Mitral valvuloplasty by inoue balloon: How to make it fast and effective

Mitral Valvuloplasty by 
Inoue Balloon: How to 
Make It Fast and Effective 
A/Prof. Phạm Mạnh Hùng, MD. PhD. FACC. FESC. 
Vice Director, Vietnam National Heart Institute 
Director, Cardiac Cath. Lab., Vietnam National Heart Institute 
Secretary General, Vietnam National Heart Association 
Vietnam National Heart Institute 
(VNHI) 
300 Beds; 4 Cath Labs; 4 Op. rooms 
832	 1015	
1232	
1619	
2729	
3022	
3905	
4735	 4940	
6001	
6242	
6711	
7883	
2000	 2001	 2002	 2003	 2004	 2005	 2006	 2007	 2008	 2009	 2010	 2011	 2012	
Volume of Cath. procedures at 
VNHI 
8883 procedures in 2014 
• 2061 PTCA/stenting, 32 PTA 
• 352 PMV, 36 PTPV, 6 PTAV 
• 354 CSI (170 ASD,118 PDA, 44 VSD) 
• 30 TEVAR, 16 stem cells, 2 RND 
• 266 EPS+ 819 Ablation, 475 PPM 
25521 
18423 
7499 
3035 
4903 
2234 
7676 
4444 
0
5000
10000
15000
20000
25000
30000
Co Angio PCI PMV Cath CHDI EP Ablation Pace
Data: VNHI 
Cumulative Procedures 
 (up to 12/2015) 
PMV at VNHI 
147 
327 
491 
560 
610 
705 
553 
523 
495 
509 504 510 
396 
322 
348 
0
100
200
300
400
500
600
700
800
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
PMV
source: VNHI data 
VNHI’s Experience 1999-2015 
Single center experience > 15 year(1/1999 - 12/2015) 
• Total PMV volume: 7499 pts (≈ 500 
pts/yr) 
• Technically success: 99.6% 
• Optimal results: 85.9% 
• Complications: < 1.0% 
• Restenosis: ≈ 5.5% over 5 years 
Challenging to the procedure 
 Unfavorable clinical situation 
 Emergency cases: APO, cardiogenic shock 
 Pregnant patients 
 Procedure-related complications 
 Acute tamponade or Acute stroke (LAA thrombus) 
 Unfavorable or deformed anatomy 
 Abnormalities of chest, heart, venous system 
 Left atrial: too small or too big (giant LA) 
 Mitral valve: very severe stenosis or unequal calcification 
 Septal position abnormal: previous heart surgery 
 Trapped balloon at septum or femoral artery access site 
  
How to Make it Easy and 
Effective? 
• Patient selection 
• Balloon Selection 
• Technical points: 
• Septal Puncture 
• Cross Mitral Valve 
• Selection Balloon Size 
• Avoid MR 
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 
Predictors for success rate of 
PMV: Our experience 
Factors OR (Odd 
Ratio) 
P 
Age > 55 2,52 < 0,01 
Gender 1,01 > 0,05 
AF 1,03 > 0,05 
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 > 0,05 
Learning curve (>300 cases) 2,35 < 0,01 
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) 
Technical 
Considerations 
Septal puncture 
 Vital component of PTMC 
 Not only avoid tamponade, but also 
made an appropriate septal site to 
facilitate balloon crossing valve 
Simplified Septal Puncture Method: 
Puncture site must inside LA border 
“Landmark” only base on LA border 
• No artery access 
• New Landmark: # sign 
• Clarify Left Atria (PA angiography if 
needed) 
• Catheter/Needle manipulation 
LA border and # landmark 
• Pull back from SVC with needle/catheter fix 
system at 4 – 5 o’clock 
• When needle tip jump, stop and turn 
posterior (to 6 o’clock) (septal in MS usally like 
a dome) 
• Turn back to 4 – 5 o’clock, nearby the desire 
puncture site 
• Push the needle/catheter fix system against 
septal 
• Release finger, make puncture 
• Test with small contrast injection 
Catheter/Needle Manipulation 
Catheter/needle fitting exercise 
Catheter/Needle Manipulation 
Anterior-Posterior (4-6 O’clock) 
Movement of the transseptal sheath 
Staining technique: thick septal 
Puncture site for vertical LV axis 
(lower) 
Puncture site for horizon LV axis 
(higher) 
Optimal puncture site for optimal 
Mitral valve crossing and Valvuloplasty 
Crossing Mitral Stenotic Valve 
 Methods: 
 Vertical method 
 Direct method 
 Sliding method 
 Alternative Loop method 
 Individually 
Crossing Mitral Stenotic Valve 
How to cross the mitral valve 
How to open the mitral valve 
Physiological techniques 
Stylet reshaping 
Stylet reshaping 
Assuring free movement of balloon 
in the LV: “accordion” maneuver to 
avoid severe MR by chordea rupture 
Pushing balloon when full 
inflation for well coaxial with 
Mitral valve orifice 
Not Pushing balloon when full inflation 
for well coaxial with Mitral valve orifice 
plan can lead to severe MR 
PMV in Some 
Special Scenarios 
PMV in patient with LAA 
thrombus 
PMV in patient with giant LA 
PMV in Patient with giant RA 
Always clarify LA border 
PMV in Kyphoscoliosis 
• LA clarify 
• # sign is still useful 
PTMC from the Left Femoral Site (1) 
• Gentle turn and go 
throught pelvis area 
• Make more angle 
needle tip 
Septal Puncture from the Left 
Femoral Site (2) 
Before (needle tip less 
angle) 
After (needle tip more 
angle) 
• PMV using Inoue balloon is still 
considered as first long-lasting temporary 
treatment of choice for rheumatic mitral 
valve stenosis 
• Proper patient & balloon selection, careful 
attention to techniques are the keys to 
success with optimizing results & 
minimizing complications 
Conclusions