Efficacy of modified technique for atrial septal puncture in percutaneous transvenous mitral commissurotomy - Phạm Nhật Minh
BACKGROUND
• Mitral Stenosis is still a big burden especially in
developing country
• The simplest technique (1st choice) for PTMC:
Using Inoue Balloon
• Effective: valid alternative to surgical therapy
in selected patients
Septal Puncture: Vital Step, not only to avoid
tamponade but also made an appropriate septal
site to facilitate balloon crossing valve
• At VNHI: Septal Puncture using modified technique
since 2005
• 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
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