Mitral valve Balloon valvotomy Procedure for Mitral Stenosis

We are moving from coronary to valve here. This is 37 year old lady of Rheumatic mitos stenosis. I can see here she is in atrial fibrillation and left atrial appendage claw type one A as based on our classification, she was anticoagulated for three months. So she's in function class three. Atrial fibrillation and heart rate on the table is about 120. Blood pressure is 100 and 2120 by 80. And we'll show the other pictures. This is next atal fibrillation. This is typical x ray of Rheumatic mitostinosis pulmonary hypertension. And you can see here, the parasternal angaxis shows dooming of the mitral valve and bit of calcium on the posterior mitral leaflet. Then in the left lower panel you can see the short axis of the mitral valve. That Rfize is less than one. And there is tr and there is pulmonary artery potential is around 70 pulmonary arteries pressure is 70. If you look at the short axis of the mitral valve, the antilateral commissioner is free from calcium while the posture of medial there is some amount of calcium. This is very, very important because if both the commissioners are calcified, then there is always a risk of leaflet tear. So at least if one of the commissioner is free from calcium, you can still have a balloon mitral valoplasty. This is transcends of Agile Echo for you. You can see clot confined to the la appendage protruding a little bit into the body. And of course there is spontaneous echo contrast. So since the clot is confined to the appendage body and anticoagulated for about three months, we are going ahead with the balloon mitral valoplasty because our hardwares will not be into the appendage at all. 

And the clot is also organized. Yeah, this is the story of this patient, Dr. Ramat. Yeah, I'm surprised they keep half hour for you, Dr. Manjina. I'm sure you'll finish in a few minutes. Okay, so only thing we have to use a three two wire for threading the mullen sheet. Because the mullen sheet doesn't go over three five because most of our laps do have only three five. So unless you have a three two wire, mullen sheet doesn't slide. So you can always see that this sparks. I mean, you can maneuver so that it is in the left denominate vein. So that when you are coming down it gets an angle onto the atrial septum. This patient actually was on anticoagulation stopped five days back INR estate was 1.3. Was she anticoagulated for a length of time earlier, or no? Yeah, she was anticoagulated for about three months. The whole objective of anticoagulation is let the clot become more adherent and more distinguish. So I'm just one space below in APVU. Then I'm going to elevate 40 low puncture. So lo 40. We have to pick up a point between pigtail anteriorly, vertebral column posteriorly. So you can see I'm just injecting. We are in the left atrium now. So now I will just advance the mullen sheath, keep over the broken baron needle, because you should not advance with the needle projecting beyond the mullen sheet because there is always a chance of perforation. So can you show the pressure? We are into the left atrium. Actually, now we are in la. So let me take a simultaneous LV as well as la pressure. Can we show that? So there is a big diastolic gradient. Okay. La pressure is 53 by 24, mean of 38. Yeah, we can see that very well. Yeah. So we'll go with the spring guideware. Now, I always keep pigtail in descending iota, any fleshes and all. You can always do it. See now to know whether you have gone to the softest portion of the septum, just the Mulin sheath itself, you can advance and see. Yes, Mulin sheath is going smoothly. So probably it has gone through the softest portion of the years. Many people say I've always punctured at four sava valleys, which I don't believe. Many a times you are across four sava valleys. Sometimes it's above four sava valleys, sometimes it's below four sava valleys. You are a very honest interventionist manjunath. So this is 30. I mean, our height is 165. So we are going to because as per the formula, we have to take 25 balloon. But I will downsize by two. See, many a time, rather than doing multiple runs of the septal dilator, you can just dilate keep it for 30 seconds. It stretches the septum nicely. Because septal puncture is not just for balloon mitral olaplasty. We have other procedures, la, appendage closure, left heart, catheterization, mitoclip device, so many things. So what are going to be the special? Other important thing is you have to always keep an eye on the special steps to avoid the clot. You have to keep an eye always on the left. Yeah. I think since it is an appendage clot, I am just doing routinely. Otherwise, if the clot were to be in the roof of the thing, we would have done over the wire technique. That is where we introduce the spring guide wire instead of la into the LV itself. See here, when once two thirds of the stretched balloon crosses this thing, you release this balloon stretching tube so that it doesn't get into that zone. Yeah, always. I never flush into the left atrium. Always. We keep aspirating because but what about the hiparion? Have you already given the hiparin. So we have to come and look for this apparent 3000 units we have given. Yeah, 3000 units given before septal puncture only I had given because sometimes you can give after septal puncture. So you can always watch for this bobbing moment. That means you are on top of the mitral valve. So one thing, you always make sure that the balloon reaches the apex, otherwise it can get stuck in the suburb apparatus. 50%. Yeah. 1 second. Yeah, 50, yeah. Come on, come on. Full breakfast. So we'll just check with the gradient as well as the mitral valve area. So because you are slightly undersized, you could go full on the inflation, right? Yeah. Elena okay, we'll superimpose. I think always you should inflate artery remit at a high pressure zone. See here, our required balloon diameter was 24. So I inflated at I have taken a 26 balloon. So if you inflate at 24 in a 26 balloon, you generate a great pressure. Suppose if you take 28 balloon and inflate at 24, then you will not generate that great pressure. So we have to inflate balloon at a high pressure zone. So if your required diameter is 24, you take 26 balloon, or if your required diameter is 22, you take 24 balloon. So is there something like soft dilatation? Like if there is an mitor Regurg people underdo the dilatation, is that acceptable or no, no. If there is a calcium or if there is AMR, you can downsize the balloon by 2 mm. So it's fine. I think with a heart rate of 144, a gradient of around almost dastella, it is touching. Just you can show the pressure. 

You'll have an echo. Yeah, you can show that. No, it's coming. Yeah, it's a white jet, actually. In fact, our la pressure mean has dropped from 35 to 17. You can see here a wide jet because of atrial fibrillation fast heart rate. You can go on the short axis and show yeah, I think you can zoom that. Freeze, freeze, freeze, freeze. Pressure running. You can see here both antilateral as well as posteriorum medial commissioner is well split. Yeah, we can see that. And there is no Mr. Hello? Yeah, we can see it well on the call contact. It's fine. Hello? Yeah, we can see it very well. How much is the area now? Is asking why they are giving Manjana 30 minutes for you? Five minutes is enough. Gradient test. So, Dr. Manjirat, you're five minutes ahead of time. Nishitani comments from you. Interesting that you are here. I don't do much of hello. What is happening with the audio valve replacement in Berthai? Lola? They worked out very well. We use the sapien hello position. We can hear you sound Bertha back in us. You don't get too much of these mitral valves, but every now and then there is prosthetic mitral valves. Where do you think the septal puncture technique would be useful for you in US. Pardon? Septal puncture techniques where it could be useful for you in United States hello. For this mitral and what is happening? Italapanda cluders. They're very important. All right, Mr. Padmana, can we switch to Dr. Kanazz? Yeah. I love it. Yeah. Yeah. So you can see here actually, you can see here the short axis of the mitral valve. Both the commissions are split. You just keep talking. So both the commissions are split. And I think India salic. Yeah. I think I don't want to dilate anything further here, because we achieved a good area is around 1.1.8 and la pressure has dropped, and the endostolic gradient is hardly two to three. See, when we are removing the balloon from the left atrium to right atrium, normally you have to put back the spring guide wire. And this thing, if it comes smoothly, it is fine. Here. It is coming smoothly. That's okay. And let me check the RV pressure rather than going for an exchange with the NH catheter I mean, endol catheter, let me check the RV pressure with the mitral balloon itself, because otherwise it takes lot of other exchange and all. Dr. Ramit? Yeah, we are watching that. Yes. You are with us. Yeah. This is RV. Right. See, RV pressure before the procedure was 75 systolic, and now it's around 59, 55, 59. Can you show the humidity? Yeah. So this is one, I think, with the same mitral balloon. You can check the RV pressure, which indirectly always gives pulmonary atrial systolic pressure. Otherwise, you have to exchange for this. Again, spring guide wire. Then you have to introduce, I mean, endol or those catheters. So this will shorten the fluoroscopic time. So definitely peer pressure has dropped from 75 to 50 50. Now. Yeah. See, when we are stretching the balloon, one point here, you have to keep the spring guide wire loop well in the at least two loops should be there in the right atrium, beyond this balloon tip. Yeah, go have the loop. Yeah. Still. See, otherwise, what happens if only tip of the wire is projecting? Then you try to stretch the balloon, that wire can get cut. So besties have two loops beyond the balloon. Then you can lock and stretch the balloon and remove it. So I think this is for you. Any questions from the panel or audience? Hello. That was excellent case demonstration. Actually, BMV is by large nowadays not done by many people. So I think this was an excellent case by step, particularly with the electrode.