|Year : 2018 | Volume
| Issue : 2 | Page : 151-154
Percutaneous transvenous mitral commissurotomy and coronary intervention in kyphoscoliosis
Gnanaraj Justin Paul1, Chandrasekaran Elangovan1, Ganesan Gnanavelu1, 2
1 Department of Cardiology, Madras Medical College, Chennai, Tamil Nadu, India
2 , India
|Date of Web Publication||13-Dec-2018|
Dr. Ganesan Gnanavelu
Department of Cardiology, Madras Medical College, Chennai, Tamil Nadu 600003
Source of Support: None, Conflict of Interest: None
Rheumatic mitral stenosis is the most common lesion among valvular heart disease in Asian countries. Coexistence of coronary artery disease and rheumatic heart disease is not uncommon. Case summary of a middle-aged woman with kyphoscoliosis, significant left circumflex artery stenosis, and severe mitral stenosis who was managed successfully with percutaneous transvenous mitral commissurotomy followed by percutaneous coronary intervention in the same sitting is presented. The major challenge was interatrial septal puncture in distorted anatomy, which was overcome by meticulous defining of septal plane by angiography and proper technique of puncture. The controversy about the timing of administration of loading dose of antiplatelet and heparin is discussed.
Keywords: Balloon angioplasty, balloon valvotomy, septal puncture, skeletal deformity
|How to cite this article:|
Justin Paul G, Elangovan C, Gnanavelu G. Percutaneous transvenous mitral commissurotomy and coronary intervention in kyphoscoliosis. Indian Heart J Interv 2018;1:151-4
|How to cite this URL:|
Justin Paul G, Elangovan C, Gnanavelu G. Percutaneous transvenous mitral commissurotomy and coronary intervention in kyphoscoliosis. Indian Heart J Interv [serial online] 2018 [cited 2019 Jan 21];1:151-4. Available from: http://www.ihji.org/text.asp?2018/1/2/151/247458
| Introduction|| |
Rheumatic heart disease (RHD) is still a major cause of cardiovascular morbidity and mortality in developing countries predominantly among children and young adults. Rarely middle aged and elderly present with the symptoms of RHD in whom coronary artery disease (CAD) is a major coexisting disease. Many patients are likely to be diagnosed in future with both RHD and CAD with the need to treat both the conditions. We report a case of combined percutaneous transvenous mitral commissurotomy (PTMC) and percutaneous coronary intervention (PCI) performed in a single sitting in a patient with severe kyphoscoliosis.
| Case Report|| |
A 43-year-old premenopausal woman presented with shortness of breath and angina NYHA (New York Heart Association) class II and occasional nocturnal dyspnea of 3 months duration. She never had palpitation, swelling of legs, or syncope. No conventional modifiable risk factor for CAD or history of rheumatic fever was reported. General examination revealed short stature (130cm), weight of 40kg, severe kyphoscoliosis, and mild anemia. Cardiovascular examination revealed regular pulse of 80 bpm with normal volume, blood pressure of 124/80mm Hg, ectopic apical impulse, loud first heart sound, mid-diastolic murmur with presystolic accentuation, and loud pulmonary component of second heart sound. Lungs were clear. She was able to lie down in supine position [Figure 1]. Electrocardiogram showed sinus rhythm with a rate of 80 bpm and left atrial (LA) enlargement. Transthoracic echocardiography (TTE) revealed severe mitral stenosis with a mitral valve area of 1.0cm2 by planimetry and pressure half-time and trivial mitral regurgitation. The valve looked pliable for valvotomy with Wilkins score of 7. In view of her age, she underwent coronary angiogram, which showed 90% discrete stenosis in the large obtuse marginal (OM) branch proximally and minimal disease in the left main and left anterior descending artery. As the mitral valve was suitable for PTMC, she was offered PTMC followed by PCI. Informed consent was obtained and surgical backup was arranged. The patient was already on dual antiplatelet (clopidogrel and aspirin) drugs. No additional dose of clopidogrel was given. Procedure was carried out through right femoral artery and venous access. Right atrial (RA) angiogram was performed in biplane frontal and lateral view until the aorta was visualized to identify the atrial septal orientation and LA silhouette [Figure 2]. Left ventricular (LV) angiogram was conducted in 30° right anterior oblique view [Figure 3] and 45° left anterior oblique view to assess the degree of mitral regurgitation, mitral valve orifice plane, LV orientation, and position of aorta. In the lateral view, interatrial septum was punctured by septal flush and stain technique. TTE helped in identifying the optimal site of puncture [Figure 4]. LA entry was confirmed by contrast injection and pressure measurement. Four thousand units of unfractionated heparin was administered. A 0.025” coil wire was placed in LA, and septal puncture was dilated using 14F plastic dilator. Mitral valve was crossed with 24-mm SYM (Lifetech) balloon using 0.038” stylet, and single dilatation of 23mm was given [Figure 5]. LA mean pressure dropped from 18 to 9mm Hg. Mitral valve area measured 2.0cm2 by planimetry in echo. Both commissures appeared split with no increase in mitral regurgitation. PCI to OM was carried out using 3.5 EBU guiding catheter and BMW elite guidewire. Additional 1000 units of unfractionated heparin was administered. OM was directly stented with 2.25×18mm XIENCE V stent [Figure 6] and [Figure 7]. The patient was hemodynamically stable throughout the procedure and was discharged after 2 days without any complication., , ,
|Figure 4: Interatrial septal puncture using transesophageal echocardiographic guidance. Left panel: Brockenbrough needle position in AP view. Right panel: Septal puncture done in lateral view|
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|Figure 6: Left coronary injection reveals significant discrete stenosis of large OM branch|
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| Discussion|| |
PTMC has been used as an alternative to surgery since 1984 when Inoue et al. initially described the procedure. In the last two decades, an increase in the number of PTMC procedures and experience has widened its application in patients with calcific valves, subvalvular disease, moderate mitral regurgitation, left atrial appendage clot, and Lutembacher syndrome, and as a hybrid therapy in patients with associated aortic valve disease. Transseptal catheterization is an important step in PTMC, which becomes difficult when there is distorted cardiac anatomy as seen in patients with kyphoscoliosis. Inoue et al. initially described septal puncture with RA angiogram with follow through LA visualization in the levophase to localize the site of septal puncture. Subsequently, Hung modified this with radiological landmarks without contrast angiogram. However, in a case of kyphoscoliosis, RA angiogram helps to localize the site of interatrial septum. In our patient, biplane RA angiogram was carried out, which helped to locate the puncture site within the area of overlap of RA and LA shadows. The needle position was confirmed in both AP and lateral views before puncturing the septum. Only very few cases of PTMC performed in patients with kyphoscoliosis have been reported.,
CAD is a condition commonly associated with mitral stenosis in patients more than 40 years of age. Mattina et al. have shown a frequency of 28% of significant CAD in patients with severe mitral stenosis and more than 40 years of age., The increase in the prevalence of RHD in the fifth and sixth decade necessitates the need to manage both CAD and RHD. Combined PCI and PTMC appears to be a better option in patients with the following:
- Contraindication for long-term anticoagulation therapy
- High surgical risk for open-heart procedure in a patient with thoracic kyphoscoliosis
- Favorable anatomical characteristics for valvular and coronary arterial lesion
PTMC may be carried out first followed by PCI for the reason that septal puncture is done before heparinizing the patient. There have been reports of patients developing cardiac tamponade when septal puncture is done after heparinizing them for PCI.
The timing of loading dual antiplatelet drugs is controversial. Our patient was already on dual antiplatelet drugs, which were not stopped. Some feel that antiplatelet drugs may be loaded after PTMC.
In the past, many of those patients with mitral stenosis and kyphoscoliosis have been treated by surgery, as there is a considerable risk of cardiac tamponade during septal puncture. In our patient, as the valve was suitable for PTMC and the patient was at high risk for surgery because of the associated skeletal deformity, we planned for PTMC and PCI. Careful septal puncture was the key to success in this patient. Only a few reports of combined PTMC and PCI performed in the same sitting are available.
| Conclusion|| |
CAD often coexists in patients with RHD in the middle-aged and elderly population. When there is significant mitral stenosis that is suitable for balloon valvotomy and coronary artery lesion, which is suitable for percutaneous intervention, both can be performed in the same sitting, and they both appear safe and seem to be a better alternative to surgery. Kyphoscoliosis makes interatrial septal puncture challenging and needs meticulous attention to locate the puncture site using angiography and echocardiography. To the best of our knowledge, this is the first report of combined PTMC and PCI in a patient with kyphoscoliosis.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]