Percutaneous Transmitral Commissurotomy Research Articles

TCT-443 Immediate Outcome Associated With Percutaneous Transmitral Commissurotomy

TCT-443 Immediate Outcome Associated With Percutaneous Transmitral Commissurotomy

TCT-629 Percutaneous Transmitral Commissurotomy in Patients With Dilated and Aneurysmal Left Atrium: Tips and Tricks

TCT-629 Percutaneous Transmitral Commissurotomy in Patients With Dilated and Aneurysmal Left Atrium: Tips and Tricks

Left atrial strain predicts improvement in left atrial functions of severe rheumatic mitral stenoses undergoing successful percutaneous transmitral commissurotomy.

Chronic rheumatic heart disease (RHD) is prevalent in India. The mitral valve in isolation or combination with the aortic or tricuspid valve is involved in 31.6% and 52.8% of chronic RHD patients, respectively. The left atrium (LA) functions as a reservoir during the cardiac cycle. Therefore, the LA enlargement leads to longitudinal lengthening, measured as a positive strain, permitting the measurement of the longitudinal strain of LA. This study aimed to assess the LA functions using peak atrial longitudinal strain (PALS) in patients with severe rheumatic mitral stenoses (MS) in sinus rhythm who underwent successful percutaneous transvenous mitral commissurotomy (PTMC). We recruited 56 patients with severe rheumatic MS for the study, of which 06 PTMC procedures were considered unsuccessful. So, 50 patients of chronic severe rheumatic MS in sinus rhythm undergoing PTMC were enrolled in a tertiary care centre of the Armed Forces from August 2017 to May 2019. Patients included in the study were not consecutive, and patients with atrial fibrillation (AF) were excluded. PALS improved post-PTMC (P<.001) in this study, effectively concluding that PALS is impaired in patients with severe symptomatic MS and is acutely enhanced after treatment. PALS is a good indicator of LA function and may predict the success of PTMC on the rheumatic mitral valve.

Percutaneous Transmitral Commissurotomy - Clinical and Echocardiographic Follow-up in Severe Mitral Stenosis

Objectives: To study the long term clinical and echocardiographic outcomes of percutaneous Trans mitral balloon commissurotomy (PTMC) performed in patients with severe mitral stenosis. Methodology: Total 103 patients were enrolled in this study. Their PTMC procedure was performed between the years 2015 to 2019. Those patients who returned for follow-up in the year 2021 were enrolled. At the time of follow-up their clinical and echocardiographic parameters were recorded. Results: The mean age was 27.44±6.26 years and 97 (94.2%) of them were female. Mitral valve area was improved significantly, planimetry; 0.813±1.39 vs. 1.288±0.21cm2 and PHT; 0.871±0.13 vs. 1.336±0.19 cm2 between baseline and follow-up, respectively. Pressure gradient across mitral valve also improved 7.233±2.81 vs. 14.407±0.92 mmHg between baseline and follow-up, respectively. Pulmonary artery pressures were also reduced significantly 24±0.27 vs. 55±2.41 mmHg as well as the right ventricular systolic pressures 24.4±2.94 vs. 62.34±10.98 mmHg between baseline and follow-up, respectively. At follow-up, 70.9% had NYHA I class, 16.5% had NYHA II class, 11.7% had NYHA III class, and 1% had NYHA IV class compared to 6.8%, 5.8%, 33.9%, and 53.4% pre-procedure, respectively. Conclusion: Long term follow-up of patients after PTMC showed satisfactory outcomes both clinically, as evident from improvement in NYHA functional class, and from echocardiographic stand point with sustained increase in mitral valve area over the period of years. Overall the results of PTMC performed in patients with severe mitral stenosis are satisfactory.

Reduction in pulmonary artery pressures on right heart cath after percutaneous transmitral commissurotomy.

Objectives: To find out the reduction in pulmonary artery pressures on right heart Cath after percutaneous trans mitral commissurotomy. Study Design: Cross-sectional Observational study. Setting: Catheterization Lab Faisalabad Institute of Cardiology, Faisalabad. Period: April 2022 till October 2022. Material &amp; Methods: After approval from hospital ethical committee 67 patients of severe mitral stenosis having pliable valve suitable for PTMC on TTE followed by TEE to exclude its contraindications and then finalized for PTMC procedure were enrolled in study after informed consent. PTMC was performed through femoral route using INNOUE balloon. Pre PTMC and post PTMC Right ventricle pressures were measured on table in cath lab. Results: Mean age was 33.8 ± 8.4 with 28.4% (n=19) were male, 71.6% (n=48) were females. 79 % patients had NYHA III symptoms of dyspnea. Mean LA diameter was 50.4mm and mean MVA was 1.02 cm2. 65.7% patients had A.fib before PTMC. Others were in sinus rhythm. Majority of patients had severe pulmonary hypertension before PTMC which had significant reduction (mean 23mmHg) in catheterization lab 10 minutes after PTMC procedure. Conclusion: PTMC is quite effective procedure with significant reduction of not only LA pressure but also of right ventricle indicating its effectiveness from the day of procedure.

Measurement of mitral valve area by direct three dimensional planimetry compared to multiplanar reconstruction in patients with rheumatic mitral stenosis.

Mitral valve area (MVA) measurement by three-dimensional transesophageal echocardiography (3D-TEE) has a crucial role in the evaluation of mitral stenosis (MS) severity. Three-dimensional direct (3D-direct) planimetry has been proposed as a new technique to measure mitral valve area. This study aimed to compare the 3D-direct mitral valve planimetry to conventional three-dimensional multiplanar reconstruction (3D-MPR) in severe MS using 3D-TEE. In this cross-sectional, prospective study; 149 patients with severe MS who were referred for transesophageal echocardiography in Shahid Madani Hospital (Tabriz Iran), just before percutaneous transmitral commissurotomy (PTMC), recruited consecutively. All patients underwent 2D transthoracic echocardiography (2D-TTE) and 3D-TEE in a single session before PTMC. During 2D-TTE planimetry, pressure half time (PHT), and proximal isovelocity surface area (PISA) were applied to measure the MVA. Transmitral mean pressure gradient (MPG) was measured. During 3D-TEE, MVA planimetry was carried out with both 3D-direct and 3D-MPR methods. 3D-direct was applied from both atrial and ventricular views. The consistency of MVA measurements with 3D-direct, 3D-MPR, and 2D-TTE methods was statistically investigated. Our sample consisted of 109 (73.2%) women and 40 (26.8%) men. The mean age was 51.75 ± 9.81years. The agreement between 3D-direct and 3D-MPR planimetry was significant and moderate (0.99 ± 0.29cm2 vs. 1.12 ± 0.26cm2, intraclass correlation = 0.716, p value = 0.001).The accuracy of the 3D-direct method reduced significantly compared to the MPR method at MVA > 1.5cm2. The maximum difference between two methods was observed in cases with MVAs larger than 1.5cm2. MVA measured with the 3D-MPR method was significantly correlated with a 2D-TTE method, with a moderate agreement (intraclass correlation = 0.644, p value = 0.001). Also, 2D-TTE and 3D-direct TEE techniques yielded significantly consistent measurements of the MVA (1.06 ± 0.026cm2 vs. 0.99 ± 0.29cm2, intraclass correlation = 0.787, p value = 0.001); however, with a slight overestimation of the MVA by the former with a net difference of 0.06 ± 0.013cm2. Mitral valve pressure gradient (MPG) had no significant correlation with planimetry results. A significant inverse correlation was seen between the MVA and pulmonary arterial systolic pressure. 3D-direct planimetry has an acceptable agreement with 3D-MPR planimetry at MVA less than 1.5cm2, but their correlation decreases significantly at MVA above 1.5cm2. 3D-direct planimetry underestimates MVA compared to 3D-MPR, especially at MVA above 1.5cm2. It seems that the saddle shape of mitral valve, interferes with 3D-direct measurement of commissures at moderate MS. The 2D-TTE planimetry has generally acceptable accuracy, but its correlation to the 3D-TEE methods is significantly reduced in cases with moderate to severe MS (i.e. MVA > 1.0cm2).

Percutaneous Transvenous Balloon Mitral Commissurotomy: A Single-Center Experience.

Rheumatic heart disease and its impact on cardiac health is still a concern in developing countries. Percutaneous trans-mitral commissurotomy (PTMC) is the standard of care in managing severe rheumatic mitral stenosis (MS). This article reports a single-center, 10-year real-world experience in Qatar. In this retrospective study, we reviewed all the patients who underwent PTMC in Qatar between January 1, 2012, and January 1, 2022. Periprocedural data were collected at baseline, postprocedural, 1 year, and during the last follow-up. The primary outcome was procedural success (improvement in valve area by 50%, final valve area >1.5 cm2, and freedom from > moderate mitral regurgitation, stroke, or pericardial effusion). Safety endpoints were freedom from death, periprocedural cardiogenic shock and cardiac arrest, stroke urgent mitral valve replacement (MVR), or pericardiocentesis. Long-term outcomes included the requirement of redo PTMC or MVR, in addition to rehospitalization due to arrhythmias, heart failure, or stroke. Sixty-five patients were included in the review (age 42 ± 10, female 38 [58.5%]). Sixty-two patients (95.4%) had a successful procedure. One patient developed a hemorrhagic pericardial tamponade and cardiogenic shock, for which he underwent pericardiocentesis and emergency aortic root repair. One patient developed acute stroke 8 h after the procedure, and one patient had tamponade resolved with emergency pericardiocentesis. Two patients required MVR after 1 and 4 years, respectively. PTMC is the mainstay of rheumatic MS management in patients with suitable anatomy as most patients have excellent outcomes with long-term freedom from surgery, which has been the case in our single-center experience.

Procedural Success and Immediate Results of Percuteneous Trans Mitral Commissurotomy: An Experience from a Tertiary Care Hospital in Northern Division of Bangladesh

Background: One of the ultimate grave consequences of rheumatic heart disease is mitral stenosis. Percutaneous trans-mitral commissurotomy (PTMC) has been practiced with good results in the world since Inoue introduced it in 1982. But in Bangladesh we have very few research-oriented data regarding the effectiveness and patient compliance of this procedure. Aim of the study: The aim of this study was to audit the procedural success, in-hospital outcome in patients undergoing percutaneous trans-mitral commissurotomy (PTMC). Methods: This observational cross-sectional study was conducted in northern division of Bangladesh with the collaboration of the Department of Cardiology, Rangpur Medical College Hospital, Rangpur & Zia Heart Foundation, Dinajpur during the period from February 2018 to November 2019. In total 45 patients who fulfill the inclusion and exclusion criteria for PTMC was enrolled in this study as the study people. Among them the procedural success & immediate results were assessed. Proper written consents were taken from all the participants before starting data collection. A pre-designed questionnaire was used in patent data collection. All data were processed, analyzed and disseminated by MS Office and SPSS version as per need. Result: In our study in analyzing the comparative Echo Doppler data of pre & post PTMC among the participants in both mean (±SD) MVA (cm2) and mean (±SD) MVPG (mmHg) we found extremely statistically significant correlation between pre and post PTMC stages where the P values were less than 0.0001. Besides these, in analyzing the pre & post PTMC hemodynamic and procedural data of participants we observed, against LA Pressure (mmHg) (Mean ± SD), RV Pressure (mmHg) (Mean ± SD), LVEDP (mmHg) (Mean ± SD) and Transmitral PG (mmHg) (Mean ± SD) there were extremely significant correlation between pre and post PTMC stages. In all the parameters the p values were less than 0.0001. Conclusion: We conclude that, percutaneous trans-mitral commissurotomy (PTMC) is a safe procedure in experienced hand with good success rate and optimal results even in patients with special problems like pregnancy, previous CVA and redo cases.

Unusual Cause of Left Ventricular Pseudoaneurysm

Closed mitral valvotomy (CMV) became an accepted surgical procedure to open a stenotic mitral valve (MV) about 50 years ago. CMV is performed through an incision in the left atrial appendage. Tubbs dilator is passed in to the left ventricle via the apex and then advanced retrogradely through the stenosed MV and is then opened within the orifice to split the commissures. The dilator is then removed and the orifice closed. Incisional left ventricular pseudo aneurysm has been described as a rare complication of this technique. Here we encountered a similar scenario. Percutaneous transmitral commissurotomy has virtually replaced CMV. But with the expanding use of the transapical approach to treat a variety of structural heart diseases, especially transcutaneous aortic valve replacement, one is likely to encounter similar complications in the modern era also.

Percuteneous Trans-Mitral Commissurotomy (PTMC); Procedural Success and Immediate Results, an Experience from Tertiary Care Hospital in Northern Division of Bangladesh

Background: One of the ultimate grave consequences of rheumatic heart disease is mitral stenosis. Percutaneous trans-mitral commissurotomy (PTMC) has been practiced with good results in the world since Inoue introduced it in 1982.&#x0D; Objective: The aim of this study was to audit the procedural success, in- hospital outcome in patients undergoing PTMC in our set up. Study Design: Observational cross sectional study. Place and Duration: The study was conducted in northern division of Bangladesh with the collaboration of department of cardiology, Rangpur Medical College Hospital, Rangpur &amp; Zia Heart Foundation, Dinazpur from February 2018 to November 2019.&#x0D; Materials and Methods: Total Thirty patients who fulfill the inclusion and exclusion criteria for PTMC was enrolled in this study. Among them the procedural success &amp; immediate results were assessed.&#x0D; Results: Among 30 patients , 22(73.33%) were female and 8(26.66%) were male showing a female predominance. The mean age was 28.28±8.4.The procedure was successful in 29(96.66%) patients. In 1(3.3%) patient, we failed due to inability to puncture the septum for unfavourable anatomy. There was no mortality related to the procedure, no systemic embolization but one patient (3.33%) had significant MR(G II ). Pre PTMC mean MVA (cm2) was 0.801± 0.1325 and post PTMC it was 1.545± 0.292 cm2. Mean MVPG pre PTMC was 27.108±5.94 mmHg and post PTMC , 6.61±5.008 mmHg with significant p value 0.0001. Mean LA pressure before procedure was 28.65±8.456 mmHg and post PTMC, 11.27±6.34 and p value was 0.0001. Most of the patients 25(83.3%) before PTMC were in severe pulmonary hypertension and after PTMC most of the patients 21(70%) were in mild pulmonary hypertension.We successfully done 7 special cases like pregnancy, re do cases, H/O CVD etc.&#x0D; Conclusions: We conclude that PTMC is a safe procedure in experienced hand with good success rate and optimal results even in patients with special problems like pregnancy, previous CVA and redo cases.&#x0D; University Heart Journal Vol. 17, No. 1, Jan 2021; 47-54

Impact of Mitral Valve Replacement on the Right Ventricle Function in Mitral Stenosis

Background: In patients with mitral stenosis (MS), right ventricular (RV) function may be altered due to an increase in the left atrial pressure and/or changes in pulmonary arteriolar vasculature or may be affected by rheumatic process directly. Aims: In this study we have evaluated the recovery of RV function upto 3 months in patients undergoing mitral valve replacement (MVR) using two dimensional and tissue Doppler echocardiographic indices (TDI). Materials and Methods: A total of 30 patients who were advised MVR were enrolled prospectively. All patients underwent MVR successfully. RV function was assessed using conventional and TDI pre-operatively, 1 week, and 3 months after surgery. Results: New York Heart Association (NYHA) functional class improved significantly at the end of one week. Mean transmitral gradient reduced postoperatively. Tricuspid regurgitation severity reduced significantly. Significant RV reverse remodelling was noted at the end of 3 months. Global RV function parameters fractional area change and RV Tei index improved significantly at the end of 3 months. In patients with mild to moderate pulmonary hypertension (PH), global RV function improved significantly, RV remodelling was seen. In patients with severe PH, both global and longitudinal functions did not improve at the end of 3 months follow up, though RV remodelling was noticed. Conclusion: In patients with severe rheumatic MS whenever per-cutaneous trans-mitral commissurotomy is not feasible, MVR promotes RV remodelling and improvement in RV function along with significant improvement in NYHA functional status. But this improvement in RV function was noted only in patients with mild to moderate PH rather than in patients with severe PH.

Quality of life assessment after successful percutaneous transmitral commissurotomy and ascertain its relationship with gender

Backgroundpercutaneous transmitral commissurotomy has become an ideal treatment option for mitral stenosis due to its less adverse events and more favorable outcomes. Patients improve symptomatically after percutaneous transmitral commissurotomy but we have minimal available data about the quality of life after percutaneous transmitral commissurotomy. Objectiveto assess the quality of life after percutaneous transmitral commissurotomy through WHOQol scoring covering different aspects of life, to determine its correlation with a net gain in mitral valve area (MVA) and to ascertain its association with gender. Methodsit was a prospective cohort study carried out for a period of 15 months. A total of 100 patients with mitral stenosis who had successful percutaneous transmitral commissurotomy done were enrolled in the study. Among the total included, 4 patients were lost to follow up and data were collected from 96 patients. Quality of life was assessed before the procedure, at 1 month and 3 months follow up after percutaneous transmitral commissurotomy using WHOQol scoring questionnaire. Resultsamong 96 patients, 64 (67%) were females and 32 (33%) were males. WHOQol scoring improved significantly after percutaneous transmitral commissurotomy from 32.8±8.9 to 54.6±11.2 and 62.8± 9.7, after one month and 3 months respectively. There was a significant association between net gain of MVA and WHOQol scoring with an R value of 0.46 and p value of 0.03. There was no difference in group comparison of all the six domains between male and female patients. Conclusionsuccessful percutaneous transmitral commissurotomy improves the quality of life in mitral stenosis patients regardless of their gender and has a positive correlation with a net gain in mitral valve area.

Level of agreement in three‐dimensional planimetric measurement of mitral valve area between transthoracic and transesophageal echocardiography

Echocardiographic measurement of mitral valve area (MVA) is critical prior to percutaneous transmitral commissurotomy (PTMC). This study aimed to compare the agreement between transthoracic (TTE) and transesophageal echocardiography (TEE) in three-dimensional (3D) planimetric measurement of the MVA among patients with severe mitral stenosis. MVA was measured with planimetry in 105 patients before undergoing PTMC. 3D reconstruction was applied to both TTE and TEE examinations. The MVA values from four different methods of 3D reconstruction were compared to the average values of 3D methods in TEE as the gold standard measurement method for the MVA in this study. The agreement levels between the two examinations were evaluated and analyzed for various reconstruction methods. The mean age was 49±12years for 28 men and 77 women who were enrolled. The image quality was graded as "excellent" in 57% of 3D images obtained by TTE, while it was graded as "excellent" in 81% of 3D images obtained by TEE. The ventricular zooming method in TTE with a bias of -0.006±0.065cm2 (P<0.0001) had the highest agreement with the 3D-MVA in TEE. While 2D-TTE and 3D-TEE measurements of the MVA (R=0.91; P<0.0001) were significantly correlated, 2D-TTE overestimated the MVA by 0.19cm2 . Although the quality of 3D images was significantly better in TEE than those in TTE, a good agreement existed between the measured 3D-TTE and 3D-TEE studies. We also demonstrated that 2D-TTE overestimated the MVA compare to 3D-TEE.

FACTORS RESPONSIBLE FOR INSIGNIFICANT DECREASE IN PULMONARY ARTERY PRESSURE IMMEDIATELY AFTER PER CUTANEOUS TRANS-MITRAL COMMISSUROTOMY IN PATIENTS OF RHEUMATIC MITRAL STENOSIS

OBJECTIVES: To determine the factors responsible for insignificant decrease in pulmonary artery pressure immediately after percutaneous trans-mitral commissurotomy (PTMC) in patients of rheumatic mitral stenosis. METHODS: This cross-sectional study was conducted on patients undergoing PTMC at Cardiology Unit, Lady Reading Hospital, Peshawar, Pakistan from 11th February, 2016 to 28th February, 2018. Pulmonary artery pressure (PAP) was noted before and after PTMC through echocardiography. Data was analyzed with SPSS Version 20.0, categorical and continuous variables were described as frequencies/percentages and mean±SD respectively. Odds Ratio was determined for factors negatively affecting the fall in PAP. RESULTS: Out of 159 patients, 108 (67.9%) were females. Mean age was 25.38±10.67 years. PAP was insignificantly decreased in patients &gt;30 years (p&gt;0.05), symptoms for &gt;5 years (p&gt;0.05), left atrium diameter &gt;4.5cm (p&gt;0.05), atrial fibrillation (p&gt;0.05), right ventricle diameter &gt;2.5cm (p&gt;0.05) and NYHA IV dyspnea (p&gt;0.05). Odds Ratio for failure of significant decrease in PAP immediately post-PTMC was 1.68 for age more than 30 years, 1.10 for symptoms more than 5 years, 3.73 for LA diameter more than 4.5 cm, 2.31 for RV diameter more than 2.5 cm , 2.32 for history of atrial fibrillation and 6.71 for NYHA IV dyspnea. CONCLUSION: Factors which negatively affect the immediate fall in PAP post-PTMC are age &gt;30years, duration of symptoms &gt;5years, LA diameter &gt;4.5cm, history of atrial fibrillation, RV diameter &gt;2.5cm and NYHA IV dyspnea and hence are the poor predictors of successful PTMC while NYHA IV dyspnea has highest Odds for insignificant decrease.

Przezskórna komisurotomia mitralna u nastolatka ze stenozą mitralną i tętniakiem lewego przedsionka — zabieg trudny technicznie

Percutaneous trans-mitral commissurotomy (PTMC) using an Accura balloon is an effective procedure for the mana- gement of patients with rheumatic mitral stenosis. It is not infrequent to encounter an aneurysmal left atrium (LA), especially in the developing world where patients often present very late. This is a technically challenging procedure as the septum often bulges into the right atrial side, making the puncture often difficult. Furthermore, it bulges anteriorly and inferiorly so it becomes even more challenging. Because of the vertical lie of the septum, the needle often dissects the septum rather than puncturing it.  Here, we describe the case of a 17 year-old boy with severe mitral stenosis with a giant, aneurysmal left atrium (LA — 13.5 × 16 cm) where an inter-atrial septal puncture was achieved by probing the fossa ovalis to enter the left atrium instead of a conventional transseptal puncture. PTMC was successfully done, increasing the mitral valve area from 0.8 cm2 to 1.9 cm2.

Znaczenie osi koniuszkowo-mitralnej w trakcie przezskórnej komisurotomii mitralnej

The development of acute severe mitral regurgitation (MR) requiring surgery is one of the most dreaded complications of percutaneous transmitral commissurotomy. We present the case of a 29 year-old female with severe rheumatic mitral stenosis whose mitral valve dilatation was performed using an Accura balloon. Once the balloon catheter had crossed the mitral valve to reach the left ventricle, it was facing away from the apico-mitral axis. It was inflated in distal portion, and mitral valve dilatation was done in the usual fashion. She developed acute severe MR. As it was misaligned with the apico-mitral axis, it caused a chordae rupture of the postero-medial papillary muscle which was identified during surgery. We conclude that a misaligned Accura balloon catheter during balloon inflation can pluck the chordae tendinae and can cause acute severe mitral regurgitation, and therefore can unearth the underlying subvalvular pathology.

Immediate results, safety and efficacy of percutaneous transmitral commissurotomy in juvenile mitral stenosis

Immediate results, safety and efficacy of percutaneous transmitral commissurotomy in juvenile mitral stenosis

Challenges in diagnosis and management of infective endocarditis by Stenotrophomonas maltophilia: A case report of an unusual nosocomial infection

Stenotrophomonas maltophilia is a Gram-negative bacillus found as a free-living organism in most aquatic and humid environments including hospital drinking water, and often associated with nosocomial infections. It is an uncommon cause of infective endocarditis. In Sri Lanka there are no reported cases in literature. Here we report a 46 years old patient who presented with fever following Percutaneous Trans Mitral Commissurotomy (PTMC). He was diagnosed as an acute mitral valve endocarditis based on echocardiograph findings and 2 blood cultures taken 6 hours apart which grew Stenotrophomonas maltophilia. The patient responded rapidly to targeted antibiotic treatment with piperacillin tazobactam and oral cotrimoxazole for 4 weeks and a further 2 weeks of cotrimoxazole. He remained well at the 3 month follow up. There is limited information on the best choice of antibiotics and the ideal duration of treatment. Early diagnosis and identification of the organism, prompt treatment with appropriate antibiotics and close collaboration between the clinical and laboratory teams contributed towards the successful management of this case.

Acute effect of treatment of mitral stenosis on left atrium function.

Aim:Peak atrial longitudinal strain (PALS) is used to evaluate left atrium (LA) function in patients with mitral stenosis (MS), before and after percutaneous transmitral commissurotomy (PTMC) and mitral valve replacement (MVR).Methods:Patients with severe symptomatic MS, who were referred to our echocardiographic laboratory for a diagnostic examination before cardiac surgery or PTMC from October of 2014 to October of 2015, were included in the study.Result:The peak systolic global LA strain improved post-PTMC (P < 0.001) and post-MVR (P = 0.012). This difference was statistically highly significant.Conclusion:PALS is impaired in patients with severe symptomatic MS and improved acutely after treatment and may be a good indicator of LA function and may predict the right time for intervention on mitral valve.

Percutaneous Trans Mitral commissurotomy (PTMC) in the background of giant left atrium using Reverse Loop Entry technique

Percutaneous trans-mitral commissurotomy (PTMC) using Accura balloon is an effective procedure for management of patients with rheumatic mitral stenosis. It is not uncommon to come across giant left atrium (LA) especially in the developing world as patient often present late in the course of the disease. This is a technically challenging situation as usual landmark changes which make the procedure difficult beginning from septal puncture to negotiation of balloon into left ventricle across the mitral valve. Here we report a case of 16-year old girl suffering from rheumatic mitral stenosis in which left atrium was giant (13cm x 11cm) where the mitral valve could not be negotiated with standard technique. Valvotomy was successfully executed by reverse loop entry technique.