Balloon Mitral ValvotomyOpening up of the narrowed valve (BMVPercutaneous transmitral commissurotomy) is also known as PercutaneousThrough the skin, without and open procedure Transmitral Commissurotomy (PTMCPercutaneous transmitral commissurotomy). It is a catheterSmall tubes introduced into the heart and blood vessels, for diagnostic and therapuetic (treatment) purposes (small tubes introduced into the heart and blood vessels) based method from dilating (enlarging) the stenosed (narrowed) valve in mitral stenosisNarrowing (of a valve or blood vessel). The approach is through the right femoral veinBlood vessel draining deoxygenated blood from the organs to the heartBlood vessel draining deoxygenated blood from the leg (blood vessel draining deoxygenated blood from the leg). Both femoral veinBlood vessel draining deoxygenated blood from the organs to the heartBlood vessel draining deoxygenated blood from the leg and arteryBlood vessel carrying oxygenated blood to the organs are cannulated using the Seldinger technique. A pigtail catheterSmall tubes introduced into the heart and blood vessels, for diagnostic and therapuetic (treatment) purposesCatheterSmall tubes introduced into the heart and blood vessels, for diagnostic and therapuetic (treatment) purposes with one end curved like the tail of a pig (catheterSmall tubes introduced into the heart and blood vessels, for diagnostic and therapuetic (treatment) purposes with one end curved like the tail of a pig) is placed in the root of the posteriorRelated to the back of sinus in the root of the aortaLargest blood vessel arising from the heart, supplying blood to the whole body. The position is confirmed by injecting contrast. This catheterSmall tubes introduced into the heart and blood vessels, for diagnostic and therapuetic (treatment) purposes is used as a position guide while puncturing the interatrial septumWall separating two chambers of the heart. Position is confirmed by contrast injection.
An 0.032″ straight guidewire is introduced into the right femoral veinBlood vessel draining deoxygenated blood from the organs to the heartBlood vessel draining deoxygenated blood from the leg and guided into the superior vena cavaLarge blood vessel draining deoxygenated blood from the head and neck into the heart (large blood vessel draining deoxygenated blood from the head and neck into the heart) through the external iliac (blood vessel in the lower abdomen above the groin), inferior vena cavaLarge blood vessel draining deoxygenated blood from the lower part of the body into the heart (large blood vessel draining deoxygenated blood from the lower part of the body into the heart) and right atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart. From the superior vena cavaLarge blood vessel draining deoxygenated blood from the head and neck into the heart, the guide wire is routed to the left brachiocephalic veinBlood vessel draining deoxygenated blood from the organs to the heartVeinBlood vessel draining deoxygenated blood from the organs to the heart draining deoxygenated blood from one arm and one side of head and neck into the superior vena cava (veinBlood vessel draining deoxygenated blood from the organs to the heart draining deoxygenated blood from one arm and one side of head and neck into the superior vena cavaLarge blood vessel draining deoxygenated blood from the head and neck into the heart). A Mullin’s sheath with dilator is threaded over the guide wire and positioned in the left brachiocephalic veinBlood vessel draining deoxygenated blood from the organs to the heartVeinBlood vessel draining deoxygenated blood from the organs to the heart draining deoxygenated blood from one arm and one side of head and neck into the superior vena cava. The guide wire and dilator are removed and a Brockenbrough needle is introduced into the Mullins sheath. The needle tip is kept about 2 finger breadths inside the sheath, from its tip. The proximal end of the Brockenbrough needle is connected to the pressure monitoring system through a three way stop cock. While monitoring pressure wave form, the Mullin’s sheath – Brockenbrough needle assembly is brought down into the superior vena cavaLarge blood vessel draining deoxygenated blood from the head and neck into the heart and then into the right atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart gently. As the asssembly descends in the right atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart, slight forward jerks are seen as it reaches the region of the fossa ovalisoval depression in the inter atrialRelated to the atrium (upper chamber of the heart) septumWall separating two chambers of the heart, on its right side. The tip of the assembly should be one space below the pigtail tip in left anteriorRelated to the front of oblique view to ensure that the site is accurate. In right anteriorRelated to the front of oblique view the tip should be midway between pigtail anteriorly and spine posteriorly. A more anteriorRelated to the front of puncture can injure the aortaLargest blood vessel arising from the heart, supplying blood to the whole body while a more posteriorRelated to the back of puncture can cause an atrialRelated to the atrium (upper chamber of the heart) stitch. AtrialRelated to the atrium (upper chamber of the heart) stitch is a puncture of posteriorRelated to the back of portion of right atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart together rather than a septalRelated to the septumWall separating two chambers of the heart (wall between two chambers of the heart) puncture. Since the needle will traverse the pericardiumOuter covering of the heart in between, it will lead to cardiac tamponadecardiac tamponade: compression of the heart by fluid in the pericardiumCompression of the heart by fluid within its covering; an emergency life threatening situation which needs immediate treatment when the needle is removed.
Once the puncture site for the septalRelated to the septumWall separating two chambers of the heart (wall between two chambers of the heart) puncture has been localised, some operators tent the septumWall separating two chambers of the heart and inject a small amount of contrast to verify the position. Once the position of the needle tip in the region of fossa ovalisoval depression in the inter atrialRelated to the atrium (upper chamber of the heart) septumWall separating two chambers of the heart, on its right side is confirmed, the needle is advanced under fluroscopic guidance, observing the needle tip pressure. The pressure wave form switches from right atrialRelated to the atrium (upper chamber of the heart) pattern to a higher pressure left atrialRelated to the atrium (upper chamber of the heart) pattern as soon as the septumWall separating two chambers of the heart is crossed. Left atrialRelated to the atrium (upper chamber of the heart) position can be further confimed by withdrawing bright red saturated blood from the needle by aspiration. As a final confirmation, dye can be injected into the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and can be seen swirling inside the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart.
Once the needle is safely inside the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart, the Mullin’s sheath is advanced over it into the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart. Then the needle is withdrawn, and a pigtail wire is introduced into the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart through the Mullin’s sheath. The pigtail wire curls in the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart with its top portion reaching the roof of the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart. Then the Mullin’s sheath is removed and a septalRelated to the septumWall separating two chambers of the heart (wall between two chambers of the heart) dilator threaded over it. The septalRelated to the septumWall separating two chambers of the heart (wall between two chambers of the heart) dilator is passed to and fro across the inter atrialRelated to the atrium (upper chamber of the heart) septumWall separating two chambers of the heartWall separating the two upper chambers of the heart (right and left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart) a couple of times to ensure adequate dilatation of the septalRelated to the septumWall separating two chambers of the heart (wall between two chambers of the heart) puncture.
Once the dilator is in position, the BMVPercutaneous transmitral commissurotomy balloon is checked for proper inflation and deflation with dilute contrast. The volume of contrast used depends on the proposed level of dilatation to be done. Height of the patient in centimeters is divided by ten and then ten is added to it. The figure obtained will give the proposed diameter of the balloon in millimeters. The position of the piston in the syringe when contrast is filled is noted so that in case of any inadvertent contrast leakage from the system, the system can be refilled without taking it out of the system.
The balloon assembly is threaded over the pigtail wire after removing the septalRelated to the septumWall separating two chambers of the heart (wall between two chambers of the heart) dilator. Once the balloon tip is in the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart, the proximal end is unscrewed and the straightener is removed, while gently pushing the balloon into the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart so that the tip will curve around the roof of the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart. The balloon tip pressure (left atrialRelated to the atrium (upper chamber of the heart) pressure) is measured and the pigtail catheterSmall tubes introduced into the heart and blood vessels, for diagnostic and therapuetic (treatment) purposesCatheterSmall tubes introduced into the heart and blood vessels, for diagnostic and therapuetic (treatment) purposes with one end curved like the tail of a pig is introduced into the left ventricleThe lower thick walled chambers of the heart (left and right) which receive blood from the atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and pump out into the body to measure the left ventriuclar diastolic pressurePressure when the heart relaxes. The transmitral gradient is calculated. The the curved stillet is then introduced into the balloon, taking care to see that the tip does not protrude out of the balloon tip and cause injury.
The balloon is gently introduced into the left ventricleThe lower thick walled chambers of the heart (left and right) which receive blood from the atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and pump out into the body. Counterclockwise torque applied to the stillet is useful in guiding the balloon into the left ventricleThe lower thick walled chambers of the heart (left and right) which receive blood from the atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and pump out into the body. A bobbing movement of the balloon catheterSmall tubes introduced into the heart and blood vessels, for diagnostic and therapuetic (treatment) purposes tip is noted when the tip approaches the mitral valveValve between the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and left ventricleThe lower thick walled chambers of the heart (left and right) which receive blood from the atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and pump out into the body. Once it is certain that the tip has crossed the mitral valveValve between the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and left ventricleThe lower thick walled chambers of the heart (left and right) which receive blood from the atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and pump out into the body into the left ventricleThe lower thick walled chambers of the heart (left and right) which receive blood from the atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and pump out into the body, The balloon is inflated. While inflating, initially the distal portion of the dumb bell shaped balloon gets expanded. Once the distal half is inflated, the balloon is pulled back to hitch the mitral valveValve between the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and left ventricleThe lower thick walled chambers of the heart (left and right) which receive blood from the atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and pump out into the body and further inflation dilates the mitral valveValve between the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and left ventricleThe lower thick walled chambers of the heart (left and right) which receive blood from the atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and pump out into the body. Once full dilatation is achieved, the balloon is promptly deflated to avoid compromise of systemic blood flow. The assembly is withdrawn into the left atriumUpper thin walled chambers of the heart (left and right). They receive the blood returning to the heart and the stillet is removed.
Transmitral gradient is measured to assess the procedure result. If the result is unsatisfactory, a repeat dilatation with slightly increased balloon diameter. Auscultationlistening with a stethoscope for reduction of mitral diastolic murmur and absence of mitral regurgitant murmur are routine while assessing the result. If an echo is available in the cathlabshort form for cardiac catheterization laboratory where angiographyimaging of the heart and blood vessels, usually with x-ray or magnetic resonance imaging equipments and interventions are undertaken., it will be quite useful to assess the result as well as to exclude any pericardial effusioncollection of fluid in the pericardiumOuter covering of the heart / tamponadecardiac tamponade: compression of the heart by fluid in the pericardium.
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