Preliminary Reports . . . works in progress

Transjugular Approach to Concurrent Mitral-Aortic andMitral-Tricuspid Balloon Valvuloplasty

George Joseph,*† MD, DM, G. Rajendiran, MD, DM, and K. Abhaichand Rajpal, MD, DM

A transjugular approach was successfully used for concurrent mitral-aortic and mitral-tricuspid valvuloplasty in one patient each. This approach simplifies antegrade trans-venous aortic valve dilatation in rheumatic aortic stenosis. Advantages obtained bytransjugular tricuspid valvuloplasty are easy crossing of the tricuspid valve and stableballoon position, co-axial with the tricuspid orifice. Cathet. Cardiovasc. Intervent. 49:335–341, 2000. © 2000 Wiley-Liss, Inc.

Key words: mitral valve stenosis; balloon dilatation; jugular veins

INTRODUCTION

A transjugular approach to percutaneous balloon val-vuloplasty is feasible and advantageous in certain casesof congenital valvar pulmonary stenosis [1,2] and rheu-matic mitral stenosis [3]. During pulmonary valvulo-plasty, the right internal jugular vein approach simplifiespulmonary valve crossing in patients with severe pulmo-nary valvar stenosis and right heart failure [1,2]. Intransvenous mitral valvuloplasty, the jugular approachsimplifies septal puncture and mitral valve crossing inpatients with huge left atrium and distorted anatomy,besides making the procedure feasible in the presence ofinferior vena caval obstruction [3]. Rheumatic mitralstenosis occasionally coexists with significant aorticand/or tricuspid valve stenosis. In such situations, bal-loon mitral valvuloplasty has been performed concur-rently with aortic and/or tricuspid balloon valvuloplastyusing a femoral approach [4–14]. The feasibility andbenefits of a transjugular approach to aortic and tricuspidvalvuloplasty have not been studied. We report two caseswherein a transjugular approach to balloon valvuloplastywas used: for concurrent mitral and aortic valve dilata-tion in one, and mitral and tricuspid valve dilatation inthe other.

CASE REPORTS

Case 1

A 38-year-old woman (M.G.) presented with a 2-yearhistory of dyspnea on exertion and was in New YorkHeart Association (NYHA) functional class II. Cardiac

auscultation disclosed features of aortic and mitral ste-nosis. The EKG displayed normal sinus rhythm and thechest X-ray revealed mild cardiomegaly. Transthoracicechocardiography (Table I) showed features of multival-vular rheumatic heart disease, with enlarged left atriumand normal left ventricular dimensions. The mitral valvewas moderately stenosed, with preserved mobility, trivialregurgitation, and morphologic score of 6 out of 16 [15].The aortic valve was tricuspid and noncalcific, withcommissural fusion, severe stenosis, and mild regurgita-tion. Mild tricuspid regurgitation was present with a peakgradient of 26 mm Hg determined by continuous waveDoppler interrogation. Concurrent balloon valvuloplastyof the mitral and aortic valves was planned. Having usedthe transjugular approach in transseptal mitral valvulo-plasty at our center with good results [3], we decided totry this approach in aortic valvuloplasty as well.

After informed consent, mild sedation, and antibioticprophylaxis, the right internal jugular vein and left bra-chial artery were cannulated percutaneously using stan-

Department of Cardiology, Christian Medical College Hospital,Vellore, India

†In accordance with the policy of the Journal, the designated authordiscloses a financial or other interest in the subject discussed in thisarticle.

*Correspondence to: Dr. George Joseph, Department of Cardiology,Christian Medical College Hospital, Vellore 632 004, South India.E-mail: cardio1@cmcvellore.ac.in

Received 1 June 1999; Revision accepted 24 August 1999

Catheterization and Cardiovascular Interventions 49:335–341 (2000)

© 2000 Wiley-Liss, Inc.

dard technique. Aortic root angiography was performedto assess aortic regurgitation (Table I). Right heart cath-eterization and pulmonary angiography, with levophaseimaging of the left atrium and aorta in 45° left anterioroblique view, was performed using a Berman angio-graphic catheter (Arrow, Reading, PA). Transjugularseptal puncture was performed in the same view using anEndrys pediatric transseptal set (Cook, Bloomington,IN). The atrial septum was punctured about 2 cm belowthe roof of the left atrium (above the fossa ovalis),midway between the aorta and anterior border of thespine [3]. We did not use echocardiographic guidanceduring the procedure, as transjugular septal puncture andmitral valvuloplasty are frequently performed in our cen-ter under fluoroscopic guidance alone [3]. A curved0.0250 wire was placed in the left atrium, followed bydilatation of the skin and septal puncture sites using a 14Fr dilator. A 20-cm-long, J-shaped sheath with hemo-static valve (Cook) was then advanced into the leftatrium. A balloon floatation catheter (Arrow) was intro-duced into the left atrium and advanced through mitralvalve into the left ventricle. Mitral valve gradient wasrecorded and a 0.0350 Amplatz wire with soft J-tip(Cook) was placed at the left ventricular apex. The mitralvalve was dilated using an 11 Fr Joseph mitral valvulo-plasty catheter (Numed, Ontario, Canada) [16] with 26-mm-diameter, 4-cm-long cylindrical balloon (Fig. 1A).The valvuloplasty balloon was removed and satisfactorysplit of the mitral valve was ascertained. Next, the aorticvalve gradient was recorded, and the balloon floatationcatheter was looped around at the left ventricular apexand advanced through the aortic valve into the descend-ing aorta. A 0.0350 Amplatz wire was positioned in the

descending aorta, and the aortic valve was dilated usinga 9 Fr balloon catheter (Numed) with 18 mm3 4 cmcylindrical balloon (Fig. 1B). The aortic valve yieldedeasily during balloon inflation using a hand-held 20-ccplastic syringe. This resulted in significant reduction inthe aortic gradient (Fig. 2) with increase in angiographicaortic regurgitation by one grade. Right heart catheter-ization was repeated and sheaths were removed immedi-ately thereafter. Total fluoroscopy time required was 24.4min. There were no complications during or after theprocedure. The patient was discharged from hospital thenext day.

Case 2

A 29-year-old woman (R.S.) underwent surgical mitralvalvotomy 7 years ago. Five years later she suffered anembolic stroke from which she made considerable recov-ery and has been on chronic anticoagulant therapy sincethen. For the last 1 year she experienced worseningdyspnea on exertion and at admission to hospital was inNYHA functional class III. Physical examination re-vealed features of mitral stenosis and pulmonary hyper-tension. The EKG showed sinus rhythm and biatrialenlargement. Transthoracic echocardiography (Table II)disclosed features of multivalvular rheumatic heart dis-ease, with enlargement of both atria and severe pulmo-nary hypertension. The mitral valve was severely ste-nosed with preserved mobility and morphologic score of6 out of 16. There was no mitral calcification or regur-gitation. The aortic valve was mildly regurgitant withoutstenosis. There was significant tricuspid stenosis, withvalve area 1.0 cm2 determined by the pressure halftimemethod, which enables reliable determination of tricus-

TABLE I. Case 1: Echocardiographic and Hemodynamic Data*

Variable Before After

Echocardiographic dataMitral valve area (planimetry) 1.3 cm2 2.1 cm2

Mitral valve area (Doppler) 1.3 cm2 2.4 cm2

Mitral regurgitation (color Doppler) Grade 1/4 Grade 1/4Aortic valve gradient (Doppler) 71 mm Hg 35 mm HgAortic regurgitation (H/LVOT) 3/14 mm 5/14 mm

Hemodynamic dataPulmonary artery pressure [(S/D(M)] 26/10 (17) mm Hg 21/4 (9) mm HgLeft atrial pressure (mean) 14 mm Hg 4 mm HgMitral valve gradient (mean) 6 mm Hg 3 mm HgLeft ventricular pressure (S/D) 168/9 mm Hg 125/12 mm HgAortic pressure [S/D(M)] 82/64 (73) mm Hga 99/49 (72) mm HgAortic valve gradient (peak-to-peak) 86 mm Hga 26 mm HgAortic valve gradient (mean) 74 mm Hga 34 mm HgAortic valve area (Gorlin) 0.47 cm2 a 0.74 cm2

Aortic regurgitation (Seller’s grade) Grade 1/4 Grade 2/4

*Before and after refer to data acquired pre- and postprocedure; H/LVOT, ratio of regurgitant jet width to left ventricular outflow tract width; S/D(M),systolic/diastolic (mean) pressures.aData obtained after mitral valvuloplasty and before aortic valvuloplasty.

336 Joseph et al.

pid orifice area [17]. The tricuspid valve also had grade3/4 regurgitation [18] with peak systolic gradient of 114mm Hg. Transesophageal echocardiography revealed noevidence of thrombus in the left atrium. Concurrent bal-loon valvuloplasty of the mitral and tricuspid valvesusing a transjugular approach was planned. We felt thatthe tricuspid regurgitation was mainly caused by severepulmonary hypertension and anticipated its ameliorationwhen pulmonary artery pressure fell after mitral valvu-loplasty. As a measure of caution, we decided to use anundersized balloon to dilate the tricuspid valve. Surgicaltherapy (mitral valve replacement, tricuspid valvotomy,and annuloplasty) was an alternative that was considered,but given the young age of the patient and the favorablemitral valve morphology, we chose balloon valvuloplastyas the first line of treatment.

After informed consent, the right internal jugular veinwas cannulated percutaneously and a 14 Fr sheath wasadvanced into the right atrium. Left arm noninvasiveblood pressure was monitored throughout the procedure.

Fig. 2. Case 1. Simultaneous left ventricular (LV) and aorticpressure tracings and transaortic gradient (Gdt.), before andafter balloon aortic valvuloplasty (BAV).

Fig. 1. A: Transjugular balloon mitral valvuloplasty in case 1. A pigtail catheter is in the aortaand a 14 Fr sheath is in the left atrium. B: Transjugular balloon aortic valvuloplasty in the samepatient. Arrows indicate the location of the aortic valve.

Transjugular Valvuloplasty 337

A balloon floatation catheter was advanced through thetricuspid and pulmonary valves into the right pulmonaryartery where a 0.0350 Amplatz wire was positioned. Adouble-lumen catheter was advanced over this wire intothe right ventricle. Simultaneous right atrial and rightventricular pressures were recorded. The tricuspid valvewas dilated using a 24 mm3 4 cm cylindrical balloon(Numed; Fig. 3A). This resulted in considerable eleva-tion of the right ventricular systolic pressure (80 to 123mm Hg) and end-diastolic pressure (2 to 11 mm Hg),probably because of increased right ventricular filling.There was significant reduction in tricuspid end-diastolicgradient (Fig. 4). The mean right atrial pressure remainedthe same. Transjugular septal puncture and mitral valvedilatation were then performed in a manner identical tothat described in case 1 (Fig. 3B). The mitral valve wassequentially dilated with 24- and 26-mm balloons, result-ing in a dramatic fall in the extremely high left atrialpressure and transmitral gradient. Repeat right heart cath-eterization showed marked reduction in pulmonary arteryand right ventricular systolic pressures and a modest fallin right atrial and right ventricular diastolic pressures.Total fluoroscopy time required for the procedure was28.7 min. Echocardiography revealed a tricuspid valvearea of 2.3 cm2 with slight reduction in tricuspid regur-gitation. The patient showed marked symptomatic im-provement and was discharged from hospital the nextday.

DISCUSSION

The right internal jugular vein can be cannulated easilyand reliably and can serve as a safe conduit for largeballoon catheters in children and adults [1–3,19]. Thesebenefits, combined with the ease of crossing the pulmo-nary valve with a balloon floatation catheter from the

jugular vein, have been utilized in pulmonary valvulo-plasty and angioplasty of peripheral pulmonary arterystenosis [1,2,19]. Jugular venous access has also been

Fig. 3. A: Transjugular balloon tricuspid valvuloplasty in case2. Indentation on the balloon (arrow) produced by the stenotictricuspid valve is evident. B: Transjugular balloon mitral valvu-loplasty in the same patient.

TABLE II. Case 2: Echocardiographic and Hemodynamic Data*

Variable Before After

Echocardiographic dataMitral valve area (planimetry) 0.7 cm2 2.1 cm2

Mitral valve area (Doppler) 0.6 cm2 2.4 cm2

Mitral regurgitation (color Doppler) Nil Grade 1/4Tricuspid valve area (Doppler) 1.0 cm2 2.3 cm2

Tricuspid regurgitation (color Doppler) Grade 3/4 Grade 2/4Hemodynamic data

Pulmonary artery pressure [(S/D(M)] 123/65 (85) mm Hga 57/32 (42) mm HgLeft atrial pressure (mean) 47 mm Hga 14 mm HgMitral valve gradient (mean) 40 mm Hga 7 mm HgRight atrial pressure (mean) 12 mm Hg 9 mm HgRight ventricular end-diastolic pressure 2 mm Hg 8 mm HgTricuspid valve gradient (mean) 12 mm Hg 6 mm Hg

*Before and after refer to data acquired pre- and postprocedure; S/D(M), systolic/diastolic (mean) pressures.aData obtained after tricuspid valvuloplasty and before mitral valvuloplasty.

338 Joseph et al.

used for transseptal mitral valvuloplasty in adults [3].The jugular approach provides a more direct route to themitral valve, without catheters having to bend over back-ward to cross the mitral valve as in the femoral trans-venous approach. In patients with huge left atrium anddistorted anatomy, the critical dependence of proceduralcomplexity and outcome, on the site of septal punctureselected during femoral transvenous mitral valvuloplasty,is considerably reduced by the jugular approach: as longas the high septum is punctured, mitral valve crossing isconsistently simple and quick [3]. Additionally, the jug-ular approach offers an alternative route for transseptalmitral valvuloplasty in patients with webs, filters, inter-ruption, obliteration, or thrombosis in the inferior venacava or iliofemoral veins. Case selection, equipment, andtechnique used have to be appropriate for transjugularmitral valvuloplasty. A large left atrium and extra cur-vature of the transseptal needle makes transjugular septalpuncture easier, as it allows a more perpendicular orien-tation of the needle tip to the atrial septum. The Endryspediatric transseptal set, which consists of an outer metaltube and an inner stylet, is suitable for transjugular septalpuncture because the curvature of its tip can be increasedeasily and its short length makes the assembly easy tohandle. A J-shaped 14 Fr sheath that is inserted into theleft atrium directs catheters toward the mitral valve andallows smooth entry and exit of balloon catheters past theskin and septal puncture sites. Additionally, its hemo-static valve prevents air entry and blood loss, while itssidearm allows measurement of left atrial pressure. Ex-tension of the transjugular approach to balloon dilatation

of stenotic aortic and tricuspid valves, which occasion-ally coexist with rheumatic mitral stenosis, is the logicalprogression of the application of this technique.

Transjugular Aortic Valvuloplasty

Combining aortic valvuloplasty with transjugular mi-tral valvuloplasty involved only a few additional steps inthe first case presented. Looping a balloon floatationcatheter around at the left ventricular apex and then outthe aortic valve into the descending aorta is relativelysimple by the jugular approach. As with the femoraltransvenous technique of aortic valvuloplasty [20,21],the jugular approach obviates the need to introduce largesheaths or balloons into the femoral artery. However,tracking of the valvuloplasty catheter over a wire andpositioning the balloon at the aortic valve is easier by thejugular approach than by the femoral transvenous ap-proach. This is because the course of the catheter withinthe heart on its way to the aortic valve (Fig. 1B) is lessconvoluted than that in the femoral transvenous ap-proach. Balloon instability was not a problem in thiscase. This may be due to the coaxial shaft design of theNumed balloon catheter, which allows rapid ballooninflation and deflation. The aortic valve yielded easily toballoon dilatation in the present case, which is consistentwith previous reports that rheumatic aortic valve stenosiswith commissural fusion responds well to balloon dila-tation [6,22]. The transjugular approach may not be ap-propriate for isolated aortic valve stenosis of nonrheu-matic etiology because the left atrium is usually notenlarged in this condition, which can make transjugularseptal puncture difficult to perform.

The sequence in which the mitral and aortic valvesshould be dilated has been debated. We chose to dilatethe mitral valve first because this could possibly makecatheter manipulations in the left ventricle and passage ofthe balloon to the aortic valve easier. However, dilatingthe mitral valve first has potential disadvantages. Sharmaet al. [12] pointed out that if severe mitral regurgitationwere to occur, it would lead to a catastrophic situation inthe presence of unrelieved aortic stenosis. Berman et al.[4], reporting on a series of elderly patients, stated thatincreased diastolic left ventricular filling in the presenceof unrelieved aortic stenosis could increase wall stressand possibly cause subendocardial ischemia. In our case,the good mitral valve morphology and the young age ofthe patient made severe mitral regurgitation and suben-docardial ischemia unlikely events. Dilating the aorticvalve first can also be disadvantageous. Sharma et al.[12] reported a patient with mitral valve area 0.4 cm2

who went into acute pulmonary edema during aorticvalve dilatation and was subsequently unable to lie su-pine.

Fig. 4. Case 2. Simultaneous right atrial (RA) and right ventric-ular (RV) pressure tracings at baseline, after balloon tricuspidvalvuloplasty (BTV), and after BTV and balloon mitral valvulo-plasty (BMV). Also shown are RA mean pressure, RV end-dia-stolic pressure (RVEDP), and transtricuspid gradient (Gdt.).

Transjugular Valvuloplasty 339

Transjugular Tricuspid Valvuloplasty

The transjugular approach appears well suited to bal-loon valvuloplasty of rheumatic tricuspid stenosis. In thesecond case presented, a balloon floatation catheter easilycrossed the stenotic tricuspid valve and tended to go onto the right pulmonary artery where the tip of a valvulo-plasty guidewire could be positioned. With the guidewirein the right pulmonary artery, a stable balloon position,coaxial with the tricuspid valve orifice, was obtained.Guidewires introduced from the femoral vein cross thetricuspid orifice obliquely if positioned in the pulmonaryartery [23–25]. This is not an ideal situation, becauselong balloons used in pulmonary valvuloplasty havecaused rupture of the papillary muscle of the anteriortricuspid leaflet [26]. If femoral guidewires are posi-tioned in the right ventricular apex [13,27], they arecoaxial with the tricuspid orifice but may not give ade-quate support to the balloon if the right ventricle is small.The Inoue balloon has been used successfully in tricuspidvalvuloplasty [5,12], but crossing the tricuspid valvewith this balloon from the femoral approach may neces-sitate an over-the-wire approach [28] or other manipula-tion [29]. The jugular approach could potentially sim-plify tricuspid valve crossing with the Inoue balloon andallow coaxial orientation with the tricuspid valve orifice.

The tricuspid valve is usually dilated to a greaterextent than the mitral valve, with some studies reportingthe use of two balloons (cylindrical, bifoil, or trefoil) oftotal cross-sectional area 7 to 10 cm2, or a single 25- to28-mm Inoue balloon to achieve adequate dilatation[12,13]. However, use of large balloons may lead tosignificant tricuspid regurgitation [12,24], the clinicalimportance of which is determined to a large extent bythe severity of coexisting mitral stenosis [24] and ade-quacy of concurrently performed mitral valvuloplasty[13]. In our case, a relatively small balloon was usedbecause of the presence of grade 3 tricuspid regurgita-tion. This increased the tricuspid valve area satisfactorilyand reduced the mean gradient by half. Tricuspid regur-gitation decreased slightly, probably because of themarked fall in right ventricular systolic pressure aftermitral valvuloplasty.

In the case presented, the tricuspid valve was dilatedbefore the mitral valve. Our decision to dilate the tricus-pid valve before the mitral valve was based on thereported occurrence of right-to-left shunting across theatrial septum leading to hypoxemia and clinical compro-mise when the reverse order of valve dilatation wasfollowed [12]. As it turned out, considerable elevation ofpulmonary artery pressure occurred after tricuspid val-vuloplasty, probably as a result of increased right ven-tricular filling. Although no acute deterioration in thepatient’s clinical or hemodynamic status occurred, the

likelihood of this happening was very real, given theextremely high left atrial pressure and transmitral gradi-ent recorded. Another point, especially relevant to pa-tients with preexisting tricuspid regurgitation, is thatdilating the mitral valve first provides the opportunity toconfirm satisfactory split of the mitral valve and fall inpulmonary artery pressure before dilating the tricuspidvalve. Hence, if we were to do a similar case of concur-rent mitral and tricuspid valvuloplasty again, we wouldreverse the sequence of valve dilatation and dilate themitral valve first. A close watch would have to be keptfor hypoxemia developing due to right-to-left shuntingacross the atrial septum after mitral valve dilatation. Insuch an event, the tricuspid valve would have to bedilated as quickly as possible.

Combining aortic or tricuspid valvuloplasty with tran-sjugular mitral valvuloplasty is feasible and easy to per-form in selected patients with multivalvular rheumaticheart disease. The transjugular aortic valvuloplasty tech-nique simplifies aortic valve crossing and obviates fem-oral artery trauma. It is simpler than the femoral trans-venous technique with respect to catheter manipulationand balloon positioning. However, the current limitationof transjugular septal puncture to patients with a large leftatrium restricts the use of transjugular aortic valvulo-plasty to patients with a combination of rheumatic mitraland aortic stenosis. The transjugular approach to tricus-pid valvuloplasty can be offered to all patients withsignificant tricuspid stenosis, irrespective of left atrialsize, and has the distinct advantages of easy tricuspidvalve crossing, stable balloon position, and coaxial ori-entation of the balloon with the tricuspid valve orifice.

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