Challenging Case of Balloon Mitral Valvuloplasty: Coronary Balloon to the Rescue

J INVASIVE CARDIOL 2021;33(9):E748-E749.

Key words: balloon rupture, cardiac imaging, complications

A 52-year-old female patient with severe rheumatic non-calcific mitral stenosis presented to the emergency department in New York Heart Association class IV heart failure. Her mitral valve area was 0.8 cm2 and mean diastolic gradient was 18 mmHg. Emergency percutaneous balloon mitral valvuloplasty (BMV) was planned with a reused Inoue balloon. The balloon was checked for damage prior to insertion. After successful entry into the left ventricle, we detected inflation failure secondary to contrast extravasation from the distal tip of the balloon (Figure 1A). Due to lack of a backup balloon and the patient’s refusal for emergency surgery, we attempted an off-label improvisation to correct the leak. The leak occurred through a single small rent at the tip. We advanced a 2 x 9 mm Sprinter non-compliant coronary balloon (Medtronic) over a 0.014" coronary guidewire through the central lumen of the Inoue balloon (Figure 1B and Figure 1C). Inflation of the non-compliant balloon to 20 atm sealed the rent (Figure 1D). After confirming successful inflation and deflation of the Inoue balloon externally (Figure 1E), the entire assembly, including the NC balloon (arrow), was reintroduced and the procedure was completed successfully (Figure 1F and Figure 1G; Video 1). The patient is doing well 10 months post procedure.

The Inoue balloon (Toray) is a trilayered device with a middle layer of polyester micromesh between 2 latex layers. The strength of this layer determines the risk of rupture. Reuse of an Inoue balloon leads to its increased wear and tear. Frequent sterilization with ethylene oxide also contributes to the structural degeneration. The most common site of rupture is the distal part of the balloon.

Owing to the demonstrated safety and cost-effectiveness, BMV is frequently performed with reused hardware. However, chances of hardware malfunction are higher in such settings, making it pertinent for operators to be adept at recognition and management of such complications. This case illustrates that when the rent is small, a coronary balloon may be used to tackle the inflation failure.