Page 34 - Journal of Structural Heart Disease - Volume 1 Issue 1

Original Research Article
28
Figure 10. Dilation of the interatrial septum.
into the aortic root. The balloon catheter is then ma- neuvered with a wire into the descending aorta. At this point, an exchange length 0.032 inch extra stiff wire is passed through the balloon catheter into the descending aorta above the aortic bifurcation (Fig- ure 7). The left femoral artery access can be used to introduce a 10-mm gooseneck snare to catch the distal end of the 0.032-inch wire (Figure 8). While it is possible to exteriorize the arteriovenous loop, there is no need for this and the snared support wire may be left parked in the descending aorta, as this will provide adequate support for antegrade balloon passage (Figure 9).
The Mullins sheath and single-lumen balloon catheter are then withdrawn through the 14 French right femoral venous sheath exchanged for Inoue balloon 14 French dilator. The septum is dilated (Figure 10). The Inoue balloon is prepped. The Inoue balloon is then introduced in it stretched configuration. In the United States, the smallest available balloon is the maximum recommended inflated diameter of 26 mm. For most women, a single balloon inflation of 24 or 25 mm can be performed. For most men, a single inflation of 25 or 26 mm, using the calibrated inflation
Figure 10 Video.
syringe, is adequate.
The stretched balloon is introduced into the left
atrium, and then unstretched. The balloon is tracked around the arteriovenous loop through the mitral valve and into the aortic valve. It sometimes requires pushing from the venous side and pulling on the ar- terial side to get the balloon into position in the na- tive aortic valve. Without any need for rapid pacing, the balloon is inflated in its usual stepwise fashion (Figure 11). The distal part of the balloon was inflated on the arch side of the aortic valve and pulled back to engage the valve and then the balloon is fully in- flated. A rapid inflate-deflate is important. It is also important, as soon as the balloon deflated, to back it out of the aortic valve into the left atrium, and to re-establish the arteriovenous loop so that there is no tension on the mitral valve leaflets.
In some cases, progressive hypotension begins as soon as the arteriovenous loop is introduced and the procedure must be aborted. In other cases, the on- set of this mitral regurgitation related hypotension is gradual and if the procedure can be accomplished rapidly, the arteriovenous loop can be decompressed or removed before significant hypotension occurs.
Structural Heart Disease, May 2015
Volume 1, Issue 1: 20-32