Percutaneous transvenous mitral commissurotomy in a case of situs inversus, dextrocardia and rheumatic mitral stenosis

Abstract

Situs inversus with dextrocardia is a rare congenital disorder. There is rare coincidence of rheumatic severe mitral stenosis in a patient with situs inversus and dextrocardia. Technical difficulties for doing percutaneous transvenous mitral commissurotomy (PTMC) in such patients are well known and there are few reports of PTMC in situs inversus with dextrocardia. Here we report a case of 53 year old female with situs inversus and dextrocardia where PTMC was successfully done with a few modifications of standard Inoue technique. The patient had dyspnea on exertion of NYHA class III with initial mitral valve area of 0.8 cm² and severe pulmonary arterial hypertension with PA systolic pressure of 106 mmHg. Femoral vein access was performed from the left side to align the septal puncture needle and balloon to the left sided IVC and to facilitate LV entry. Septal descent of the septal puncture needle (Brockenbrough needle) was performed in the AP view with the needle rotated from 12 o’clock to 7 o’clock position instead of 5 o’clock position. The right border of the spine was used as a landmark for trans-septal puncture. The LA pressure fell from 19 mmHg to 9 mmHg with no residual gradient across the valve. PA systolic pressure dropped to 48 mmHg. Echocardiography showed a well-divided anterior commissure with a MVA of 1.8 cm² and mild mitral regurgitation with mild pulmonary hypertension. In summary, PTMC is feasible in the rare patient with dextrocardia with additional modifications of the Inoue technique and protocols for groin and septal puncture.

Keywords: Mitral commissurotomy; Inoue technique; Situs inversus;
Dextrocardia; Rheumatic mitral stenosis