An Inadvertent Event During Percutaneous Transvenous Mitral Commissurotomy

J INVASIVE CARDIOL 2023;35(6):E327-E328. doi: 10.25270/jic/22.00331

Key words: percutaneous transvenous mitral commissurotomy, echocardiography, fluoroscopy

A 50-year-old

male presented with breathlessness on exertion for 3 years. He had loud S1 and a mid-diastolic murmur at apex. Electrocardiogram (ECG) showed sinus rhythm, P mitrale, and right ventricular hypertrophy with strain. 2D echocardiography revealed severe mitral stenosis (valve area .6 cm²) with 18 mmHg mean valve gradient.

Considering symptomatic severe mitral stenosis and suitable valve anatomy, percutaneous transvenous mitral commissurotomy (PTMC) was planned. Transeptal puncture was done under fluoroscopy guidance using Brockenbrough needle/Mullins 8 Fr dilator combination. Needle’s position in the left atrium (LA) was ascertained with pressure tracing and by withdrawal of bright red blood. To confirm and delineate LA anatomy, on contrast injection via Mullins sheath, an unexpected ovoid shaped, contrast-stained structure was noticed even before the left atrium was filled with contrast (Panel A).

Possibilities considered included stitch phenomenon, interatrial septal dissection, and juxtaposed right atrial appendage. Since LA pressure had been demonstrated prior to injection, inadvertent aortic wall injury was not considered. Unsure of the possible etiology, the dilator and needle were removed. Echocardiography showed no pericardial collection after a waiting period ruling out stitch phenomenon. Computed tomography showed no evidence of juxtaposed right atrium and no aortic wall injury. Transesophageal echocardiography clinched the diagnosis by showing tunnel-like interatrial septal dissection (Panels B and C). Seven days later, the patient underwent successful transseptal puncture and PTMC without complications.

Success rate of fluoroscopy guided transseptal puncture is >90%, but atrial septal dissection is reported in 1.2%. The most possible explanation for septal dissection here could be a possible puncture into septum secundum.

Affiliations and Disclosures

From ¹Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, JIPMER Campus Road, Dhanvantari Nagar, Puducherry.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was received for the publication of the images herein.

Manuscript accepted December 8, 2022.

Address for correspondence: Ramanathan Velayutham, MD, Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research JIPMER Campus Road, Dhanvantari Nagar, Puducherry, Email: nadalram@gmail.com