Down the Memory Lane of Tamponade During Balloon Mitral Valvotomy

Dear Editors:

I read with interest about the hemopericardium following transseptal puncture during balloon mitral valvotomy (BMV), their management strategies and outcomes by Panneerselvam et al.¹ I want to congratulate the authors for addressing this complication. However, there are certain issues that need to be clarified regarding the hemopericardium during transseptal puncture. First, the authors should have focused more on the mechanism of cardiac perforation during transseptal puncture and noted how many patients had “stitch phenomenon” as a cause of hemopericardium during BMV, which is a rare complication when the needle pierces the intrapericardial space from the right atrial side and re-enters the left atria. Second, the authors might have forgotten to acknowledge the large study by Joseph et al.² Although the study design was different from the present study, Joseph et al² elegantly published the mechanisms of cardiac perforation in 10 cases (1.1%) of cardiac tamponade in a single-center series of 903 BMV procedures. In Table 1, I tried to compare various large studies on tamponade during BMV,  including the site of perforation and mortality after tamponade.

Sincerely,

Sourabh Agstam, MBBS, MD, Assistant Professor, Department of Cardiology, VMMC and Safdarjung Hospital, New Delhi, India 110029. Email: sourabhagstam@gmail.com

Authors’ Response:

We thank the author for their careful appraisal of our study.¹ The author highlights the relevant prior studies focusing on hemopericardium during BMV, with emphasis on mechanisms of cardiac perforation.^2,3

Hemopericardium is a major complication during BMV, resulting from perforation at specific sites within the heart. The sites of perforation could be one of the cardiac chambers or the aortic root. They occur at distinct time points during the procedure — either during transseptal puncture or manipulation of balloon catheters and wires during mitral valve dilation, and rarely due to temporary pacing catheter positioned in the right ventricular apex.² We fully agree it is important to understand the exact mechanism to plan effective preventive and treatment strategies. The main aim of our study was to evaluate the safety and feasibility of completing BMV in the same sitting with a second transseptal puncture. Importantly, our study cohort only included patients with hemopericardium following transseptal access and all cases of BMV were completed by Inoue technique using the Accura balloon catheter (Sanare Medical Products). Furthermore, only one-fifth of the patients (6 patients) underwent emergency surgery for hemopericardium. The majority of the patients did not undergo surgery and the precise location of perforation could not be ascertained. Therefore, we did not highlight on mechanisms of perforation in our study. None of our patients had “stitch phenomenon” as a cause of hemopericardium during BMV. In this situation, the catheter/needle will perforate the right atrial wall and then re-enter the left atrium through the pericardial space. This is an alarming situation as blood enters the pericardial space from both the atria and warrants an emergency surgery.⁴

The study by Joseph et al is indeed one of the landmark studies on hemopericardium during BMV. Nonetheless, in 60% of the cases, the hemopericardium was unrelated to transseptal access. Notably, all cases were related to the double-balloon technique and hence are not necessarily relevant to other BMV techniques, such as the Inoue balloon technique that was performed in our study. Furthermore, all patients in the study by Joseph et al² underwent emergency surgery. It is clear from our work that the majority of patients developing hemopericardium following transseptal access during BMV do not mandate an emergency surgery.

Sincerely,

Arunkumar Panneerselvam, MD, DM; Satvic C. Manjunath, MD, DM; Rajiv Ananthakrishna, MD, DM

Address for correspondence: Dr Satvic C. Manjunath, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Jaya Nagar 9th Block, BG Road, Bangalore, India 560069. Email: drsatvic@gmail.com

1. Panneerselvam A, Ananthakrishna R, Srinivas BC, et al. Hemopericardium following transseptal puncture during balloon mitral valvotomy: management strategies and outcomes. J Invasive Cardiol. 2020;32:70-75. 
2. Joseph G, Chandy ST, Krishnaswami S, Ravikumar E, Korula RJ. Mechanisms of cardiac perforation leading to tamponade in balloon mitral valvuloplasty. Cathet Cardiovasc Diagn. 1997;42:138-146. 
3. Pan M, Medina A, Suárez de Lezo J, et al. Cardiac tamponade complicating mitral balloon valvuloplasty. Am J Cardiol. 1991;68:802-805.
4. Deshpande J, Vaideeswar P, Sivaraman A, Kulkarni H. Balloon mitral valvotomy: an autopsy study. Int J Cardiol. 1995;52:67-76.