Percutaneous transvenous mitral commissurotomy: a modified over-the-wire technique for difficult left ventricle entry

Percutaneous transvenous mitral commissurotomy (PTMC) is an acceptable and preferred alternative to surgical commissurotomy in suitable patients with severe rheumatic mitral stenosis. Various over-the-wire techniques have been described in the past for difficult left ventricle (LV) entry during PTMC. Here, we report two cases of successful PTMC with difficult LV entry with a new modified over-the-wire technique. After several failed attempts using classical steps of Inoue PTMC technique, an AR-1 diagnostic catheter was introduced in the left atrium. The AR-1 has a favorable shape when faced end-on to the critically stenosed mitral orifice, hence facilitating LV entry by 0.035″ hydrophilic glidewire. The hydrophilic wire was then exchanged with a 0.035″ Amplatz super-stiff guidewire, which was coiled in vitro to make small loops of its floppy portion. This extra-stiff wire provided enough support to track the Inoue PTMC catheter to the LV cavity and small loops didn't caused any arrhythmia during the procedure. Thus, this technique may help in reducing procedural failure for "difficult LV entry" situations in critically stenosed mitral valves.