Difficulties to enter the left ventricle during percutaneous transvenous mitral commissurotomy (PTMC)- our experiences of 80 cases with modified techniques.

BACKGROUND: Percutaneous transvenous mitral commissurotomy (PTMC) is the standard of treatment for symptomatic severe rheumatic mitral stenosis (MS). PTMC has the standard Inoue technique, but we have to modify the procedure in many technically challenging cases, especially to cross the mitral valve. METHODOLOGY: Two over-the-wire strategies to enter the LV were taken in 80 complex cases of PTMC. The first one was done by exchanging the J-shaped wire from the balloon, introducing the spring wire into it, and pushing it into LV. The second one-removal of balloon keeping the spring wire in LA and the Mullin's sheath was introduced, and the tip of the wire was pushed into LV, and the balloon was introduced over the wire. We also changed the left atrium (LA) graphy in the RAO view instead of the AP view to facilitating entry into LV. RESULTS: We succeeded in 76 (95 %) cases. Strategy one was applied to all but successful in only 25 cases (31 %), and strategy 2 was applied in the remaining. Strategy 1 required less procedural time and fluoroscopic time in comparison to strategy 2 (40 ± 10 vs 60 ± 16 min, 25 ± 7 vs 35 ± 8 min). After modification of taking the LA graphy in RAO view, our rate of facing the difficulties decreased from 21 % to 9 %. Critical MS (31 %) and the giant LA (30 %) were the topmost causes of difficulties. No major complications were recorded. CONCLUSION: Over-the-wire entry into LV is cost-effective, requiring no new equipment and is safe and can be used in complex cases.

Libman-Sacks endocarditis in a Bangladeshi patient suffering from rhupus.

Libman-Sacks endocarditis (LSE) is one of the most characteristic cardiac lesions in systemic lupus erythematosus (SLE). Patients may remain asymptomatic, while symptomatic patients often suffer with systemic emboli. These commonly test positive for anti-phospholipid antibody (aPA). The association of LSE with an overlap of rheumatoid arthritis (RA) and lupus (also known as 'rhupus') is rare. We report such a patient, who had been diagnosed as having RA seven years before and had suffered an acute ischaemic stroke one year previously and had echocardiographic evidence of LSE found during routine evaluation. However, she tested negative for aPA.

Chiari network: A case report and brief overview.

The Chiari network is mobile, net-like structures occasionally seen in right atrium near the opening of inferior vena cava and coronary sinus. This is usually of no clinical significance and is often diagnosed incidentally. However, sometimes it may cause diagnostic confusion with right atrial pathologies, and may favour thromboembolism by causing flow obstruction. It may be associated with infective endocarditis, arrhythmias, and migraine. Sometimes, it acts as a physical barrier during invasive procedures. The Chiari network has also been described to protect from pulmonary embolism by acting as an inferior vena cava filter due to its sieve-like effect at the cavo-atrial junction. Here, the Chiari network has been described in a case of Ebstein anomaly of tricuspid valve which produced diagnostic confusion during echocardiography. A brief overview has also been presented.