Efficacy of modified technique for atrial septal puncture in percutaneous transvenous mitral commissurotomy - Phạm Nhật Minh

• No artery access 
• New Landmark: # sign 
• Clarify Left Atrium (PA angiography if needed) 
• Catheter/Needle manipulation 
Catheter/needle fitting exercise 
Catheter/Needle Manipulation 
Simplified Technique 
“# technique” 
LA border and # landmark 
PTMC procedure 
OBJECTIVES 
1. To Evaluate the efficacy of the modified 
technique for Septal Puncture in 
Percutanenous Transvenous Mitral 
Commisurrotomy 
2. To define some clinical factors affect the 
result of this technique 
Patient Selection 
Severe MS with symptom 
None combination of MR > 2/4 or/and 
moderate/severe AS/AR 
Echo Score: Wilkins; Padial; Comer 
LA without thrombus 
Some special scenarios: pregnancy; emergency; 
kyphoscoliosis; junior 
Consent 
Patient Selection and Methods 
Patient selection: 173 MS patients in 
Vietnam National Heart Institute 
undergone PTMC from 06/2013 to 
09/2014 
Method: Cross Sectional Study 
Statistical analysis: SPSS 16.0 
Balloon selection and sizing 
Reference Size (RS) 
(Patient’s height (cm) / 10) + 10 
Inoue balloon selection 
Valvular morphology Balloon 
Pliable RS - matched (PTMC 26 for 
 RS = 26) 
Calcified/SL One size < RS-matched 
Balloon sizing 
Valvular status Initial Increment 
Pliable RS - 2 (mm) 1or 0,5 mm more 
Calcified RS - 4 (mm) 1 mm (LP) 
 0.5 mm (HP) 
Research Parameter 
General Parameter 
Age, Sex, History of PTMC, History of Surgery, 
Pregnancy 
SubClinical 
ECG: Sinus Rhythm, AF 
Cardiac Ultrasound (Transthoracic, Transesophageal) 
LA diameter (mm) 
Pulmonary Artery pressure (mmHg) 
MVA (2D and PHT) (cm2) 
Wilkin Score 
Research Parameter 
Result of Septal Puncture 
Success: Septal puncture and perform PTMC 
successfully 
Fail: (1) Complication that lead to stop 
procedure, (2) can not advance needle into LA 
or, or (3) can not advance balloon through valve 
Favourable SP: SP ≤ 2 times 
Difficult SP: SP > 2 times 
Research Parameter 
Procedure time (mins) 
Radiation exposure time (mins) 
Day of inpatient after PTMC (days) 
Procedure result : Technical success 
and no complocation. 
Complication: Death, Tamponade 
Research Parameter 
Access vessel: Right or Left Femoral Vein 
Cardiothoracic ratio: 
Normal (≤ 55%) 
Enlarged (> 55%) 
LA diameter and distance from lateral line of right 
atrium and middle point of the spine (mm) 
Pulmonary artery pressure, LA pressure (before 
and after procedure) (mmHg) 
Research Parameter 
Crossing Inoue balloon into mitral stenotic valve 
Favourable: direct or vertical method 
Difficulty: sliding or alternative loop method 
Fail: balloon can not cross 
Operator Experience: 
Group 1: ≤ 100 cases 
Group 2: 101 – 200 cases 
Group 3: > 200 cases 
RESULT AND DISCUSSION 
General parameter of patients 
 (X  SD) / n (%) 
Age 46,49  11,93(16-74) 
Sex 
Male 35(20,23%) 
Femal 138(79,77%) 
Wilkin score 8,42  0,58 
Wilkins ≤ 8 
Wilkins > 8 
102 (58,96%) 
71 (41,04%) 
History of PTMC or mitral valve surgery 27(15,43%) 
Male/Female = 0.25, Võ Thành Nhân: (n=147) 0.25, Iung (1024) 0,2 
Age: Võ Thành Nhân (n=147) 37,81 ± 9,46. Iung (n=1024) 49 ± 14 
General technical aspects 
n Tỷ lệ % 
R femoral vein 173 100 
PA angiography 159 91,91 
NO PA angio 14 8,09 
R femoral vein: Most favourable vessel access for PTMC. Although some 
authors reported some cases with L femoral vein access 
Angio Parameter 
 x ± SD (mm) / n (%) 
Distance from lateral line of 
right atrium and middle point of 
the spine 
33,95  7,84 
LA diameter 90,57  10,02 
Cardiothoracic ratio 
Normal 30/61 (49,18%) 
Enlargerd 31/61 (50,82%) 
Cross Inoue Balloon into Mitral Stenotic valve 
n=171 Tỷ lệ % 
Balloon 
crossing 
Favourable (≤2 times) 152 88,89 
Difficult (>2 times) 18 10,53 
Fail 1 0,58 
Direct Slide and loop method 
Result of Septal Puncture 
Nguyễn Quang Tuấn: (n=220) 96% 
Jui Sung Hung: (n=219) 97% 
Võ Thành Nhân: (n=147) 99,3% 
98.27% 
1.73% 
Septal Puncture 
Success
Fail
Procedure time, radiation exposure time and days of 
inpatient after procedure 
X  SD 
(current study) 
X  SD 
(Võ thành Nhân) 
P 
Procedure time(n=58) 32,77 ± 13,13(mins) 75,67 ± 41,98(mins) < 0.001 
Radiation exposure time 
(n=61) 
10,97 ± 10,96(mins) 14,3 ± 10,9(mins) < 0.001 
Days of inpatient after 
procedure(n=171) 
3,27 ± 1,72(days) 
Procedure result 
Success: Technical success, MVA >1.5 cm2, no 
complication, no MR after procedure 
83.82% 
16.18% 
PTMC result 
Success
Fail
Procedure result 
0
5
10
15
20
25
30
35
Before PTMC After PTMC
30.61 
18.71 
LA Pressure (Angio) 
LA Pressure
(Angio)
LA pressure before and after PTMC (mmHg) 
 (p<0.001) 
Procedure result 
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2D PHT
0.99 0.99 
1.61 
1.69 
Before PTMC
After PTMC
MVA before and after PTMC (cm2) 
 (p<0.001) 
0
5
10
15
20
25
30
35
40
45
50
PAP max
(Ultrasound)
PAP max
(Angio)
48.73 
46.71 
37.98 
33.36 
Before PTMC
After PTMC
PA pressure before and after PTMC (mmHg) 
 (p<0.001) 
Complication 
n (%) 
Main Complication 
Cardiac death 0(0%) 
Aortic root puncture 1/173 (0,58%) 
Free wall puncture 1/173 (0,58%) 
Cardiac tamponade 0(0%) 
MR > 2/4 after procedure 15/170 (8,72%) 
Cummulative 17/173(9,88%) 
Minor Complication 
Vasovagal 13 (7,52%) 
Nguyễn Quang Tuấn (n=220): Death 0,5%, Tamponade (1,8%), MR: 2,3% 
(Wilkins =6,7 ± 2,3), Stroke 0,9% 
Septal Puncture result 
108 
65 
Septal Puncture 
Favourable
Difficult and fail
Septal Puncture: Technical aspects (regression 
multifactor analysis) 
Group 1 (Favourable) 
(n=108) 
Group 2 (Difficult and fail) 
 (n=65) 
OR 
(95%CI) 
P 
LA diameter (Transthoracic 
ultrasound) 
44,09  4,50 50,69 4,54 
1,51 
(1,32-1,73) 
< 0,001 
Operator 
experiences 
(number of 
cases) 
≤ 100 50 28 
1,20 
(0,51-2,87) 
 > 0,05 
101 - 200 28 23 
1,76 
 (0,70-4,46) 
> 200 30 14 
Age 45,6 ± 12,36 47,97±11,13 
1,02 
(0,99-1,04) 
> 0,05 Sex 
Male 19 16 1,53 
(0,72-3,24) Female 89 49 
MVA before procedure 1,02 ± 0,81 0,93 ± 0,18 
0,59 
(0,16-2,15) 
Septal Puncture: Technical aspects 
Group 1 
(Favourable) 
(n=33) 
Group 1 
(Difficult) 
(n=28) 
OR 
(95%CI) 
P 
LA diameter (Angio) 86,52 8,02 95,34 10,17 
1,11 
(1,04-1,19) 
0,002 
Enlarged RA (Angio) 
30,82  7,90 37,63 6,07 
1,15 
(1,05-1,25) 
0,002 
Cardio-
thoraci ratio 
Normal 
22 8 
5 
(1,67-14,92) 
< 0.01 
Enlarged 
11 20 
Septal puncture in Pt with history of PTMC 
or surgery compared to 1st time PTMC 
PTMC or 
Surgery 
history 
1st time of 
PTMC 
P 
Septal 
Puncture 
Favourable 16 92 
> 0,05 Difficult 11 51 
Fail 0 3 
(n=173) 27 146 
Operator Experience 
Septal Puncture 
Favourable Difficult Fail 
P 
n % n % n % 
Operator 
experience 
(Number of 
cases) 
≤ 100 50 64,10 25 32,05 3 3,85 
>0,05 
101- 
200 
28 54,90 23 45,10 0 0 
> 200 30 68,18 14 31,82 0 0 
Total 108 62,42 62 35,84 3 1,74 173 
CONCLUSION 
1. Modified technique for Septal Puncture (# technique) : 
 High technical success rate: 98,27% 
 Decrease procedure time 32,77 ± 13,13(mins), 
decrease radiation exposure time 10,97 ± 
10,96(mins). 
 PTMC result using this technique (PAP, LA 
pressure, MVA), days of inpatients after PTMC 
comparable to classic technique 
 Only one venous access 
CONCLUSION 
2. Some clinical aspects when using this 
technique: 
Enlarged LA and RA diameter: more 
difficult for Septal Puncture 
Age, sex, MVA, history of PTMC or 
surgery of patients have no affection on 
result of Septal Puncture 
 Experience operator (>100 cases). 
Thank you for your attention! 
Septal puncture: 
Tips and Tricks 
Always Clarify LA border 
Good catheter/needle manipulation 
Avoid puncture RA, Ao, Tricuspid valve and 
coronary sinus: inside LA border, # sign 
landmark, at 4 – 6 o’clock 
Needle tip reshaping 
Confirmation of LA entry before advance 
sheath to LA 
Crossing Mitral Stenotic Valve 
Methods: 
Vertical method 
Direct method 
Sliding method 
Alternative Loop method 
Individually 
Padial echo 
score 
Padial LR, Abascal VM, 
Palacios IF. Am J Cardiol. 
1999; 83:1210-1213. 
Parameters 
Age 
Gender (male) 
Atrial fib. 
MR pre PTMC 
Wilkins  8 
Padial score  10 
Calcified valve (X ray) 
RR 
0.85 (0.28 <RR< 2.53) 
1.38 (0.45 <RR< 4.23) 
1.17 (0.29 <RR< 4.74) 
 0.4 (0.15 <RR< 1.26) 
1.38 (0.41 <RR< 4.62) 
 8.18 (3.25 <RR< 14.41) 
 3.96 (1.28 <RR< 12.2) 
 Predictor of severe MR after PTMC 
Our experience 
VNHI’s Experience 1999-2010 
• Single center experience 12 year (1/1999-12/2010) 
• Total PTMC volume: 5930 pts (≈ 500 pts/yr) 
• Using Inoue balloon: 99.1% (5870/5930 pts) 
• Technically success: 99.3% (5830/5870 pts) 
• Optimal results: 88.9% (5220/5870 pts) 
• Complications: 1.5% (88/5870 pts) 
• Restenosis: ≈ 5.5% over 5 years 
Restenosis and Clinical status on 
F/U 
Authors n F/u(moths) % Restenosis Criteria % clinical stability 
Vahanian 100 9 4 A 87 
Palacios 39 13 21 B 89 
Arora 590 37 2 E 99 
Chen 85 60 6.8 C 93 
Herrmann 63 63 16 C 89 
Park 69 12 12 D - 
VNHI 600 24 5,5 A 85 
Criteria: A= decreased MVA > 50% and MVA  1.5cm2; B= Decreased MVA > 
50%; C = Clinical symptoms of restenosis; D = decreased MVA > 25%; E = 
decreased MVA > 50% or MVA< 1.5 cm2 or both. 
Clinical stability: NYHA I or II or no worsening on F/U later on. 
Predictors for success rate of 
PTMC: Our experrience 
Factors OR (Odd 
Ratio) 
P 
Age > 55 2,52 < 0,01 
Gender 1,01 < 0,01 
AF 1,03 < 0,01 
Prior Commisurotomy 1,35 < 0,01 
Combine MR 2/4 1,45 < 0,01 
Wilkins score 3,01 < 0,01 
MVA prior PTMC 1,25 < 0,01 
PA pressure prior PTMC 1,07 < 0,01 
Learning curve (>300 
cases) 
2,35 < 0,01