Malfunction of Accura Balloon during Percutaneous Transmitral Commissurotomy in calcified mitral valve
Background
Accura Balloon is composed of three layers- two latex layers with a third mesh layer between them. The mesh regulates maximum diameter and internal pressure of balloon. Over inflation or rapid increase of inner pressure during inflation may damage mesh layer especially if in cases of calcified valve.
Methods
Percutaneous Transmitral Commissurotomy (PTMC) using standard technique was performed using Accura balloon (Vascular Concepts, Essex, UK) among patients with severe mitral stenosis [mitral valve area (MVA) ≤ 1.5cm2] having Wilkin’s score ≤ 8. Bizarre shape indicating deformation of balloon architecture was considered as marker of rupture.
Results
PTMC was successfully performed among 1479 patients (age: 19.9±08.7 years; males-898; females-581) at LPS Institute of Cardiology, Kanpur between May 2009 and December 2018. 117 patients (7.9%) had calcified restenosed valve. Mean left atrial fell from 38±13 to 13±3 mmHg (P<0.005) while postprocedural MVA was 1.89±1.83 cm2. 251 patients (16.9%) required multiple attempts to cross mitral. Rupture of Accura balloon was noted in 8 patients (proximal-3; distal-5) which were partial (n=7;87%) and complete (n=1;13%). Complete rupture was noted in patient with severely calcified and restenosed valve (MVA=0.6cm2; calcium score=3). All ruptures were self contained without any embolization of latex material, mesh or air. Calcium over the valve could have been the offender by causing tear either by abrasion or avulsion under high transmitral gradient while crossing the mitral valve.
Conclusions
Rupture of balloon catheter is concern while intervening calcified especially restenosed valve. Site of tear may be proximal, though more common in distal part of Accura balloon. Therefore, one should be very careful while intervening severely calcified, and restenosed valve.