Percutaneous Transvenous Mitral Commissurotomy Via Left Femoral Vein Approach — Exploring an Unusual Approach for Left Atrial Entry

ABSTRACT: Percutaneous transvenous mitral commissurotomy (PTMC) using Inoue technique through a right femoral vein approach (RFVA) is well established. Left femoral vein approach (LFVA) is traditionally contraindicated because of certain technical issues. We report a case of PTMC successfully done through this unusual approach, which should be reserved exclusively for cases with right femoral vein occlusion. It also opens up the avenue for other interventions requiring a septal puncture, left atrial entry and use of bulky devices.

J INVASIVE CARDIOL 2011;23:E145–E146

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Percutaneous transvenous mitral commissurotomy (PTMC) using the Inoue technique through a right femoral vein approach (RFVA) is well established. The left femoral vein approach (LFVA), however, is traditionally contraindicated. We report a case of PTMC performed via the LFVA, which should be reserved for patients with right femoral vein occlusion.

Case Report. A 27-year-old female patient was admitted to the Intensive Care Unit with a confirmed diagnosis of severe rheumatic mitral stenosis, severe PAH, and sinus rhythm. 2-dimensional echo color Doppler study revealed pliable mitral valve (MV) with area of 0.9 cm² and severe pulmonary artery hypertension (estimated right ventricular systolic pressure of 75 mmHg). Patient had right femoral vein (RFV) occlusion because of previous groin injury confirmed by venous Doppler study. Informed consent for a PTMC procedure through the left femoral vein approach (LFVA) was given. After LFV cannulation, a Mullins dilator was advanced over a 0.032˝ standard guidewire into the superior vena cava (SVC). The Brockenbrough needle was preshaped, with a gentle curve about 15 cm proximal to its tip in the same direction. While negotiating the needle in the Mullins dilator, significant resistance was felt at the junction of the inferior vena cava (IVC) and left iliac vein. The acute angle at the junction prevented the entry of the stiff Brockenbrough needle into the IVC. At this point, we used a “telescoping” technique, i.e., simultaneous gentle push of the needle while pulling the Mullins dilator (Figure 1A). This maneuver allowed smooth entry of the needle into the IVC and then SVC by minimizing the friction at the venous angulation. Transseptal puncture was then performed using the standard technique. After placement of a 0.025˝ coiled guidewire in the left atrium (LA), a 14 Fr septal dilator was introduced over-the-wire. The acute venous angle was crossed smoothly, using a corkscrew movement of the dilator along with simultaneous “telescoping” technique (Figure 1B). After septal dilatation, a slenderized Inoue balloon catheter was negotiated over-the-wire and PTMC was performed using its standard procedure (Figures 1C and 1D). The mean gradient was reduced from 20 mmHg to 1 mmHg and the patient made an uneventful recovery. A 2-dimensional echo color Doppler study revealed MV area of 2 cm². The patient was discharged on the fourth day in a stable hemodynamic condition.

Discussion. Although traditionally contraindicated, there is a mention in the literature about LFVA for PTMC using the Inoue technique.¹ LFVA is not preferred because of certain technical issues, including negotiation of a stiff Brockenbrough needle through an acute IVC-left iliac vein angle, difficult location of a correct puncture site, as well as negotiation of a 14 Fr septal dilator and a bulky slenderized Inoue PTMC catheter across the acute venous angle.^1–3

The transseptal puncture technique was developed by Ross et al in the late 1950s to allow left heart catheterization, principally for the evaluation of valvular heart disease.⁵ Initially, this technique was advocated through either the right or left femoral venous approach.^4,5 However, with the introduction of PTMC, particularly using the Inoue technique, RFVA is traditionally preferred and recommended for transseptal puncture, since it is easy to negotiate a septal puncture needle, a bulky 14 Fr septal dilator and a slenderized Inoue PTMC catheter through a relatively straight venous course.^6,7 Because of the global reduction in the incidence of rheumatic fever and rheumatic heart disease, there is a steep decline in the number of PTMC procedures. However, it is important to understand the steps of septal puncture technique because of the evolution of new interventions requiring its application and LA entry. They include an umbrella closure of atrial septal defect or patent foramen ovale, a percutaneous placement of LA appendage occluder, a pulmonary venous access for atrial fibrillation ablation and a left-sided bypass tract ablation.^8–10 Just like the Inoue technique, these procedures involve negotiation and tracking of bulky devices through the venous route in the left atrium.

Traditionally, LFVA is avoided because of acute venous angle. We have shown the feasibility of LFVA for PTMC by doing certain modifications in the traditional steps of the Inoue technique. First, pre-shaping the proximal part of a Brockenbrough needle in the same direction as its natural curve at the tip helped maintain the contact of the tip to the septum and provided comfortable LA entry. Second, the “telescoping” method helped reduce the friction because of stretching of the acute venous angle while negotiating a 14 Fr dilator and a slenderized Inoue PTMC catheter. LFVA for PTMC using the Inoue technique should be reserved for situations such as RFV occlusion. However, understanding the steps of this technique may help in successful completion of other interventions involving a septal puncture and LA entry through LFVA when the RFV is occluded.

References

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From ¹the Department of Cardiology, Sheth V.S. General Hospital, and ²Total Cardiovascular Solutions Private Limited, Ahmedabad, India.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted September 28, 2010, final version accepted October 15, 2010.
Address for correspondence: Tejas Patel, MD, FACC, FSCAI, FESC, Professor and Head, Department of Cardiology, Sheth V.S. General Hospital, Ahmedabad-380 006, India. Email: tejaspatel@tcvsgroup.org