Asian Cardiovasc Thorac Ann 1998;6:227-228
© 1998 Asia Publishing EXchange Pte Ltd
Balloon Mitral Valvotomy in Pregnant Patient with Anomalous Inferior Vena Cava
Manoj K Agarwala, DM,
Mandeep Singh, DM,
Anil Grover, DM,
Jagmohan S Varma, DM
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Department of Cardiology Postgraduate Institute of Medical Education and Research Chandigarh, India
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For reprint information contact: Anil Grover, DM Department of Cardiology Postgraduate Institute of Medical Education and Research Chandigarh 160012, India Tel: 91 172 54 1031 Ext. 380 Fax: 91 172 54 0401
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ABSTRACT
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Successful balloon valvotomy was performed by the Inoue technique in a pregnant lady with severe mitral stenosis and pulmonary edema. Total pelvic and abdominal shielding was used and a transseptal puncture was carried out through the left femoral vein because of an anatomically anomalous course of the inferior vena cava.
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INTRODUCTION
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Rheumatic heart disease and mitral stenosis are major problems in developing countries. The hemodynamic changes that occur during pregnancy in such patients adversely affect fetal and maternal outcome.1 Recently, numerous studies have confirmed the hemodynamic and symptomatic benefits as well as the safety of balloon valvotomy during pregnancy.2 However, a complex situation can arise when there is a major anatomical variation in the course of inferior vena cava (IVC) where one may have to deviate from the standard technique. We report the case of a pregnant lady with critical mitral stenosis who presented in pulmonary edema and required emergency valvotomy. During the procedure, an anomalous course of the IVC was detected and valvotomy was performed through the left femoral vein.
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CASE REPORT
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A 25-year-old female presented in the 8th month of her third pregnancy with recurrent orthopnea and paroxysmal nocturnal dyspnea. Examination revealed normal sinus rhythm, raised jugular venous pressure, blood pressure of 110/80 mm Hg, and a respiratory rate of 48 per minute. Bilateral fine crepitations were audible up to the lower third of her chest. A cardiovascular examination showed severe mitral stenosis and pulmonary arterial hypertension. There was liver dullness on the right side and stomach tympany on the left side. There was evidence of left atrial enlargement and right axis deviation in the electrocardiogram. Echocardiography showed that her abdominal situs was solitus and she had severe mitral stenosis (mitral valve area 1 cm2), trivial mitral regurgitation, and mild tricuspid regurgitation. Emergency valvotomy was undertaken as the patient did not improve with maximal medical therapy.
Balloon mitral valvotomy was performed by the standard Inoue balloon technique. Before the procedure, the pelvic and abdominal areas were shielded to protect the fetus from radiation. To decrease the fluoroscopy time, neither angiography nor detailed hemodynamic studies were performed. Arterial and venous punctures were made in the right groin. However, while introducing a Mullin's dilator, an anomalous course of the IVC was detected. In view of this, a transseptal puncture followed by mitral valvotomy were performed through the left femoral vein. Mean left atrial pressures before and after the procedure were 30 and 8 mm Hg respectively. The end-diastolic gradient across the mitral valve dropped from 25 to 6 mm Hg. The severity of mitral stenosis and mitral regurgitation after valvotomy was assessed by echocardiography. After the valvotomy, the mitral valve area was 1.64 cm2 without an increase in mitral regurgitation.
One day after the valvotomy, the patient delivered a premature baby who had neonatal jaundice that gradually improved. The child is presently alive and healthy. An IVC angiogram was carried out 2 months after the procedure and the vessel was seen to form in the normal anatomical location and then course upwards on the left side of the midline. It then crossed back to the right side at the level of the renal veins and continued upwards on the right side to drain into the right atrium (Figure 1A and 1B
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Figure 1 (A&B). Inferior vena cava angiogram showing the major abdominal venous system. No right canal segment was demonstrated. Note the point of crossing of the inferior vena cava to the right at the renal vein level.
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DISCUSSION
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Anatomic variations in the formation and course of the IVC have been described. Double inferior venae cavae and a left-sided IVC have an incidence of 3% and 0.5% respectively.3,4 Only a few case reports of a single left-sided IVC have been described in the literature.5 IVC anomalies are of three types. The first is designated azygos continuation or absence of the IVC. In this anomaly, the IVC empties into the azygos or hemiazygous vessel and from there into the right or left superior vena cava. The second type of anomaly is a major left IVC carrying the greatest portion of the venous flow but associated with a detectable remnant of a right IVC. The third variety is similar but no right caval rudiment can be demonstrated, there is abdominal situs solitus and the eventual drainage of the vessel is normal. Our case belongs to the third category with the formation and infrarenal course of the IVC on the left side. At the level of the renal veins, the IVC crossed the midline to ascend on the right side of the abdominal aorta and drain into the right atrium.
Balloon mitral valvotomy through the right femoral vein is the standard practice. Occasionally, it has been performed through the left femoral vein.6 During the valvotomy in our patient, she was detected to have an anatomically aberrant IVC that resulted in failure to insert the transseptal needle through the IVC. A successful valvotomy was carried out through a left femoral vein puncture. The anomalous course of the IVC gave rise to problems with the Mullin's dilator and transseptal needle, however, the balloon valvotomy was uneventful. We believe this is the first report of balloon mitral valvotomy in a patient with a major anatomical variation in the course of the IVC.
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REFERENCES
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Metcalfe J, McAnulty JH, Veland K. Heart disease and pregnancy. Physiology and management. Boston: Little Brown 1986;185–222.
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Ribeiro PA, Fawzy ME, Awad M, Dunn B. Balloon valvotomy for pregnant patients with severe pliable mitral stenosis using the Inoue technique with total abdominal and pelvic shielding. Am Heart J
1992;124:1558–62.[Medline]
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Rischbieth H. Anomaly of the inferior vena cava: duplication of the post renal segment. J Anat
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Milloy FJ, Anson BJ, Cauldwell EW. Variations in the inferior vena caval veins and in their renal and lumbar communications. Surg Gynaecol Obstet
1962;115:131.
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Becker FF. A singular left-sided inferior vena cava. Anat Rec
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Rawal J, Dahi S, Patel T, Shah S. Balloon mitral valvuloplasty using Inoue balloon catheter: the left femoral vein approach. Indian Heart J
1996;48:531.
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ABSTRACT
INTRODUCTION
