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Efficacy of modified Technique
for atrial Septal Puncture in
Percutaneous Transvenous
Mitral Commissurotomy


Volume of PTMC at VNHI
705
610
560

553

491

523

495 509 504 510

327
6240 procedures in 2010
1419 PTCA,
510 PTMC,
458 CSI,
1165 EPS/PPM

143

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010


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
Frontal

Lateral


Classic Septal Puncture

Inoue

J.S Hung


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
Pliable
RS - matched (PTMC 26 for
RS = 26)
Calcified/SL
One size < RS-matched
Balloon sizing
Valvular status
Initial
Increment
Pliable
RS - 2 (mm)
1or 0,5 mm more
Calcified
RS - 4 (mm)
1 mm (LP)
0.5 mm (HP)


Research Parameter
General Parameter
Age, Sex, History of PTMC, History of Surgery,
Pregnancy…

SubClinical
ECG: Sinus Rhythm, AF…

Cardiac Ultrasound (Transthoracic, Transesophageal)
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
Favourable SP: SP ≤ 2 times
Difficult SP: SP > 2 times


Research Parameter

Procedure time (mins)
Radiation exposure time (mins)
Day of inpatient after PTMC (days)
Procedure result : Technical success
and no complocation.
Complication: Death, Tamponade…


Research Parameter

Access vessel: Right or Left Femoral Vein
Cardiothoracic ratio:
Normal (≤ 55%)
Enlarged (> 55%)

LA diameter and distance from lateral line of right
atrium and middle point of the spine (mm)
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
(X  SD) / n (%)
46,49  11,93(16-74)

Age
Sex

Male

35(20,23%)

Femal

138(79,77%)
8,42  0,58
102 (58,96%)

Wilkin score
Wilkins ≤ 8
Wilkins > 8

History of PTMC or mitral valve surgery

71 (41,04%)

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
n

Tỷ lệ %

R femoral vein

173

100

PA angiography

159

91,91

NO PA angio

14

8,09

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

33,95  7,84

the spine

90,57  10,02

LA diameter
Cardiothoracic ratio
Normal

30/61 (49,18%)

Enlargerd

31/61 (50,82%)


Cross Inoue Balloon into Mitral Stenotic valve

Balloon

n=171

Tỷ lệ %

Favourable (≤2 times)

152

88,89

Difficult (>2 times)

18

10,53

Fail

1

0,58

crossing

Direct

Slide and loop method