Kỹ thuật nong van hai lá bằng bóng inoue

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; Cath Labs; Op rooms Volume of Cath procedures at VNHI 8883 procedures in 2014 • 2061 PTCA/stenting, 32 PTA • 352 PMV, 36 PTPV, PTAV • 354 CSI (170 ASD,118 PDA, 44 VSD) • 30 TEVAR, 16 stem cells, RND 4735 • 266 EPS+ 819 Ablation, 475 PPM 7883 6711 6001 6242 4940 3905 2729 832 1015 1232 2000 2001 2002 3022 1619 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Cumulative Procedures (up to 12/2015) 30000 25521 25000 18423 20000 15000 7676 7499 10000 4903 3035 5000 4444 2234 Co Angio PCI PMV Cath CHDI EP Ablation Pace Data: VNHI PMV at VNHI 800 705 700 610 600 560 553 523 495 491 500 509 504 510 396 400 348 327 322 300 200 147 100 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: pts/yr) 7499 pts (≈ 500 • Technically success: 99.6% • Optimal results: 85.9% • Complications: < 1.0% • Restenosis: ≈ 5.5% over 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 Age > 55 Gender AF Prior Commisurotomy Combine MR 2/4 Wilkins score MVA prior PTMC PA pressure prior PTMC Learning curve (>300 cases) OR (Odd Ratio) 2,52 1,01 P < 0,01 > 0,05 1,03 1,35 1,45 3,01 1,25 1,07 2,35 > 0,05 < 0,01 < 0,01 < 0,01 < 0,01 > 0,05 < 0,01 Physiological techniques How to cross the mitral valve How to open the mitral valve 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) Conclusions • 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 ... 0,05 < 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