheter assembly
While executing this maneuver, our balloon-stylet was across the ASD. BMV was then performed with two
assembly consistently veered into the RA through the serial balloon dilatations (increasing the contrast volume
ASD. This occurrence likely stemmed from the relatively by 1 ml post-first inflation) (Figure 2C). More than a 50%
smaller LA size in LS, compounded by the instability reduction in LA pressure was achieved, along with TTE
during catheter manipulation. The large inter-ASD, unlike confirmation of bilateral MV commissure splitting. Next,
in routine BMV cases, could not function as a stable pivot the ASD closure was performed using the same 8F Mullin’s
for the balloon catheter. sheath and a Lifetech Cera ASD occluder (16 mm) device
(Figure 2D). Following ASD closure, the peak RV pressure,
Consequently, we found ourselves repeating the as estimated from the TR jet, decreased to 19 mmHg, and
aforementioned steps multiple times. Despite employing the mean transmitral gradient was down to <1.5 mmHg
various techniques, such as reverse-loop entry and reshaping (Figure 3A and B).
the stylet to form a large radius curve, we encountered
persistent challenges in successfully crossing the MV. In The post-procedure recovery went smoothly without
response, we applied the modified Inoue technique, where neurological or cardiac complications. The patient was
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the valvuloplasty catheter was exchanged with a 6F Judkins discharged the next day and prescribed oral aspirin (75 mg)
Right (JR) catheter. The catheter was parked in the LA and and clopidogrel (75 mg) once daily for 3 months, followed
its tip maneuvered to point towards MV in RAO view. We by oral aspirin (75 mg) alone for the following 3 months,
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then crossed the MV with a Terumo 035” wire. Next, we after which the antiplatelet therapy was discontinued. The
advanced this wire across the aortic valve into the ascending patient has been on a 12-month follow-up. His exercise
aorta for maximum support (Figure 2A). The JR catheter capacity has improved dramatically, and the mean trans-
was then advanced across MV, and Terumo wire was now mitral gradient was less than 5 mmHg on subsequent TTE
exchanged with spring coil wire to prevent LV perforation examinations, with no residual ASD shunt (Figure 3C).
during balloon advancement (Figure 2B). The JR catheter
3. Discussion
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A B MS occurs in approximately 4% of patients with ASDs.
While the presence of ASD theoretically simplifies the
process of BMV in LS, recent case reports have shed light
on the unique challenges faced by interventionalists. 5,6
First, the hemodynamic physiology in LS permits left
atrial decompression, resulting in a smaller LA (with a
larger RA) compared to isolated MS. This anatomical
abnormality complicates the manipulation of the balloon
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to pass the MV. Second, the substantial defect causes the
C D
balloon catheter to float freely, exacerbating its instability
during maneuvers to cross the stenosed MV, unlike in
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isolated MS, where the normal interatrial septum supports
the catheter shaft, facilitating an acute curve with the
balloon tip pointing toward the MV orifice.
Therefore, percutaneous intervention in LS goes
beyond the mere combination of two individual
procedures — BMV and ASD device closure. The unique
anatomic and hemodynamic aspects of this condition
Figure 2. (A) 035” Terumo wire crossed across MV and AV and finally should be thoroughly considered in advance, and the
parked into the aorta for maximal stability; (B) SYM balloons (size 26) interventionalist must be well-versed in employing

being advanced across the MV over the spring coil wire parked in the LV various techniques that facilitate balloon manipulation

cavity; (C) balloon dilatation of MV with SYM balloon; (D) ASD device and entry across the MV. These techniques encompass the
16 mm post-deployment across ASD. 8
Abbreviations: ASD: Atrial septal defect; AV: Aortic valve; LV: Left modified Inoue technique, the use of balloon floatation
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ventricle; MV: Mitral valve. catheters, reshaping the stylet, the over-the-wire (OTW)
Volume 2 Issue 1 (2024) 3 https://doi.org/10.36922/bh.1701