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IMAGES IN INTERVENTION

Successful Balloon Mitral Valvotomy in aCase of Inferior Vena Cava ObstructionWhere There Is a Will, There Is a Way

Madan Tarun, MD, DNB, Garg Rajiv, MD, DM, Thakkar Bhavesh, MD, DM

A 30-year-old woman with known rheumaticheart disease presented with New York HeartAssociation functional class III dyspnea. Thepatient had undergone balloon mitral valvotomy 14years previously. Transthoracic echocardiographydemonstrated severe mitral stenosis with meangradient of 18 mm Hg across the mitral valve and apulmonary artery pressure of 70 mm Hg.

FIGURE 1 Pre-procedure Venous Angiogram

(A) Right Iliac venous angiogram demonstrating partially obstructed right

cava. (B) Total occlusion of the inferior vena cava (arrow). (C) Two cath

complete occlusion of the inferior vena cava and venous collateral (arro

From the U.N. Mehta Institute of Cardiology and Research Centre (UNMICRC

they have no relationships relevant to the contents of this paper to disclose

Manuscript received December 9, 2013; accepted December 19, 2013.

The patient was to undergo balloon mitral valvot-omy, but the lower limb venous access was notgiving way. A venous angiogram showed a partiallyobstructed right external iliac vein and complete oc-clusion of the right common iliac vein and inferiorvena cava in the infrahepatic segment (Fig. 1). Theoption of performing the balloon mitral valvotomyvia the internal jugular vein or femoral route was

common iliac vein and collaterals reforming distally into inferior vena

eters (1 each via the jugular and femoral access) are seen showing

w).

), Ahmedabad, India. The authors have reported that

.

http://dx.doi.org/10.1016/j.jcin.2013.12.209

FIGURE 2 Balloon Angioplasty of the Common Iliac Vein and Inferior Vena Cava

(A) Terumo wire crossed from the right femoral vein into the inferior vena cava via the occluded segment. (B) Balloon angioplasty of the right

common iliac vein done using an OptaPro balloon (Cordis Corporation, San Jose, California). (C) Balloon angioplasty of the vena cava and

proximal right common iliac vein using the SYM balloon (Lifetech Scientific, Shenzhen, China). (D) Brisk flow in the inferior vena cava after

balloon angioplasty.

FIGURE 3 Balloon Mitral Valvotomy Via the Inferior Vena Cava

(A) A Mullins dilator passed from the inferior vena cava into the left atrium through a transseptal puncture. (B) A 0.025-inch coiled tip wire

placed in the left atrium through the Mullins dilator. (C) Mitral valve being dilated with the SYM balloon Lifetech Scientific, Shenzhen, China).

Tarun et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 7 , N O . 8 , 2 0 1 4

Successful balloon mitral valvotomy in inferior vena cava obstruction A U G U S T 2 0 1 4 : e 9 9 – 1 0 1e100

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 7 , N O . 8 , 2 0 1 4 Tarun et al.A U G U S T 2 0 1 4 : e 9 9 – 1 0 1 Successful balloon mitral valvotomy in inferior vena cava obstruction

e101

evaluated. The inferior vena cava route was thoughtto be more appropriate.

After accessing the right internal jugular vein andright common femoral vein, a roadmap was created ofthe occluded inferior vena cava segment. The occludedsegment of the inferior vena cava was crossed with0.035-inch J-tipped Terumo wire (Terumo Interven-tional Systems, Somerset, New Jersey) via rightfemoral venous access. Balloon angioplasty of the rightexternal iliac vein, right common iliac vein, and infe-rior vena cava was done sequentially using a 4 �150-mm Admiral Extreme balloon (Invatac, Ronca-delle, Italy), an 8 � 40-mm OptaPro balloon (CordisCorporation, San Jose, California), and a 24-mm SYMballoon (Lifetech Scientific, Shenzhen, China) (Fig. 2).After the balloon angioplasty, there was brisk flow in

the right common iliac vein and inferior vena cava.Successful venous access for balloon mitral valvotomywas established from the right lower limb, and balloonmitral valvotomy was done successfully in a conven-tional manner using a 26-mm SYM balloon (LifetechScientific), and the transmitral gradient decreasedfrom 18 mm Hg to 4 mm Hg (Fig. 3).

REPRINT REQUESTS AND CORRESPONDENCE: Dr.Tarun Madan, Department of Cardiology, U.N. MehtaInstitute of Cardiology and Research Centre, CivilHospital Campus, Asarwa, Ahmedabad, Gujrat380016, India. E-mail: drtarunmadan@yahoo.co.in.

KEY WORDS balloon angioplasty, balloon mitral valvotomy,inferior vena cava

mailto:drtarunmadan@yahoo.co.in

Successful Balloon Mitral Valvotomy in a Case of Inferior Vena Cava Obstruction