Editorial Comment

A New View of an Old Picture

Jui-Sung Hung, MD

China Medical College HospitalTaichung, Taiwan

Kean-Wah Lau, MD, M MED

Singapore Heart CenterSingapore

Since the introduction of percutaneous balloon mitral commissur-otomy (BMC) by Inoue et al. [1] in 1984, data accrued from bothobservational and randomized studies [2–5] have demonstrated thatthe procedure yields excellent short- and long-term outcomes thatare comparable or even better than those of surgical commissur-otomy. BMC is conventionally performed using the antegradeapproach via the femoral vein, either with catheter balloons that aresize-adjustable and self-positioning (Inoue-balloon catheters) orthose without these options (fixed-sized balloon catheters). A muchless frequently practiced approach is the retrograde transarterialtechnique without transseptal access [6].

In this issue, Joseph and associates [7] describe yet another novelapproach in BMC, that of the transjugular transseptal approachusing the Inoue-balloon catheter. Based on their study results in amodest series of 20 relatively well-selected young patients withlargely favorable mitral valve morphology and reasonable leftatrial size (mean of 49 mm), Inoue-BMC appears feasible and isassociated with an acceptable procedural outcome. Their findingsalso reinforce a number of important technical points previouslyobserved with the transfemoral approach. First, the transseptalpuncture site has to be optimal to ensure a problem-free passage ofthe Inoue-balloon catheter across the stenosed mitral valve, andthus the site need not necessarily be at the fossa ovale [8,9]. In thetransjugular approach, Joseph et al. found the optimal puncture siteto be at the high septum, which allows for a straight path for theballoon catheter to cross the mitral valve with or without a stylet.Second, the risk of creating significant inter-atrial shunt correlateswith septal thickness. In our (unpublished) experience, septalresistance encountered during inter-atrial septal puncture—a surro-gate of septal thickness—was independently linked with the risk ofsignificant post-procedural atrial septal defect. A similar findingwas noted by Joseph et al. [7]: whereas no detectable shunt wasdemonstrated in cases of high-septal puncture where the septum ismore muscular and thicker, this complication, albeit minor, wasobserved in two of four cases in whom septal punctures wereperformed at the fossa ovale. Last, but not least, regardless of theapproach used in BMC, severe mitral regurgitation may occur incases of adverse valve morphology [10,11]. Hence, careful con-trolled stepwise dilatation is mandatory in this valve setting [9,11].

Although preliminary results of the transjugular Inoue-BMC areencouraging, its feasibility and safety have to be verified in largertrials involving the authors and operators in other centers proficientin the techniques of transseptal access and BMC. However, prior tothese studies, in order to facilitate the procedure, several technical‘‘teething’’ issues have to be addressed and resolved. First,although Joseph et al. were able to offer simple solutions to preventfurther occurrence of the one instance each of cardiac tamponade,air embolism, and transient atrioventricular block observed in theirstudy [7], the true safety of the transjugular approach is yet to bedetermined. Second, their study is too small to determine whetherthe relatively ‘‘straight and direct’’ balloon catheter course acrossthe mitral valve provided by high-sepal puncture is equallyapplicable in the setting of grossly distorted inter-atrial septalanatomy, such as giant left atrium where the septum is both rotatedand displaced anteriorly, not uncommonly encountered in large-volume centers. Moreover, it is questionable whether the procedureis indeed safe without the use of a stylet to steer the catheter clear ofthe left atrial appendage in patients with left atrial appendagethrombus. Third, the radiation hazard to the operator is a majorconcern in the transjugular approach, given the close proximity ofthe operator to the X-ray tube. Procedural time of transjugularBMC must thus be clearly shorter than that of the transfemoralapproach in order to minimize operator irradiation. Finally, as theauthors point out, some modifications to the Inoue-balloon cath-eters are indeed needed to make the transjugular approach lesscumbersome.

Notwithstanding these unresolved issues, the promise of thetransjugular approach lies in its theoretical possibility of allowingBMC (in conjunction with transradial left heart catheterizationrather than transbrachial artery cannulation as described by Josephet al. [7]) to be performed on an outpatient basis in selectedpatients. In addition, the transjugular technique certainly providesan alternative approach in the rare scenarios where the antegradetransfemoral route may be impossible or potentially problematic(e.g., obstructed inferior vena cava or femoral vein, and congenitalanomaly of inferior vena cava).

REFERENCES

1. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N: Clinicalapplication of transvenous mitral commissurotomy by a newballoon catheter. J Thorac Cardiovasc Surg 87:394–402, 1984.

2. Turi ZG, Reyes VP, Raju BS, Raju AR, Kumar DN, Rajagopal P,Sathyanarayana PV, Rao DP, Srinath K, Peters P, Connors B,Fromm B, Farkas P, Wynne J: Percutaneous balloon versussurgical closed commissurotomy for mitral stenosis: A prospec-tive, randomized trial. Circulation 83:1179–1185, 1991.

3. Patel JJ, Shama D, Mitha AS, Blyth D, Hassen F, Le Roux BT,Chetty S: Balloon valvuloplasty versus closed commissurotomy

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5. Lau KW, Ding ZP, Hung JS: Percutaneous balloon mitral commis-surotomy versus surgical commissurotomy in the treatment ofmitral stenosis. Clin Cardiol 20:99–106, 1997.

6. Stefanadis C, Toutouzas P: Retrograde nontrasseptal mitral valvu-loplasty: In Topol EJ (ed): ‘‘Textbook of interventional cardiol-ogy,’’ 2nd Edition, Philadelphia, WB Saunders Co., 1994, pp1253–1267.

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S: Transjugular approach to transseptal balloon mitral valvulo-plasty. Cathet Cardiovasc Diagn 42:219–226, 1997.

8. Hung JS: Atrial septal puncture technique in percutaneous transve-nous mitral commissurotomy: Mitral valvuloplasty using the Inoueballoon catheter technique. Cathet Cardiovasc Diagn 26:275–284,1992.

9. Hung JS, Lau KW: Pitfalls and tips in Inoue balloon mitralcommissurotomy. Cathet Cardiovasc Diagn 37:188–199, 1996.

10. Hung JS, Chern MS, Wu JJ, Fu M, Yeh KH, Wu YC, Cherng WJ,Chua S, Lee CB: Short- and long-term results of catheter balloonpercutaneous transvenous mitral commissurotomy. Am J Cardiol67:854–862, 1991.

11. Lau KW, Hung JS: A simple balloon sizing method in Inoue-balloon percutaneous transvenous mitral commissurotomy. CathetCardiovasc Diagn 33:120–129, 1994.

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