Feasibility of on-line transesophageal echocardiography during balloon mitral valvulotomy: experience with 93 patients

Percutaneous balloon mitral valvulotomy (PBMV) has become an established method of treating symptomatic patients with rheumatic mitral stenosis. PBMV is performed with fluoroscopic guidance alone in most centres. However, even experienced operators can be misled by radiographic anatomic landmarks. Transesophageal echocardiography (TEE) provides high-quality images of the atrial septum, left atrium, mitral valve, and surrounding structures and has a number of unique advantages that make it a useful adjunct to fluoroscopy for guidance and monitoring of patients during PBMV. The aim of this study was to demonstrate the feasibility, safety, and utility of on-line TEE during PBMV on awake patients. TEE was performed on 93 consciously sedated, awake patients in the cardiac catheterisation laboratory during PBMV. Ninety five patients were successfully intubated in the supine position. Two patients were excluded from PBMV based on mobile thrombi near the mouth of the left atrial appendage. The TEE was well-tolerated in the 93 patients who underwent PBMV, and no complications of TEE were detected. Major complications of PBMV were detected in 7 patients (severe MR, n = 3; tamponade, n = 1; large ASD, n = 3). We conclude that on-line TEE during PBMV is feasible, safe, and well tolerated. TEE-guidance facilitates transseptal catheterization and proper positioning of balloon catheters across the mitral orifice. TEE can help monitor the adequacy of PBMV and help decide whether or not subsequent dilatations are necessary. TEE can rapidly detect complications and thereby guide appropriate management of these complications.