Misadventure during balloon mitral valvuloplasty, a complication despite all precautions

Accidental aortic puncture is a much dreaded and potentially serious complication of transseptal catheterization was recognized in the initial description technique by J. Ross Jr colleagues 1958.1Ross J, Braunwald E, Morrow A. Left Heart Catheterization Transseptal Route. A Description Technique its Applications. Circulation 1960; 22(5): 927-934. DOI: https://doi.org/10.1161/01.CIR.22.5.927Google Scholar However, inadvertent pulmonary artery, although theoretically possible despite vast experience with balloon mitral valvuloplasty (BMV), has never been described. We present unique case where BMV pregnant patient complicated right main artery (PA). also discuss mechanisms approach to management. 40-year-old grand multipara (G9P8L8A1) referred our institution for severe rheumatic stenosis (MS). All her previous pregnancies were unremarkable. into second trimester current pregnancy, she becoming increasingly dyspneic at mild moderate levels physical exertion. At 18 weeks gestation, transthoracic echocardiogram revealed normal left ventricular (LV) dimensions systolic function. The ventricle (RV) normal. atrium (LA) severely enlarged. valve (MV) stenotic. MV area (MVA) measured 1.4 cm2 using pressure half-time (PHT) method 1.5 on planimetry. mean gradient 12 mmHg sinus rate 100 beats per minute. Wilkin’s score 7 out 16 points. (PA) moderately elevated an estimated PA (PASP) 51 mmHg. branch dilated. She remained furosemide bisoprolol, therefore, (BMV). this time, past 30 gestation. transesophageal (TEE) MVA PHT method. had increased 110 now dilated RV tricuspid regurgitation hypertension PASP 65 Anticipating difficult access, TEE briefly used during procedure guide puncture. hemodynamic measurements are summarized supplemental table S1. attempted BRK needle (BRK Needle, St. Jude’s Medical, Belgium) 8.5 Fr SL-0 sheath (Swartz SL-0, Plymouth, USA). This proved quite challenging after multiple attempts, interatrial septum (IAS) pierced more superior location. Upon connecting end manometer, arterial tracing obtained (Figure-1). confirmed gentle contrast injection though tip dilator (Supplemental Video S1). 0.032” wire advanced through appeared course down PA. No anticoagulation administered yet. Since probe already withdrawn, bedside performed new small circumferential pericardial effusion without signs tamponade. slowly gradually withdrawn back LA. Serial echocardiograms reassuringly stability effusion. operators still access LA, standard LA secured double loop within cavity S2). point, unfractionated heparin administered. unchanged throughout procedure. then 26-mm INUOE (Toray balloon, Toray Industries, Tokyo, Japan) significant reduction transvalvular Table After procedure, hospital five days monitoring. detailed following day residual 1.8 planimetry 5 Only degree seen. observed (mild moderate) , as well pressure, flow seen across IAS color doppler. Three later, presented chest increasing dyspnea found have large 34-weeks underwent urgent caesarean section bilateral tubal ligation. drained surgically yielded serous fluid. Intraoperative inspection no tear or laceration. cardiac computed tomogram showed diverticulum supero-anterior aspect roof immediately adjacent (Figure-2). There minimal extravasation. managed conservatively. one month, repeat re-accumulation. associated adverse events 1:100 cases. Commonly described complications include tamponade, puncture, systemic cerebral embolism, persistence iatrogenic septal defect.2Tzies S. Andrikopoulos G. Deisenhofer I. et al.Transseptal catheterization: considerations caveats.Pacing Clin Electrophysiol. 2010; 33: 231-242Crossref PubMed Scopus (50) Google Aortic rare, but life-threatening occurs 0.05% It usually happens situations excessive rotation heart distorts usual relationship between root fossa ovalis corresponding fluoroscopic landmarks. likely mechanism injury case. 30-wk gravid uterus displaced diaphragm upwards, confounded further cephalad migration supine position required resulted myocardium being horizontally placed. As result, right-ward bulging IAS, now, tilted horizontal configuration, positioning farther away from assembly dropping vena cava, consistently biasing it location along causing slip superiorly if all engage mid-septum. penetrating would encounter case, readily exited coursing over Perhaps favourable modification be use angulated (e.g. BRK-1, BRK-2), which lower IAS. Potential difficulties crossing due low could overcome over-the-wire technique.3Manjunath CN, Srinivasa KH, Patil CB, Venkatesh HV, Bhoopal TS, Dhanalakshmi C. Balloon valvuloplasty: modified Catheter Cardiovasc Diagn. 1998; 44(1): 23-26. 10.1002/(sici)1097-0304(199805)44:1<23:aid-ccd6>3.0.co;2-9Google Recently, specialized devices introduced refine allow controlled Among these needle-on-wire such SafeSept® guidewire [Pressure Products] radiofrequency-based VersaCross® [Baylis Medical]. Once punctures advances support, guidewires assume atraumatic curved shape rendering them incapable penetration.4Kaplan R.M. Wasserlauf Knight B.P. access: review contemporary tools.J 2022; 1927-1931https://doi.org/10.1111/jce.15428Crossref (1) Unfortunately, neither available us time. followed same principle literature managing punctures. 5Hartono B. Razakjr O.A. Munawar M. Amplatzer occluder sealed complicating perforation catheterization.JACC Interv. 2012; 5: 450-451https://doi.org/10.1016/j.jcin.2011.12.016Crossref (10) Scholar, 6Wasmer K, Zellerhoff S, Kӧbe Mӧnning G, Pott C, Dechering DG, Lange PS, Frommeyer Eckardt L. Incidence management placement aorta Europace 2017; 19(3): 447-457. https://doi.org/10.1093/europace/euw037Google 7Chen H. Fink T. Zhan X. Chen Long D. Ma Rosso R. Mathew Xue Y. Ju W. Wasmer K. Yang Maurer Heeger C.H. Ho S.Y. Kuck K.H. Wu Ouyang F. Inadvertent root: narrow edge luck catastrophe interventional cardiology.Europace. 2019; 0: 1-10https://doi.org/10.1093/europace/euz042Crossref (9) Scholar. distal slow, gradual withdrawal cavity. conceivable that flap raised aligned parallel direction blood conjunction near localized perforation. Several bail-out options considered including surgical repair, close LA-PA track. In track fortunately spontaneously, allowing complete valvuloplasty. worth mentioning presentation tamponade reactive developing response original hemopericardium. intraoperatively when non-hemorrhagic collection drained. ⁃A rotated predisposes overlying vascular structures.⁃A guided transoesophageal echocardiography intracardiac acutely might avert complication.⁃Various strategies can implemented treating repair obliterate Download .docx (.01 MB) Help docx files eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4ZjM0YTAxOWM5ZmMwYTM3OTY2YTc3YTQ4MGMxMzM3OSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3NzU5NDgzfQ.XihyjSXWzKP8PrzLCfYDYmjttfMf3QBbYG9KHK1gVMPcHJxTmlfsZYwyUBt4_uekiGM0EYd1URPYblDMkkTbTF7fyO8yT2071CpIkvQnuNxx0MZhoGaoDgmt9B3UDMhG-jeXx4ukGSzZxJRD7aNvQvToUdTATlxLoz2MuEyVyEdDjDCFKXdS1KcF3pGXTCMf8IiPSXPHZ_KA_NhrPOmwguulX8Md5vTPum8R-ZSanH8Y8po4vti2aJFg9XwyNOFjKzT47vei2LwcaMrOm-AcUOVB9OOiOeBVfrJKD1OpiguWik1kfTZljDR4qiTFcXsGyBkJS6WF-fOlU2kCpXySuA .mp4 (0.83 eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3YTRhNDZiN2M0YjYwNzBkMjU3Y2RmYzdjMTRiMjEwOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3NzU5NDgzfQ.L6FXwNdFKhGDJ6xa4sSXz8yPhQUGk8IYeqTeehq9vCUqvsSlV16aRROW51O_NHYqXICkb3ET7RJ7gagMvRKY2u3RsINmbatH3Sz4c2iXq2JyD49chmY1kjlgKn8eHkpvEfnyF68TQwqLbIjGhupcELOkPguIRGyvms7WxTakfWQv_TWgbNKaMQIquKmYZazSJ0vRlSpCytEYW3v9lWdDw7h_SEA8Tb0-gjJW7pnyzP_pFJ6eH3fP8ShBTwMYTjUChG7xDr8CMNE57kcn9DUlQa-y-yqrKxtLiZjWL4T4WDk-QYbKts4FErvdyLc8wXgVUHPchd5_Ief1_3T7PdPawQ (1.01