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Case Report

Percutaneous balloon pulmonary valvuloplasty: Amodified over-the-wire Inoue balloon technique fordifficult right ventricular anatomy

Surender Deora*, Chirayu Vyas, Sanjay Shah, Tejas Patel

Department of Cardiovascular Sciences, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College,

Gujarat University, Ellisbridge, Ahmedabad 380006, Gujarat, India

a r t i c l e i n f o

Article history:

Received 29 July 2013

Accepted 4 December 2013

Available online 25 December 2013

Keywords:

Pulmonary stenosis

Balloon pulmonary valvuloplasty

Superstiff wire

Inoue PTMC catheter

* Corresponding author. Tel.: þ91 8238422947E-mail address: drsdeora@gmail.com (S.

0019-4832/$ e see front matter Copyright ªhttp://dx.doi.org/10.1016/j.ihj.2013.12.010

a b s t r a c t

Percutaneous balloon pulmonary valvuloplasty (BPV) is the mainstay of treatment for

significant pulmonary stenosis with doming leaflets. Various techniques have been

described in the literature including the use of Inoue Percutaneous Transseptal Mitral

Commissurotomy (PTMC) catheter with standard 0.02500 guidewire. But if right ventricular

anatomy is not suitable, 0.02500 guidewire doesn’t provide enough support to track the

Inoue PTMC catheter. Here, we report a case of successful BPV using a novel technique of

slenderizing the Inoue Percutaneous Transseptal Mitral Commissurotomy (PTMC) catheter

over an Amplatz superstiff 0.03500 guidewire. This technique may be useful during BPV in

difficult right ventricular inflow and outflow tract anatomy in patients with congenital

pulmonary valve stenosis.

Copyright ª 2013, Cardiological Society of India. All rights reserved.

1. Introduction

Congenital valvular pulmonary stenosis (PS) accounts for

5e10% of all congenital heart disease. Inmost of the cases, the

stenosis is due to fusion of commissures leading to “doming”

of the valve leaflets and rarely may be due to dysplastic leaf-

lets. Balloon pulmonary valvuloplasty (BPV) is safe and effec-

tive in attaining both immediate and long term reduction of

pulmonary valvular gradients and is currently the preferred

therapeutic modality for “doming” valvular PS. Successful BPV

has been reported with standard Inoue Percutaneous Trans-

septal Mitral Commissurotomy (PTMC) catheter but has limi-

tation in difficult right ventricle anatomy due to inadequate

support of the 0.02500 guidewire and rigidity of themetal stylet.

Here, we describe a case of successful BPVwithmodified over-

; fax: þ91 79 26842288.Deora).2013, Cardiological Societ

the-wire technique in patient with congenital valvular PSwith

difficult RV anatomy.

2. Case report

A 23-year-oldmale patient presented with exertional dyspnea

and fatigue for last 2 years. On clinical examination, patient

was hemodynamically stable with Grade 4/6 ejection systolic

murmur in 2nd and 3rd left intercoastal space near the ster-

num. Two-dimensional cross-sectional echocardiographic

and Doppler examination revealed thickened and doming

pulmonary valve leaflets with severe stenosis and significant

right ventricular (RV) dysfunction. Right atrium was signifi-

cantly dilated with severe tricuspid regurgitation (TR). On

cardiac catheterization, the mean right atrial (RA) pressure

y of India. All rights reserved.

Fig. 1 e Right ventricular angiogram in lateral view revealing trabeculated right ventricle, stenotic pulmonary valve (Arrow)

and main pulmonary artery (Panel A). An over-the-wire inflated Maxi LD balloon catheter in main pulmonary artery

(Panel B).

i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 2 1 1e2 1 3212

was 15 mmHg and RV systolic pressure was 150 mmHg. RV

angiography revealed severe valvular PS with a pulmonary

valve annulus of 19 mm and a distorted RV inflow (massively

dilated right atrium and severe tricuspid regurgitation) and

outflow anatomy (Fig. 1A, S Video 1). With informed consent,

BPV was planned. The pulmonary valve was crossed with a

0.03500 hydrophilic 260 cm long guidewire (Radifocus, Terumo

Corp, Japan) over which a 6 Fr JR 4 diagnostic catheter (Cordis,

Johnson & Johnson, USA) was tracked. Peak systolic pulmo-

nary artery (PA) pressure was 20 mmHg, yielding a peak-to-

peak gradient across the PV of 130 mmHg. A 0.03500 Amplatz

superstiff 260 cm long guidewire (Cordis, Johnson & Johnson,

USA) was positioned in the distal right PA branch. A 12 Fr

Sheath was inserted into the right femoral vein. An over-the-

wire 20 � 40 mm Maxi LD balloon catheter (Cordis, Johnson &

Johnson, USA) was introduced through this sheath and

negotiated across the pulmonary valve. However, constant

forward slippage of the balloon into the PA or back into the RV

outflow tract prevented optimal balloon positioning at the

pulmonary valve despite using RV pacing (Fig. 1B). Further-

more, balloon inflation was associated with prolonged

bradycardia and severe hypotension. Thereafter, BPV was

attempted with standard Inoue PTMC balloon catheter but

due to inadequate support with 0.02500 stainless steel guide-

wire the catheter couldn’t be tracked. Therefore, the 0.02500

stainless steel guidewire was exchanged for the 0.03500

Amplatz superstiff guidewire and positioned in the distal right

PA. Subsequently, the Inoue PTMC catheter was slenderized

without themetal stylet over the Amplatz superstiff guidewire

(an off label use) and advanced across the pulmonary valve

without difficulty. The stenotic pulmonary valve was dilated

with the Inoue PTMC catheter at 22 mm with stable position

(Fig. 2A and B). After dilatation, the RV systolic pressure was

reduced to 65mmHg and the PA systolic pressure increased to

35 mmHg. Catheter pull back revealed a residual gradient of

4 mmHg across the PV and an infundibular gradient of

25 mmHg. The mean RA pressure was reduced to 6 mmHg.

Patient was discharged in hemodynamically stable condition.

Supplementary video related to this article can be found

online at http://dx.doi.org/10.1016/j.ihj.2013.12.010

3. Discussion

Since its first description in 1982 by Kan et al, percutaneous

balloon valvuloplasty has revolutionized the treatment of

congenital valvular PS.1,2 It is currently the preferred

therapeutic modality for valvular PS in children and in

adults.3e6 Current approaches of BPV utilize various fixed

size balloon catheters using a single or a double balloon

technique. Use of over-the-wire fixed size balloons with a

0.03500 Amplatz superstiff guidewire is used for management

of critical valvular PS, but balloon instability and long infla-

tionedeflation time causes bradycardia and hypotension as in

our case. These limitations were addressed using an Inoue

PTMC catheter as it has relatively short and flexible balloon

unlike the standard fixed size balloon catheter which has a

longer balloon portion and a sharper tip. It also has a unique

property of self positioning, enabling it to anchor at the pul-

monary valve during inflation, thus preventing abrupt for-

ward movement and damage to the PA.7,8 Another advantage

is its rapid inflation and deflation cycle (approximately 4e5 s)

allowing fast hemodynamic recovery and also allows graded

dilations by increasing the size of the same balloon, thus

preventing cumbersome exchanges of balloons. In the stan-

dard over-the-wire technique, the Inoue PTMC catheter after

slenderizing over the metal stylet is usually advanced over its

accompanying 0.02500 floppy tipped stainless steel guidewire.

It can also be advanced freely but in relatively simpler RV

inflow and outflow anatomy.8 In patients with difficult RV

anatomy as in our case the standard technique is limited by

the rigidity of the metal stylet and also by inadequate support

of the 0.02500 guidewire for tracking the Inoue PTMC catheter

across the pulmonary valve. This creates difficulty in optimal

positioning of the balloon across the pulmonary valve. Slen-

derizing the Inoue PTMC catheter (without the metal stylet)

Fig. 2 e Partially inflated (Panel A) and completely inflated (Panel B) Inoue PTMC balloon across the stenotic (Arrow)

pulmonary valve.

i n d i a n h e a r t j o u rn a l 6 6 ( 2 0 1 4 ) 2 1 1e2 1 3 213

over a 0.03500 Amplatz superstiff guidewire provides an extra

support for tracking the balloon with its optimal positioning

across a critically stenosed pulmonary valve. This modified

over-the-wire technique has advantage of both the Inoue

balloon and 0.03500 Amplatz superstiff guidewire for adequate

support thus increases the chances of successful BPV in

difficult right ventricular inflow and outflow tract anatomy in

patients with congenital pulmonary valve stenosis.

4. Conclusion

This case highlighted the advantage of slenderizing the Inoue

PTMC catheter over a 0.03500 Amplatz superstiff guidewire.

This modified over-the-wire technique can be reserved for

patients with severe pulmonary stenosis and difficult RV

anatomy during BPV.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

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3. Fawzy ME, Mercer EN, Dunn B. Late results of pulmonaryballoon valvuloplasty in adults using double balloontechniques. J Interven Cardiol. 1988;1:35e42.

4. Kveselis DA, Rocchini AP, Snider AR, et al. Results of balloonvalvuloplasty in the treatment of congenital valvularpulmonary stenosis in children. Am J Cardiol. 1985;56:527e553.

5. Sherman W, Hershman R, Alexopoulos D, et al. Pulmonicballoon valvuloplasty in adults. Am Heart J. 1990;119:186e190.

6. Henmann HC, Hill JA, Krol J, et al. Effectiveness ofpercutaneous balloon valvuloplasty in adults with pulmonicvalve stenosis. Am J Cardiol. 1991;68:1111e1113.

7. Lau KW, Hung JS, Wu JJ, et al. Pulmonary valvuloplasty inadults using the Inoue balloon catheter. Cathet CardiovascDiagn. 1993;29:99e104.

8. Patel TM, Dani SI, Shah SC, et al. Inoue balloon pulmonaryvalvuloplasty using a ‘free-float technique’. J Invasive Cardiol.1996;8:374e377.