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Mitral Balloon Valvuloplastyin the era of TAVI/Mitra Clip
Th Addi Ab b Mit l t iThe Addis Ababa Mitral stenosis project, a technology transferproject, a technology transfer
experience
Hany Ragy & Thomas Kellerthy gyNHI, Cairo , Egypt
& Orebro University, SwedenTCT AP 2012
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Conflict of InterestConflict of Interest
• NONE
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Circulation. 2001; 104: 2746‐2753
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project mitral stenosis backgroundproject mitral stenosis‐background
• h ti f i id 2 50/100 000 i ffi i t d t f• rheumatic fever, incidence 2‐50/100 000, insufficient data from African countries
• rheumatic heart disease– global prevalens: 20 million– mitral valve always affected (MS/MR)– aortic valve affected in 20‐30%– tricuspid valve disease usually subclinical
• rheumatic mitral stenosisrheumatic mitral stenosis– latency 2‐40 years– congestive heart failure
stroke– stroke– AF– pulmonary hypertension
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1987
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20112011
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• Ethiopian/Swedish/Egyptian collaboration, operation Mitral Stenosis part of largeroperation Mitral Stenosis, part of larger operation involving surgery .St t d b t i i i C i D b 2010• Started by training in Cairo December 2010 where a Swedish/Ethiopian team trained at NHI f k f i f MBV ifor one week performing cases of MBV using the Inoue technique for the first time.
• Continued in Addis Ababa, as of today 18 cases performed all using the same balloons used in p gCairo after resterilization..
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Learning @Imbabathe septostomy
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Learning @Imbaba, the MBVWhy Imbaba Egypt? Many dailyWhy, Imbaba Egypt? Many daily patients ,Very few limits in MBVp y
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Case Examples, MBV post AVR, giant LA, previous failure
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all techniques used, Inoue, double balloon, Multitrack, abanoned the Metal Valvutome
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MBV for all : MBV in Situs InversusMBV for all : MBV in Situs Inversus
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Situs InversusSitus Inversus
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Few limits: Echo guided MBV in early pregnancywithout Xraywithout Xray
Solely Echo guided Solely Echo guided septostomyseptostomySolely Echo guided Solely Echo guided septostomyseptostomy
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The valvuloplasty balloon as it is inflated across the MV (contd )The valvuloplasty balloon as it is inflated across the MV (contd )The valvuloplasty balloon as it is inflated across the MV (contd.)The valvuloplasty balloon as it is inflated across the MV (contd.)
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MVA = 1.6 cm² & mean pressure gradient = 5 mmHgMVA = 1.6 cm² & mean pressure gradient = 5 mmHg
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Associated conditions, MBV in Cor Tri triatum
TEE apical 4‐chamber view shows a clear membrane dividing left atrium into two chambersTEE apical 4‐chamber view shows a clear membrane dividing left atrium into two chambers
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MVA 1 9 ² & di t li di t 14/7 HMVA 1 9 ² & di t li di t 14/7 HMVA = 1.9 cm² & diastolic pressure gradient = 14/7 mmHgMVA = 1.9 cm² & diastolic pressure gradient = 14/7 mmHg
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balloon mitral valvuloplasty, ACH, 2011
t i i i C i d 2010• training in Cairo dec 2010• first case ever in Ethiopia april 11, 2011• until today 18 cases• Last 5 cases performed mainly by Ethiopian team transfer of knowledgeLast 5 cases performed mainly by Ethiopian team, transfer of knowledge.
• 11 female, 7 male • age: mean 31.8 (range 14 – 51)g ( g )
• NYHA‐class: mean 2.3 (range 2 – 4)• AFib: 33% 4 patients with previous stroke hsitory• medications:
– diuretics: 72%– digitalis: 22%
warfarin: 44%– warfarin: 44%– betablocker: 78%– antibiotics: 72%
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it l l
balloon mitral valvuloplasty, ACH, 2011
• mitral valve:– area: mean 0,8 cm2 (range 0,4 – 1,3)mean gradient mean 19 mmHg (range 10 36)– mean gradient: mean 19 mmHg (range 10 – 36)
– valve score: mean 7,8 (range 5 – 9)
• pulmonary hypertension: 78%
• preop TEE performed 100%i d h b 2 (11%)– organized thrombus: 2 pts (11%)
– smoke: 3 pts (17%)
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BMV ACH 2011; procedure• Inoue balloon
BMV, ACH, 2011; procedure• Inoue balloon• size: 4 x 24 mm, 10 x 26 mm, 4 x 28 mm
ll l d h h d h f h fl• all cases evaluated with V‐scan echocardiography after each inflation• stepwise inflations stopped due to new/increased MR: ( 5 cases)• Stepwise inflation stopped if splitting of commisures adequate in PSSAX
• no of inflations: mean 2.1 (range 1 – 4)• procedural complications (MACE,Stroke, Bleeding, severe MR): 0p p ( , , g, )
• 1 simultaneous MS and TS dilatation inpresence of large LA thrombus• 1 PBV thrown in for good measure!1 PBV thrown in for good measure!• Both last 2 cases NYHA class 3‐ 4 very sick patients
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BMV ACH 2011; evaluation day 1
h di h
BMV, ACH, 2011; evaluation day 1
• echocardiography:– valve area: mean 1.84 cm2 (range 1.2 – 2.4)– mean gradient 5.3 mmHg (range 3 – 13)g g ( g )– MR: 4 pts increase 1 (4 step scale), 1 pt increase 2– MR > 2/4: 0
• success: 83% (15 of 18)definition: MVA increase > 50% and > 1.5 cm2, and mean gradient , g
< 10 mmHg
ll t h d i > 50%• all pts had area increase > 50%• all 3 pts not meeting above criteria had > doubling of valve
area
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BMV, ACH, 2011; evaluation 1‐3 months
• 11 pts
• all NYHA 1all NYHA 1
• mean NYHA improvement: 1,5 (range 1 – 3)
• echo findings unchangedecho findings unchanged
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Teaching septostomy using atrialflush/stain technique
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Lateral image showing septostomyusing septal stain technique
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Stepwise increase in size guided by echo till full size +1 mm
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Breaking limits in Addis’s early experience. Associated TV stenosis!
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Using Hand Held echo (Vscan) to make up for absence of pressure recording& injectorabsence of pressure recording& injector
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V Scan showing adequate MV opening post MBV, and some MR
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MS, TS pre and post showing spontaneous echo contrast & thrombus pre MBV andecho contrast & thrombus pre MBV , and
echo post procedure
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case: congenital pulmonary valve stenosis on Day 2 in Addis
l 27• male 27 yrs• severely symtomatic, NYHA 4, cyanotic, CHF• echo:• echo:
– valvular PS, gradient > 150 mmHg, – severe RVHsevere RVH– ASD with R‐L shunt‐scheduled for open heart surgery
• pulmonary balloon valvotomy, 25 mm balloon– SAO2 immedately from 63 – 99%
i fi il d d– cyanotic fingernails turned red– 3 month follow: up NYHA I (Truck driver!), acyanotic,gradient 20 mHgy ,g g
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No ASD just a PFONo ASD, just a PFO
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Crossing the PV, MP catheter and Terumo Glidewire
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PBVPBV
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ConclusionConclusion
Th i id if i h li f di l• There is a wide rift in the quality of medical care between the developed and the developing worlds.Whil i t i th lit f lif f• While we aspire to improve the quality of life for elderly patients, with palliative expensive procedures (like TAVI); let us not forget that there are thousands of(like TAVI); let us not forget that there are thousands of young, otherwise healthy patients, in poor nations specially sub saharan africa who are both miserable p yand/Or dying of valve disease which WE can easily palliate with minimal effort and cost ($3000 per ti t?!) d t i thipatient?!) we need someone to organize this‐no
industry interest.