Steerable Catheter Research Articles

A Prospective, Randomized, Noninferiority Study to Evaluate the Safety and Effectiveness of Steerable Ureteroscopic Renal Evacuation Compared with Standard Ureteroscopy: 30-Day Results of the ASPIRE Study.

Purpose: We report the first multicenter, prospective, randomized noninferiority controlled trial of steerable ureteroscopic renal evacuation (SURE) for nephrolithiasis treatment. Materials and Methods: Candidates for laser lithotripsy ≥18 years with ≥1 renal stone ≥7 mm and 7-20 mm stone burden were randomized 1:1 SURE vs ureteroscopy (URS). SURE was performed using the CVAC Aspiration System, a novel steerable irrigation-aspiration catheter. The primary efficacy end point was noninferiority in stone-free rate (SFR) based on zero residual fragments (RFs) 30 days postprocedure on noncontrast computed tomography. Secondary end points were superiority tests, stone clearance (percent stone volume reduction), residual stone volume (RSV), SFR (no RF >2 mm), and SFR (no RF >4 mm) 30 days postprocedure. Results: Of the subjects, 123 were randomized and 101 qualified for efficacy analysis (SURE 46 vs URS 55). Despite randomization, baseline URS stone volume was higher (SURE 485.0 ± 432.5 mm3 vs URS 713.3 ± 558.5 mm3). The primary noninferiority end point was achieved (SURE SFR 48% vs URS SFR 49%, p = 0.027, -1.3% [90% confidence interval; -18%, 15%]). Stone clearance was significantly higher for SURE vs URS subjects (SURE 96.9 ± 5.6% vs URS 92.9 ± 11.6%, p = 0.036); RSV was significantly lower (SURE 14.3 ± 3 0.9 mm3 vs URS 70.2 ± 144.9 mm3, p = 0.012). SURE stone clearance and RSV were independent of baseline stone volume, but for URS degraded with increasing baseline stone volume. Safety was comparable between groups. Conclusions: SFR for SURE subjects was noninferior compared with URS subjects; stone clearance and RSV were significantly better with SURE, independent of baseline stone volume.

Anterior Circulation Stroke Mechanical Thrombectomy With Transradial Balloon Guide Catheter: Single-Center Pilot Study

This study evaluates the feasibility, safety, and efficiency of using a balloon guide catheter (BGC) through transradial access (TRA) for mechanical thrombectomy (MT) in patients with anterior circulation strokes. A retrospective case series of patients who underwent MT using BGC through TRA for acute ischemic stroke in the anterior circulation was conducted. Data collected included procedural times (from puncture to revascularization), technical success, complication rates, and clinical outcomes. Patients' baseline characteristics, stroke severity, and post-procedural outcomes were also analyzed. Thirty patients were included, with a mean age of 64.4 ± 13.6 years. The median admission NIHSS score was 13, and 17 % received intravenous thrombolysis before thrombectomy. Right-sided occlusions were more frequent (57 %). TRA was successful in 27 patients (90 %), with 3 (10 %) requiring conversion to femoral access. The median puncture-to-revascularization time was 32 minutes, and first-pass revascularization was achieved in 40 % of cases. A favorable TICI 2b or higher was accomplished in 97 %, with no access site complications. Hemorrhagic conversion occurred in 20 %, including one symptomatic intracerebral hemorrhage (3 %). At discharge, 57 % of patients had favorable outcomes (mRS 0-2), and by 90 days, 54 % achieved functional independence, with a mortality rate of 3 %. This case series highlights the feasibility of using BGC through TRA in MT for anterior circulation strokes, demonstrating promising safety and efficiency. Future multicenter studies with larger cohorts are necessary to compare clinical outcomes of TRA versus transfemoral access and guide standardized protocols for stroke interventions.

Utility of the turn-back supporting technique using a steerable intermediate catheter: illustrative case.

Selective shunt occlusion (SSO) for intracranial dural arteriovenous fistulas (DAVFs) is a safe and effective method that directly intercepts the shunted pouch from the affected sinus with minimal materials. However, it can be challenging to obliterate the shunted pouch if the microcatheter is not supported adequately. A 68-year-old woman presented with tinnitus and was diagnosed with multiple shunted DAVFs in the right transverse-sigmoid sinus (TSS) and the superior sagittal sinus (SSS). Although the entire sinus packing of the right TSS was performed, a follow-up angiography 7 months later revealed significant cerebral venous reflux due to occlusion of the left TSS and an increasing residual shunt flow in the venous pouch at the confluence of the SSS. A guiding catheter was introduced into the isolated sinus transvenously. Then, a steerable intermediate catheter (SIC) was manually steered into a hairpin shape and hooked on near the pouch prior to navigating a microcatheter into the fistula point. Finally, the fistula pouch was completely obliterated using only two coils under the adequate support of the turned-back intermediate catheter. The turn-back supporting technique using an SIC was useful in achieving SSO for DAVFs, providing both adequate support and guidance for the coaxial microcatheter. https://thejns.org/doi/10.3171/CASE24467.

Effectiveness of Steerable Microcatheters During Transarterial Chemoembolization for Hepatocellular Carcinoma.

Although transarterial chemo-embolization (TACE) is a key treatment for hepatocellular carcinoma (HCC), its effectiveness depends on the cannulation of the microcatheter tip into the feeding artery. Steerable microcatheters allow remote operation of the tip, enabling its insertion into feeding arteries otherwise difficult to reach. This study investigated the indications and effectiveness of steerable microcatheters in TACE for HCC. We retrospectively examined 22 patients with HCC who underwent TACE using steerable microcatheters at our Department between December 2014 and July 2024. Previous TACE administration, number of TACE sessions, and feeding artery disruption affecting TACE were examined. Among the first TACE cases requiring steerable catheters, three demonstrated steep bifurcation of the celiac artery or superior mesenteric artery from the parent artery, two had sharp bends in the posterior segment, and four had the left hepatic artery bifurcating from the left gastric artery. All three procedures performed in the inferior phrenic artery required second TACE sessions. Steerable microcatheters were used in two patients during their eighth TACE session; both procedures involved selective cannulation of neovessels feeding from a new anastomotic branch to segment 4, following damage to the main feeding artery from repeated treatments. Steerable microcatheters were effective in reaching steep or strongly bending branches of the parent or feeding artery in the first TACE cases or neovessels and anastomotic branches in previous TACE cases. Studies with larger sample sizes are warranted to validate the use of steerable microcatheters for effective TACE.

Intraoperative Position System guided with Augmented Reality Improves the Learning Curve of Endovascular Navigation in Endovascular Naïve Operators

ObjectiveThis study aimed to compare the completion of gate cannulation task performed by participants of varying experience using fluoroscopy, the Intra-Operative Positioning System (IOPS) – an FDA-cleared endovascular navigation system that has been developed to reduce dependence on fluoroscopy – or an investigational augmented reality electromagnetic navigation technology based on IOPS. MethodsThe task consisted in the cannulation of the gate of a GORE Excluder AAA endoprosthesis bifurcated aortic stent graft (W.L. GORE & Associates, Flagstaff, AZ USA) deployed into a 3D printed abdominal aortic aneurysm (AAA) model connected to a 7000 MDX flow pump (Sarns Inc/3M, Ann Arbor, MI USA) reproducing physiological conditions. The procedure was performed in a hybrid operating room (GE Allia IGS 7). Each participant performed the cannulation task with fluoroscopy, standard IOPS guidance with flat screen display (IOPS-FS), and the investigational IOPS with augmented reality headset (IOPS-AR), in a randomly assigned order. All participants used the same sensorized guidewire and steerable 6Fr catheter during their three cannulation tasks. A total of 26 participants were classified in three groups of experience: Group 1 (endovascular naïve; n = 13), Group 2 (surgeon in training; n = 12) and Group 3 (one expert surgeon). Primary endpoints included cannulation time and technical success, which was defined as the advancement of the catheter over the guidewire within the main body of the aortic stent graft within a maximum 15 minutes cutoff time for each trial. ResultsIn group 1, the mean cannulation time was shorter using IOPS-AR versus fluoroscopy (4.3 ±4.4 min vs 7.1±4.9 min; P=.04), but not statistically different when comparing IOPS-FS and fluoroscopy (6.3±4.5 min vs 7.1±4.9 min; P=.63). In group 1, technical success was 77% with fluoroscopy and 92% with both IOPS-FS and IOPS-AR (P=.59). In group 2, although there was no significant difference between cannulation time amongst the three different endovascular approaches, there was a trend towards shorter cannulation times with IOPS-FS or IOPS-AR as compared to fluoroscopy (mean time of 2.5±0.9, 4.4±4.0 and 5.2±4.5 min, respectively). In group 2, technical success was 92% with fluoroscopy and 100% with both IOPS-FS and IOPS-AR (P>.99). The expert vascular surgeon repeated the cannulation task four times for each endovascular approach, with 100% technical success and no difference in mean cannulation time between the imaging modalities (P=.89). ConclusionsAugmented reality allows for reducing the gate cannulation time as compared to fluoroscopy in participants with no previous exposure to any endovascular procedure. This suggests that augmented reality can be beneficial for individuals early in their career and can mitigate the learning curve. As individuals become experts, their ability to adapt to different endovascular modalities increases, eliminating the learning curve altogether.

Mitigation of pacing-induced cardiomyopathy with superficial right ventricular mid-septal pacing: A long-term retrospective comparison with apical pacing.

It remains unclear if pacing induced cardiomyopathy (PICM) may be minimized by standard pacing of the right ventricle (RV) at sites other than the RV apex. The purpose of this study is to compare the relative frequency of PICM in a population of patients paced at either the superficial RV mid septum (RVMS) or RV apex (RVA), and other outcomes that may differ between these sites. A retrospective evaluation was performed on all patients undergoing pacemaker implantation between 2011 and 2022. Potential study patients were those with Medtronic 3830 superficial RVMS leads placed with septal specific guidance catheters, and any with RVA leads. Patients were included if they had ≥20% RV pacing, available baseline and follow-up measurements of left ventricular ejection fraction (LVEF) at least 6 months postimplantation, and a baseline LVEF ≥50%. PICM was defined as a decline in the LVEF of at least 10%, resulting in LVEF <50%. Patients were excluded for Biventricular devices, and for alternative causes of cardiomyopathy. The study criteria were met in 324 patients, with 220 RVMS and 104 RVA paced patients. PICM occurred in 4.5% of RVMS patients, and 22.1% of RVA patients (p < .001). Additional differences were demonstrated in paced QRS duration (144 ± 15.5 ms in RVMS, 166 ± 19.4 ms in RVA; p < .001); QRS axis (2.3 ± 64.9 in RVMS, -65.2 ± 49.5 in RVA; p < .001), and various qualitative QRS morphologic characteristics. Patients with normal LVEF experienced significantly less PICM with superficial RVMS pacing performed via septal specific guidance catheters than similar counterparts with RVA pacing. Narrower paced QRS duration and less left axis deviation was also demonstrated.

Safety and efficacy of leadless pacemaker extraction using a novel retrieval tool: a multicenter analysis

Abstract Background Leadless pacemakers (LP) have emerged as a safe and effective alternative for cardiac pacing, increasingly adopted by the medical community. While rare, complications such as pacemaker syndrome or device dislodgment can occur. In such instances, the extraction of the leadless pacemaker and its replacement with a new device should be considered. Purpose This multicenter study aimed to describe the use of the Aveir retrieval sheath during Micra extraction procedure and to assess the success rates and potential complications associated with the procedure. Methods In this observational study, we analyzed prospectively collected data from 14 patients that underwent leadless pacemaker using Abbott retrieval catheter at three high volume centers for pacemaker extraction and leadless implant in United States. Thought femoral vein the Aveir steerable retrieval catheter is advanced to the right atrium and then across the tricuspid valve. Under TEE and fluoroscopy guidance the snare is advanced over the Micra, and the button is secured. A protective sleeve is advanced over the LP. With application of traction to snare and countertraction with the sleeve against the endocardium, the LP is free from the myocardium and removed via the sheath. (Fig. 1) The procedural duration should be intended as the combined total of the time taken for the extraction of the existing pacemaker and the implantation time of the new device. Extractions performed during the first year were described as early and thereafter as late. Procedural success was described as complete extraction of LP without procedural complication. Results The reason for early explant was LP dislodgment and for late explant was pacemaker syndrome. Median time to extraction was 4±2 months in early explant and 35±9 months in late explant. Procedural time in early and late groups was 68.7 and 72.3 min respectively (P=0.32). Fluoroscopy time in early and late groups was 12.2 and 16.4 respectively (P= 0.18). LP was then replaced with a transvenous pacemaker. Success was 100% in both groups. No complication occurred in both groups. Conclusion Micra pacemaker using Aveir retrieval catheter is an effective tool irrespective of dwell time.

Successful reintervention using a novel steerable catheter after dislocation of a transluminal gallbladder stent.

Successful reintervention using a novel steerable catheter after dislocation of a transluminal gallbladder stent.

Safe Endovascular Recanalization of Internal Carotid Artery Occlusion Using Retrograde Aspiration Angiography

ObjectsCerebral infarction, resulting from acute internal carotid artery (ICA) occlusion, typically manifests with a wide ischemic area and severe symptoms. Mechanical thrombectomy proves effective within 24 hours of disease onset and in less ischemic infarction core. However, in cases with well-developed collateral flow and mild symptoms, conservative treatment is initially selected. If symptoms worsen or ipsilateral hemisphere perfusion decreases, superficial temporal artery (STA) – middle cerebral artery (MCA) anastomosis is considered. Revascularization therapy may also be effective. Contralateral angiography allows for ipsilateral blood flow verification once complete revascularization is achieved, albeit with potential treatment-related complications. Here, we describe retrograde angiography using an intermediate catheter (IMC) and contralateral contrast injection to achieve safer revascularization. MethodsWe present ten acute ICA occlusion cases caused by thromboembolism, arteriosclerosis, carotid artery stent occlusion, or embolic stroke of undetermined source. Employing bilateral femoral artery puncture, one catheter was guided to the occluded ICA, while another was positioned for diagnostic purposes in the contralateral ICA or vertebral artery. The IMC was navigated through the occluded vessel, with contralateral imaging performed during aspiration. The catheter was gradually retracted to confirm the extent of occlusion and recognize recanalization. ResultsRecanalization was successfully achieved in all cases. Symptomatic ischemic complication and hyperperfuison was not seen in all cases. No cases were decreased modified Rankin scale after treatment. ConclusionAdvancements in IMC technology facilitate distal catheter guidance to the ICA, even in proximal occlusion. Combining this technique with contralateral imaging allows us to confirm the extent of occlusion and recanalization status without antegrade imaging, making recanalization therapy safer.

Thermally Drawn Polymeric Catheters for MR-Guided Cardiovascular Intervention.

Cardiovascular diseases (CVDs), including congenital heart diseases (CHD), present significant global health challenges, emphasizing the need for safe and effective treatment modalities. Fluoroscopy-guided endovascular interventions are widely utilized but raise concerns about ionizing radiation, especially in pediatric cases. Magnetic resonance imaging (MRI) offers a radiation-free alternative with superior soft tissue visualization and functional insights. However, the lack of compatible instruments remains a major obstacle. An adapted thermal drawing platform that enables low-cost and rapid prototyping of instruments for MR-guided endovascular interventions is introduced. This platform is demonstrated through the development of two exemplary catheter systems: a tendon-driven steerable catheter with helical lumina and an active tracking Tiger-shaped catheter with an embedded coaxial wire. These catheters exhibit mechanical properties comparable to commercial counterparts and show promising outcomes in both in vitro and in vivo feasibility testing. This scalable thermal drawing platform addresses the limitations of existing manufacturing approaches and facilitates the exploration of diverse designs, potentially accelerating advancements in catheter technologies for MR-guided cardiovascular interventions.

TCT-993 Can Contrast Injections Cause or Propagate Coronary Injuries? Insights From Vessel and Guiding Catheter Hemodynamics

TCT-993 Can Contrast Injections Cause or Propagate Coronary Injuries? Insights From Vessel and Guiding Catheter Hemodynamics

TCT-99 Contemporary Utilization of Guide Catheter Extensions in Percutaneous Coronary Intervention: Lessons From a Single Center Experience

TCT-99 Contemporary Utilization of Guide Catheter Extensions in Percutaneous Coronary Intervention: Lessons From a Single Center Experience

Can Contrast Injections Cause or Propagate Coronary Injuries? Insights From Vessel and Guiding Catheter Hemodynamics

Can Contrast Injections Cause or Propagate Coronary Injuries? Insights From Vessel and Guiding Catheter Hemodynamics

Characterization of Conventional Endovascular Devices in Treatment of Abdominal Aortic Aneurysms

Abstract Abdominal aortic aneurysms (AAA) are often repaired through an endovascular approach known as endovascular aneurysm repair (EVAR). The success and duration of these challenging procedures are primarily attributable to the accuracy and reliability of navigating corresponding interventional devices. This study investigates the performance of conventional nonsteerable and steerable catheters in EVAR procedures, focusing on two primary metrics: reachable workspace and gate cannulation success. We developed two abdominal aortic aneurysm (AAA) phantoms using patient CT images for our experiments. Under X-ray fluoroscopy guidance, the reachable workspace was quantified, and gate cannulation success rates, cannulation time, and fluoroscopy times were recorded for both nonsteerable and steerable catheters and were compared. We were unable to observe statistically significant differences between the two catheter types in overall cannulation success rates or fluoroscopy time. However, in challenging anatomical scenarios (particularly a more challenging gate location), the steerable catheter showed statistically significant advantages in success rates and cannulation times. While there were no statistical differences in reachable workspace between nonsteerable and steerable catheters when considering the whole aneurysm, segmented analysis showed that the steerable catheter performed better in the central region, and nonsteerable catheters performed better in the peripheral region. This study provides a systematic method for quantifying the performance of endovascular devices. The findings suggest that while steerable catheters may offer advantages in complex anatomical conditions, nonsteerable catheters are preferable in peripheral areas of the aneurysm. These insights can inform catheter selection in EVAR, potentially influencing device design and clinical practice.

PneumaOCT: Pneumatic optical coherence tomography endoscopy for targeted distortion-free imaging in tortuous and narrow internal lumens.

The complex anatomy of internal luminal organs, like bronchioles, poses challenges for endoscopic optical coherence tomography (OCT). These challenges include limited steerability for targeted imaging and nonuniform rotation distortion (NURD) with proximal scanning. Using rotary micromotors for distal scanning could address NURD but raises concerns about electrical safety and costs. We present pneumaOCT, the first pneumatic OCT endoscope, comprising a steerable catheter with a soft pneumatic actuator and an imaging probe with a miniature pneumatic turbine. With a diameter of 2.8 mm, pneumaOCT allows for a bending angle of up to 237°, facilitating navigation through narrow turns. The pneumatic turbine enables adjustable imaging speeds from 51 to 446 revolutions per second. We demonstrate the pneumaOCT in vivo imaging of mouse esophagus and colon, as well as targeted and distortion-free imaging of peripheral bronchioles in a bronchial phantom and a porcine lung. This advancement substantially improves endoscopic OCT for navigational imaging in curved and narrow lumens.

Robust Path Planning via Learning from Demonstrations for Robotic Catheters in Deformable Environments.

Navigation through tortuous and deformable vessels using catheters with limited steering capability underscores the need for reliable path planning. State-of-the-art path planners do not fully account for the deformable nature of the environment. This work proposes a robust path planner via a learning from demonstrations method, named Curriculum Generative Adversarial Imitation Learning (C-GAIL). This path planning framework takes into account the interaction between steerable catheters and vessel walls and the deformable property of vessels. In-silico comparative experiments show that the proposed network achieves a 38% higher success rate in static environments and 17% higher in dynamic environments compared to a state-of-the-art approach based on GAIL. In-vitro validation experiments indicate that the path generated by the proposed C-GAIL path planner achieves a targeting error of 1.26 ±0.55mm and a tracking error of 5.18 ±3.48mm. These results represent improvements of 41% and 40% over the conventional centerline-following technique for targeting error and tracking error, respectively. The proposed C-GAIL path planner outperforms the state-of-the-art GAIL approach. The in-vitro validation experiments demonstrate that the path generated by the proposed C-GAIL path planner aligns better with the actual steering capability of the pneumatic artificial muscle-driven catheter utilized in this study. Therefore, the proposed approach can provide enhanced support to the user in navigating the catheter towards the target with greater accuracy, effectively meeting clinical accuracy requirements. The proposed path planning framework exhibits superior performance in managing uncertainty associated with vessel deformation, thereby resulting in lower tracking errors.

Feasibility of transthoracic echocardiographic guidance for multicatheter electrophysiological mapping studies in horses.

Improved characterization of arrhythmias is based on minimally invasive catheterizations. However, these catheterizations have been poorly explored in horses because apart from 3-dimensional (3D) mapping systems, continuous guidance of the catheter's position with adequate detail is difficult using current imaging modalities. Position multiple electrophysiology catheters simultaneously at predetermined strategical positions in the heart using transthoracic echocardiographic guidance. Eight adult healthy horses. Observational study. Two electrophysiological studies were performed: 1 procedure with catheters positioned in the right heart in the standing sedated horse and 1 procedure under general anesthesia with catheters positioned in the left heart. Except for the coronary sinus catheter, each catheter positioning was simultaneously guided by right-parasternal transthoracic echocardiography and 3D electro-anatomical mapping. For each catheter position, a central imaging plane was taken as the starting point, after which the imaging probe was shifted, rotated, and angulated to visualize the catheter over its entire length, including its distal electrode. Catheter positionings in the right heart and left ventricle were successfully guided in the majority of the horses whereas catheter positionings in the left atrium, and especially the pulmonary veins, were challenging to guide echocardiographically. Ultrasound guidance of catheters to specific positions useful for electrophysiological mapping was feasible in the right heart and left ventricle but challenging for the left atrium. This approach creates a perspective for minimally invasive arrhythmia diagnosis without the need for a 3D mapping system. Left parasternal views and intracardiac echocardiography might provide better guidance for left atrial positions.

Guide catheter extension use in chronic total occlusion percutaneous coronary intervention: insights from the PROGRESS CTO registry.

There are limited data on the use of guide catheter extensions (GCE) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the frequency and temporal trends of GCE use in a large multicenter CTO-PCI registry and compared the clinical and angiographic characteristics and outcomes of cases with vs without GCE use. A GCE was used in 4106 of 14 521 CTO PCIs (28%) with increasing frequency from 18.8% in 2012 to 29.9% in 2023. The most used GCE size was 6 French (Fr) (45%), followed by 7 Fr (34%), and 8 Fr (21%). CTOs that required GCE use were more likely to have unfavorable lesion characteristics such as moderate-to-severe calcification (59% vs 40%, P < .0001), moderate-to-severe tortuosity (35% vs 28%, P < .0001), proximal cap ambiguity (39% vs 33%, P < .0001), and had higher J-CTO scores (2.78 ± 1.15 vs 2.20 ± 1.27, P < .0001). Advanced techniques like the retrograde approach (44% vs 24%, P < .0001) and antegrade dissection and re-entry (28% vs 17%, P < .0001) were more likely to be used in GCE cases. Technical success (86.6% vs 86.8%, P = .816) was similar between the 2 groups. However, major adverse cardiovascular events (MACE) (3.8% vs 2.4%, P < .0001) and procedural complications (11.2% vs 8.7%, P < .0001) were more frequent in the GCE group. In summary, GCE use in CTO PCI significantly increased between 2012 and 2023. Cases that required GCEs were more complex and had similar technical success, but higher incidence of MACE compared with cases that did not require GCEs.

Introduction of novel intravascular ultrasound preceding with angled guiding catheter (I-PAD) technique to treat chronic total occlusions in peripheral artery disease

BackgroundThe optimal endovascular treatment (EVT) for chronic total occlusion (CTO) lesions in patients with peripheral artery disease (PAD) has remained unestablished. We encountered a patient with PAD in whom CTO was successfully treated using a novel technique that involved intravascular ultrasound (IVUS) and angled guiding catheter: IVUS Preceding with Angled guiDing catheter (I-PAD) technique.Case presentationA 74-year-old male presented with intermittent claudication attributed to CTO of the right external iliac artery. EVT was performed via the right common femoral artery. We retrogradely advanced the I-PAD system (i.e. partially extending the IVUS transducer portion from the tip of the angled guiding catheter) in the CTO lesion under the real-time guidance of IVUS imaging. We successfully traversed the CTO lesion without the use of a guidewire in approximately three minutes. The procedure concluded successfully without any procedure-related complications, following optimal stenting.ConclusionsThe I-PAD might be an effective technique to accurately, quickly, and safely pass through CTO lesions.

Controlled mitral valvuloplasty using steerable catheter- waist- formed balloon system: A clinical case series.

As the general population ages, the incidence of degenerative mitral stenosis (MS) among patients has increased. Percutaneous mitral valvuloplasty (PMV) has emerged as a well-established option for mitral rheumatic stenosis with specific characteristics. However, a blank therapeutic space must be filled with the treatment options for degenerative or rheumatic mitral stenosis in patients with many comorbidities and contraindication for valvuloplasty. We here present a comprehensive overview of the current possibilities, despite their scarce success. That is the reason why we propose a case series to facilitate a better understanding of our innovative technique in this challenging clinical context.