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

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 3, May/June 2018

170

AFRICA

guide wire. Although techniques using arteriovenous loops have

been described previously,

19,22

they never gained widespread

acceptance, either because the wire was snared inside the left

ventricle,

or because the balloon was advanced through the

arterial end of the loop.

With the current catheters, guide wires

and snares available, our technique is definitely much more

straightforward than the originally proposed variants.

This technique may be considered a good option in resource-

limited settings where the Inoue balloon is not always an available

option. Compared with the Inoue balloon, the total cost of the

Nucleus balloon and its associated hardware is significantly less.

Besides, the Nucleus balloon is easier to clean and resterilise as it

has a single layer, compared to cleaning the Inoue balloon. It can

be reused multiple times, offering a significant cost advantage

in resource-limited settings such as ours. This technique may

also be easier for use in children by paediatric interventionists

who may not be familiar with the Inoue balloon technique but

frequently use arteriovenous loops for other interventions.

One of our patients developed a tear in the anterior mitral

valve leaflet and underwent valve replacement surgery. This

complication may not be associated specifically with the

described technique and could potentially occur with the Inoue

balloon and other techniques. In fact, when inspected by the

surgeon, the valve appeared too dysplastic to attempt repair.

However, our technique carries a potential complication of

inflating the balloon partially in the left ventricular outflow tract,

thus avulsing the sub-valvar mitral apparatus. Great care has to

be taken to not fully inflate the balloon if it seems to engage

partially in the outflow tract during gentle initial inflation.

Although our patient population was small, the outcomes

achieved in terms of increase in mitral valve area and reduction

of mean transmitral diastolic gradient were comparable to

those obtained with the Inoue balloon and other techniques.

21,23

Estimated pulmonary artery pressure also dropped significantly.

These outcomes were maintained on follow up at close to two

years. Except for one patient who had an anterior leaflet tear

leading to severe mitral regurgitation, the degree of mitral

regurgitation was mild or less in all cases at the last follow up.

A limitation is that the number of patients in our study was

relatively small. Furthermore, we did not compare our technique

head to head with other techniques; it was based rather on a

literature review.

Conclusion

The Inoue balloon is not usually available in our centre as we get

most of our consumables on donation. Our modified Nucleus

balloon technique for mitral valve dilation in patients with mitral

stenosis is effective and safe. The technique differs from other

over-the-wire balloon techniques described in the past in that it

avoids placing a stiff wire in the left ventricle, avoiding the risk

of ventricular arrhythmia. It also offers better balloon stability

and control owing to the arteriovenous loop. This technique can

potentially be used with any other balloon available and may

be easier for use by paediatric interventionists who might not

be familiar with the Inoue balloon technique. TEE guidance is

very useful to avoid the potential risk of inflating the balloon

in the left ventricular outflow tract or through the sub-valvar

apparatus. The Nucleus balloon can also be resterilised and used

multiple times.

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