Cardiovascular Journal of Africa: Vol 29 No 3 (May/Junel 2018)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 3, May/June 2018 AFRICA 167
Percutaneous transmitral balloon commissurotomy using
a single balloon with arteriovenous loop stabilisation:
an alternative when there is no Inoue balloon
Endale Tefera, Mohamed Leye, Patrick Garceau, Denis Bouchard, Joaquim Miró
Abstract
Background: The Inoue balloon technique is the standard
technique for mitral valve balloon commissurotomy at this
stage. However, the hardware for this technique is expensive
and may not always be available in resource-limited settings.
Objectives: This article reports our experience with percuta-
neous transmitral balloon commissurotomy using a single
balloon (Nucleus) with arteriovenous loop stabilisation.
Methods: Eleven young patients, aged 12–26 years and
weighing 23–48 kg, underwent transmitral balloon commis-
surotomy using the described technique at our centre from
April to May 2014.
Results: Mean fluoroscopy time was 22.6 ± 6.4 min (18.5–
30.0). Mean transmitral gradient decreased from 24.1 ± 5.9
(16–35) to 6.6 ± 3.8 (3–14) mmHg, as measured on tran-
soesophageal echocardiography. Mean mitral valve area
increased from 0.69 ± 0.13 cm2 (range 0.5–0.9) before dilation
to 1.44 ± 0.25 cm2 (1.1–1.9) after dilation (p < 0.001). Mean
estimated pulmonary artery systolic pressure decreased from
110.0 ± 35 mmHg (75–170) before dilation to 28.0 ± 14.4
mmHg (range 10–60) after dilation.
Conclusion: Our modified Nucleus balloon technique for
mitral valve dilation in young patients with mitral stenosis is
effective and safe. The technique differs from other over-the-
wire techniques in that it avoids placing stiff wire in the left
ventricle. It also offers better balloon stability and control
owing to the arteriovenous loop. This technique may be easier
for use by paediatric interventionists who might not be famil-
iar with the Inoue balloon technique.
Keywords: arteriovenous loop stabilisation, balloon mitral
commissurotomy, modified Nucleus balloon technique, mitral
valvotomy in resource-limited settings
Submitted 9/12/16, accepted 29/1/18
Published online 19/2/18
Cardiovasc J Afr 2018; 29: 167–171
DOI: 10.5830/CVJA-2018-010
Although it has become exceedingly rare in the developed world,
rheumatic heart disease continues to be a serious health problem
in developing nations.1 Unlike other valvular lesions, which
might be attributed to multiple aetiologies, mitral stenosis alone
or in combination with other valvular lesions is the only lesion
almost exclusively attributed to rheumatic heart disease.2,3 Studies
from developing countries have shown that mitral stenosis
progresses rapidly and may lead to serious disability early in
life.4-7 Commissural fusion, leaflet thickening and alteration of
the subvalvular apparatus are the dominant mechanisms causing
clinically important mitral stenosis of rheumatic origin.8
As mitral stenosis is a mechanical obstruction to forward
flow, the only definitive treatment is mechanical relief of
the obstruction. Such invasive treatments include closed
mitral commissurotomy, open mitral valve repair, mitral
valve replacement, or percutaneous transmitral balloon
commissurotomy. 9-11 Percutaneous transmitral commissurotomy
is associated with significant changes in mitral valve morphology
in terms of splitting of the fused mitral commissures, increased
mitral valve area, improved leaflet excursion and splitting of the
sub-valvular structures.12
A variety of hardware and techniques has been described.
These include the Inoue balloon technique, single-balloon
over-the-wire techniques, double-balloon technique, multi-track
system, metallic valvotome and other similar techniques.13-17
Currently, the Inoue balloon is the standard technique. However,
the hardware for this technique is expensive and may not always
be available in resource-limited settings. In this article, we
describe a technique for balloon mitral commissurotomy using
a single Nucleus balloon, with arteriovenous loop stabilisation.
Methods
This technique is a modification of the regular single-balloon,
over-the-wire technique described previously,18 and adapted by
subsequent workers.19 It was modified according to the available
materials at our centre during that period, and to adapt to the
relatively small size of our patients.
A total of 11 patients, all teenagers or young adults, underwent
transmitral balloon commissurotomy using the described
technique in our centre from April to May 2014. Eight patients
(72.7%) were female. In all patients, diagnosis of mitral stenosis
was made on the first presentation to medical attention.
Department of Paediatrics and Child Health, Cardiology
Division, School of Medicine, Addis Ababa University,
Addis Ababa, Ethiopia
Endale Tefera, MD,
Division of Paediatric Cardiology, CHU Sainte-Justine,
Université de Montréal, QC, Canada
Mohamed Leye, MD
Joaquim Miró, MD
Department of Medicine, Montréal Heart Institute,
Université de Montréal, QC, Canada
Patrick Garceau, MD
Division of Cardiovascular Surgery, Montreal Institute of
Cardiology, Université de Montréal, QC, Canada
Denis Bouchard, MD