Author + information
- Received December 9, 2013
- Accepted December 19, 2013
- Published online August 1, 2014.
- Madan Tarun, MD, DNB∗ (, )
- Garg Rajiv, MD, DM and
- Thakkar Bhavesh, MD, DM
- ↵∗Reprint requests and correspondence:
Dr. Tarun Madan, Department of Cardiology, U.N. Mehta Institute of Cardiology and Research Centre, Civil Hospital Campus, Asarwa, Ahmedabad, Gujrat 380016, India.
A 30-year-old woman with known rheumatic heart disease presented with New York Heart Association functional class III dyspnea. The patient had undergone balloon mitral valvotomy 14 years previously. Transthoracic echocardiography demonstrated severe mitral stenosis with mean gradient of 18 mm Hg across the mitral valve and a pulmonary artery pressure of 70 mm Hg.
The patient was to undergo balloon mitral valvotomy, but the lower limb venous access was not giving way. A venous angiogram showed a partially obstructed right external iliac vein and complete occlusion of the right common iliac vein and inferior vena cava in the infrahepatic segment (Fig. 1). The option of performing the balloon mitral valvotomy via the internal jugular vein or femoral route was evaluated. The inferior vena cava route was thought to be more appropriate.
After accessing the right internal jugular vein and right common femoral vein, a roadmap was created of the occluded inferior vena cava segment. The occluded segment of the inferior vena cava was crossed with 0.035-inch J-tipped Terumo wire (Terumo Interventional Systems, Somerset, New Jersey) via right femoral venous access. Balloon angioplasty of the right external iliac vein, right common iliac vein, and inferior vena cava was done sequentially using a 4 × 150-mm Admiral Extreme balloon (Invatac, Roncadelle, Italy), an 8 × 40-mm OptaPro balloon (Cordis Corporation, San Jose, California), and a 24-mm SYM balloon (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 valvotomy was established from the right lower limb, and balloon mitral valvotomy was done successfully in a conventional manner using a 26-mm SYM balloon (Lifetech Scientific), and the transmitral gradient decreased from 18 mm Hg to 4 mm Hg (Fig. 3).
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 9, 2013.
- Accepted December 19, 2013.
- American College of Cardiology Foundation