Percutaneous Balloon Valvuloplasty of Coexisting Mitral and Tricuspid Stenosis: Single-Wire, Double-Balloon Technique

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J INVASIVE CARDIOL 2008;20:E126-E128

Technique. Percutaneous transmitral commissurotomy (PTMC) was first described by Inoue et al in 1984 as an alternative to surgical closed mitral commissurotomy for severe rheumatic mitral stenosis (MS).¹ PTMC is less traumatic, cosmetically more acceptable and its early and mid-term results in selected cases are similar or better than surgical commissurotomy. Two techniques have been established for balloon mitral valvotomy: single- (Inoue) and double-balloon.² Both procedures have been shown to produce an improvement in mitral valve area, hemodynamics and functional class.^3–9 In developing countries, cost issues are the major problem in managing rheumatic MS due to the low socioeconomic status of many patients. This problem was addressed by Cribier et al¹⁰ and Arora et al¹¹ with the development of a percutaneous metallic device that can be autoclaved and reused. The Multi-Track^™ single-wire, double-balloon device (NuMED, Inc., Hopinkton, New York) was introduced by Bonhoeffer in 1999. It is simple to use, inexpensive, can be reused after sterilization in ethylene oxide and has shown optimal results.¹²
Tricuspid stenosis (TS) has been successfully treated with balloon valvuloplasty.¹³ Concurrent successful percutaneous valvuloplasty of combined mitral and tricuspid value stenosis employing either the Inoue technique^14–16 or a metallic valvotome and Inoue balloon have been reported in the literature.¹⁵ To our knowledge, we are reporting the first case of balloon valvotomy in a patient with coexisting MS and TS in whom we used a single-wire, double-balloon technique with the Multi-Track system. Immediate 2-year follow-up results are described.

 
Case report.On May 2005, a 25-year-old male patient with combined rheumatic MS and TS was diagnosed by clinical examination which revealed signs of severe MS and TS and severe pulmonary hypertension. Electrocardiography (ECG) showed sinus rhythm and biatrial enlargement. A two-dimensional (2-D) transthoracic Doppler echocardiogram revealed thickened, domed and pliable mitral and tricuspid valves with severe MS and a mitral valve area (MVA) of 1 cm², as well as severe TS (tricuspid valve area [TVA] of 0.9 cm² with mild tricuspid regurgitation [TR] secondary to pulmonary artery hypertension). The patient was subjected to simultaneous double-valve dilatation in a single setting using the Multi-Track balloon catheter of different sizes. This was performed in the catheterization laboratory at the National Institute of Cardiovascular Diseases (NICVD) in Karachi, Pakistan.

Cardiac catheterization and procedure. After measuring baseline right- and left-heart catheterization (Figures 1 and 2), percutaneous balloon valvuloplasty (PBV) using a double balloon on a single wire12 (Bonhoeffer Multi-Track system) was performed. The mitral valve was dilated using 14 mm and 16 mm Multi-Track balloons (Figure 3), resulting in an immediate decrease in the patient’s transmitral pressure gradient from 15 mmHg to 2 mmHg (Table 1 and Figure 1). After PBV of the mitral valve, the tricuspid valve was also dilated with Multi-Track balloons, but of different sizes (20 mm and 14 mm). The mean tricuspid valve gradient decreased from 7 mmHg to 3 mmHg. Postprocedural echocardiography revealed a MVA of 2.2 cm² and a TVA of 3.0 cm².

Follow up. After the procedure, the patient was asymptomatic with New York Heart Association (NYHA) functional class II. Follow-up Doppler echocardiography studies at 6 months, 1 year and 2 years showed sustained benefit and improved NYHA functional class.

Discussion. Immediate results with the single- or doubleballoon techniques have varied in the literature, but longterm results are similar.^16,17 With the Multi-Track technique, 2 balloon catheters are used on a single guidewire. Instead of using a single Inoue balloon for both MS and TS valvuloplasty or a metallic valvotome for the mitral valve, we opted to use the Multi-Track device to compare outcomes in concurrent mitral and tricuspid valvuloplasty using either a single balloon or valvotome with a balloon in different centers.^15,18

Different techniques have been used in mitral valvuloplasty, PMMC,¹⁰ Inoue balloon and double-balloon procedures. 1,¹⁹ MVA using these different techniques was shown to increase from 1.84 cm² to 1.93 cm².^19,20 With the Multi- Track system, the MVA has been reported to increase from 0.75 ± 0.22 cm² to 2.0 ± 0.32 cm²,¹² which can be compared to our case, in which it was 2.2 cm². The Multi-Track system is cost effective, particularly in developing countries,¹² as it can be reused and produces fewer complications such as MR and cardiac tamponade.
Mitral and tricuspid stenosis were successfully dilated with the Multi-Track system, which is simple to use and requires less fluoroscopy time. The overall average fluoroscopy time for an experienced operator employing this technique is 30 minutes; 12 our case required 15 minutes of fluoroscopy, which is similar to fluoroscopy times with the Inoue technique. Moreover, during the 2-year follow-up period, our patient maintained the same MVA and improvement in NYHA functional class. Several reports have concluded that optimal valve area is an important predictor for long-term outcomes.¹⁶ Conclusion In conclusion, percutaneous balloon valvuloplasty with the Multi-Track system for combined MS and TS is simple, cost effective and offers optimal outcomes, and is comparable with the Inoue technique.

References

1. Inoue K, Owaki T, Nakamura T, et al. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thoracic Cardiovasc Surg 1984;87:394–402.
2. Al Zaibag M, Ribeiro PA, Al Kasab S, Al Fagih MR. Percutaneous double-balloon mitral valvotomy for rheumatic mitral valve stenosis. Lancet 1986;1:757–761.
3. Chen C, Lo Z, Huang Z, et al. Percutaneous trans-septal balloon mitral valvuloplasty: The Chinese experience in 30 patients. Am Heart J 1990;115:937–947.
4. Herrmann HC, Kleaveland JP, Hill JA, et al, for the M-Heart Croup. The Mheart percutaneous balloon mitral valvuloplasty registry: Initial results and early follow up. J Am Coll Cardiol 1990;15:1221–1226.
5. Palacios IF, Block PC. Percutaneous mitral balloon valvotomy (PMV): Update of immediate results and follow up. Circulation 1989;8(Suppl II): II 489.
6. Chen CR, Huang D, Lo ZX, Cheng TO. Comparison of single rubber-nylon balloon and double polyethylene balloon valvuloplasty in 94 patients with rheumatic mitral stenosis. Am Heart J 1990;119:102–111.
7. Mc Kay CR, Kawanishi DT, Kotlewaski, et al. Improvement in exercise capacity and exercise hemodynamics 3 months after double balloon, catheter balloon valvuloplasty treatment of patients with symptomatic mitral stenosis. Circulation 1988;77:1013–1021.
8. Al Zaibag M, Ribeuro PA, Al Kasab S, et al. One year follow up after percutaneous double balloon mitral valvotomy. Am J Cardiol 1989;63:117–126.
9. Palacios IF, Block PC, Willeims GT, Weyman AE. Follow up of patients undergoing percutaneous mitral balloon valvotomy: Analysis of factors determining restenosis. Circulation 1989;79:573xs–579.
10. Cribier A, Rath PC, Letac B. Percutaneous mitral valvotomy with a metal dilater. Lancet 1997;7;349:1667.
11. Arora R, Kalra GS, Sing S, et al. Non-surgical mitral commissurotomy using metallic commissurotome. Indian Heart J 1998;50:91–95.
12. Bonhoeffer P, Esteves C, Casal U, et al. Percutaneous mitral valve dilatation with the Multi-track system. Catheter Cardiovasc Interv 1999;48:178–183.
13. Zaibag AM, Ribeiro P, Kasab AS. Percutaneous balloon valvuloplasty in tricuspid stenosis. Br Heart J 1987:57:51–53.
14. San Carktar O, Kumbasar SD, Semiz E, Yabcinkaya S. Late results of combined percutaneous balloon valvuloplasty of mitral and tricuspid valves. Cathet Cardiovasc Diagn 1998:45:246–250.
15. Sharieff S, Saghir T, Shah-e-Zaman K. Concurrent percutaneous valvuloplasty of mitral and tricuspid valve stenosis. J Invasive Cardiol 2005:17:340–342.
16. Orrange SE, Kawashini DT, Lopiz BM, et al. Actuarial outcome after catheter balloon commissurotomy with mitral stenosis. Circulation 1997;95:382–389.
17. Palacios IF. Farewell to surgical mitral commissurotomy for many patients. Circulation 1998;97:223–226.
18. Bahl VK, Chandra S, Mishra S. Concurrent balloon dilatation of mitral and tricuspid stenosis during pregnancy using an Inoue balloon. Int J Cardiol 1997;59:199–202.
19. Vahanian A, Cormier B, Lung B. Percutaneous transvenous mitral commissurotomy using the Inoue balloon International experience. Cathet Cardiovasc Diagn 1994;2:8–15.
20. Chen CR, Cheng TO. Percutaneous balloon mitral valvuloplasty by the Inoue technique. A multi-centre study of 4832 patients in China. Am Heart J 1995;129:1197–1203.