Mechanisms of Cardiac Perforation Leadingto Tamponade in Balloon Mitral Valvuloplasty

George Joseph, 1* MD, DM, Sunil Thomas Chandy, 1 MD, DM, Shanker Krishnaswami, 1 MD, DM,Edwin Ravikumar, 2 MS, MCh, and Roy John Korula, 2 MS, MCh

Mechanisms of cardiac perforation in 10 cases of cardiac tamponade encountered in asingle-center series of 903 balloon mitral valvuloplasty procedures were elucidated byprecise localization of the site of perforation at subsequent surgery. These mechanismswere perforation of the aortic root and adjacent right atrium by sliding up of thetransseptal set (2), apical tears by straight-tip balloon catheters driven distally duringmitral valve dilatation (3), apical perforations by guidewires introduced through catheterswedged in the apex (2), tear of the posterior right atrial wall by dilatation of the trackproduced by very low septal punctures (2), and right ventricular perforation by a pacingcatheter (1). Multivariate analysis showed cardiac perforation to be significantly related tothe total experience at the center (inversely) and to patient age (directly). Left ventricularperforation occurred exclusively in patients G40 yr of age. Understanding these mecha-nisms has enabled formulation of effective strategies to prevent cardiac perforation.Cathet. Cardiovasc. Diagn. 42:138–146, 1997. r 1997 Wiley-Liss, Inc.

Key words: mitral valve stenosis; balloon dilatation; cardiac tamponade

INTRODUCTION

Cardiac perforation leading to tamponade is a life-threatening acute complication of balloon mitral valvulo-plasty (BMV). Its incidence has ranged from 0 to 9%,accounting for 17 of 29 procedure-related deaths reportedin 11 studies [1–11]. Although the presentation andmanagement of cardiac tamponade complicating BMVhave been reported frequently [12–19], the mechanismsof cardiac perforation leading to tamponade have notbeen described in sufficient detail. The present reportanalyzes mechanisms of cardiac perforation in 10 patientswho developed cardiac tamponade during BMV, based onprecise localization of the site of perforation duringsubsequent surgery.

METHODS

Patients

Between December 1990 and October 1996, 903patients with rheumatic mitral valve stenosis and mitralvalve area of#1.3 cm2 underwent BMV at a single center(Table I). Exclusion criteria were presence of severemitral regurgitation, evidence of left atrial thrombusoutside the appendage, or a highly deformed mitral valveon echocardiography. Patients with atrial fibrillationreceived anticoagulation for at least 10 d prior to theprocedure.

Echocardiography

Two-dimensional and Doppler echocardiography wereperformed before and 24 h after BMV. Patients with atrialfibrillation also underwent transesophageal echocardiog-raphy in the later part of the series. Mitral valve morphol-ogy was scored [20], and mitral valve area was deter-mined by using continuous-wave Doppler [21] andtwo-dimensional planimetry. Mitral regurgitation wasgraded as mild, moderate, or severe according to thedistribution of the regurgitant jet within the left atrium[22]. Transthoracic or transesophageal echocardiographicguidance was not utilized during the BMV procedure.

Catheterization Laboratory Protocol

All patients were brought to the catheterization labora-tory in a fasting state after prior informed consent.Premedication with morphine, promethazine, and diaz-epam and broad-spectrum antibiotics were administered.Right and left heart catheterization and oximetry run were

1Department of Cardiology, Christian Medical College Hospital,Vellore, India2Department of Cardiothoracic Surgery, Christian Medical Col-lege Hospital, Vellore, India

*Correspondence to: George Joseph, M.D., Department of Cardiology,Christian Medical College Hospital, Vellore, India.

Received 23 December 1996; Revision accepted 9 April 1997

Catheterization and Cardiovascular Diagnosis 42:138–146 (1997)

r 1997 Wiley-Liss, Inc.

performed. Early in the series, temporary pacing catheterswere placed in the right ventricular apex during theprocedure. Later on, pacing catheters were positioned inthe pulmonary artery and withdrawn to the right ventriclewhen required or not used at all.

Transseptal Catheterization

In all cases, an 8-French Mullinsy transseptal catheterintroducer set (USCI division, C.R. Bard, Tewksbury,MA) was inserted through the right femoral vein andadvanced over a 0.032-in. guidewire into the superiorvenacava [23]. A curved Brockenbroughy needle (USCIdivision, C.R. Bard) was inserted into the transseptal set,and the entire assembly was withdrawn into the rightatrium under fluoroscopic monitoring. The external needleindex was oriented posteromedially (between 4 and 5o’clock when looking from below) throughout. Early inthe series, the site of transseptal puncture was localizedby the tactile sensation of engaging the limbic ledge at thesuperior margin of the fossa ovalis with the catheter tip(Fig. 1) [24] while limiting fluoroscopic visualization tothe anteroposterior projection. Later on, the techniquedescribed by Croft and Lipscomb [25] was used, in whichthe right anterior oblique (40–50°) projection was utilizedwith a pigtail catheter positioned in the noncoronaryaortic sinus, which served as a landmark during transsep-tal puncture. Needle entry into the left atrium wasconfirmed by recording left atrial pressure and by contrast

injection. The transseptal set was then advanced into theleft atrium, and 5,000 units of heparin were administered.

Mitral Valve Dilatation

The mitral valve was dilated by using conventionaltransseptal single or double balloon technique in 826patients (92%) and by the Inoue balloon technique [26] inthe remaining 77 patients (8%). In the single or doubleballoon method, the mitral valve was crossed by using aballoon-tipped wedge pressure catheter (Arrow, Reading,PA) inserted through the transseptal sheath. A 260-cm-long, 0.035-in.-diameter, appropriately shaped, valvulo-plasty guidewire (Schneider, Minneapolis, MN) waspositioned at the left ventricular apex. In most cases, asecond such wire was similarly positioned after advanc-ing the transseptal sheath into the left ventricle over thefirst wire. The track through the atrial septum was dilatedby using a 8-mm angioplasty balloon prior to introductionof valvuloplasty balloons. Early in the series, all valvulo-plasty balloons used had straight tips; later in the series,most balloons used had pigtail tips.

Operators

BMV was performed by four independent operatorsworking over different overlapping periods of time. Twoof the four operators performed more than 300 caseseach. Because the center is part of a teaching institution,

TABLE I. Baseline Characteristics of Patients UndergoingBalloon Mitral Valvuloplasty *

Characteristic N (%)

Patients 903Male 340 (38)Female 563 (62)

Mean age6 SD (yr) 30.76 10.3Range (yr) 8–77

Mean mitral valve area6 SD (cm2) 0.86 0.2Range (cm2) 0.4–1.3

Mitral valve morphologic scoreRange 3–13Score.8 116 (13)

RhythmSinus rhythm 80 (89)Atrial fibrillation 101 (11)

Previous surgical valvotomy 84 (9)Mitral regurgitation

Mild 266 (29)Moderate 15 (2)

Symptom class (New York Heart Association)I 35 (4)II 399 (44)III 456 (51)IV 13 (1)

Pregnancy 26 (3)

*Data are number (%), mean6 SD, or range.Fig. 1. Ideal septal puncture at the superior limbus of the fossaovalis (right atrial aspect of the atrial septum is seen in the rightanterior oblique projection).

Cardiac Perforation in Mitral Valvuloplasty 139

many procedures were performed by fellows under directsupervision of these two operators. For the purpose ofanalysis, such procedures were considered to have beenperformed by the supervising operator.

Statistical Methods

Data for all cases were collected prospectively andanalyzed with SPSS/PC1 software. Means and standarddeviations were determined for continuous variables.Multivariate analysis using multiple logistic regression[27] was performed on 15 baseline variables to determinethe predictors of cardiac perforation. The chi-square testwith the Yates continuity correction and tests of signifi-cance were used to compare incidence of perforation andmean age, respectively, in different groups of patients.

RESULTS

The mean post-BMV mitral valve area was 2.0660.39 cm2. A successful outcome, defined as a post-BMVmitral valve area of$1.5 cm2 in the absence of majorcomplications, was achieved in 801 (88.7%) patients.Suboptimal result (post-BMV mitral valve area of,1.5cm2 without major complications) was obtained in 44(4.9%) patients, and the procedure was incomplete due totechnical difficulties in 11 (1.2%) patients. Major compli-cations (Table II) occurred in 47 (5.2%) patients, includ-ing 10 (1.1%) patients who developed cardiac tamponade(Table III). All cases of cardiac tamponade were related tothe conventional double balloon technique. In addition,there were 5 cases of cardiac perforation during transsep-tal puncture not associated with symptoms or hemody-namic compromise and not requiring treatment. Thesepatients were carefully monitored, and BMV was per-formed successfully a few days later.

Cardiac Tamponade

Cardiac tamponade was suspected when features suchas still cardiac silhouette, hypotension, and elevated rightatrial pressures were noted and was confirmed by echocar-diography when immediately available or by the charac-teristic swirl of radiographic contrast injected into thepericardial space. All 10 patients who developed cardiac

tamponade underwent emergent surgery because onlypartial hemodynamic stabilization could be achieved bypericardiocentesis with a pigtail catheter and autohemoper-fusion. In one patient, balloon dilatation of the mitralvalve was carried out after onset of cardiac tamponade toimprove further the hemodynamic status. Surgery wasperformed within 30–45 min of onset of tamponade. In allcases, the heart was decompressed by opening thepericardium, after which the site of perforation wasidentified and secured. In one patient, the pericardialspace was inadvertently drained of blood prior to identify-ing and securing a right atrial tear. This action resulted inair embolism and subsequent death. Two patients whodeveloped tamponade early in the series suffered cerebralhypoxia from prolonged hypotension and had residualneurological deficits. This condition was due to delay inrecognizing tamponade and instituting appropriate treat-ment. The remaining seven patients made completerecoveries.

Mechanisms of Cardiac Perforation Leadingto Tamponade

At surgery, distinct patterns of perforation were found,with nearly identical findings within each group. Whenstudied with the sequence of events preceding onset oftamponade, the underlying mechanisms of cardiac perfo-ration become evident.

Aortic Perforation

Cardiac perforation in two patients occurred in theright lateral aspect of the root of aorta adjacent to thesuperior venacava. There was also perforation of the rightatrium at the junction of the right atrium and the superiorvenacava, opposite the site of aortic perforation. In bothcases, the right atrial perforation had sealed spontane-ously, but the aortic perforation continued to bleed. Onsetof tamponade was immediate in one case in which theentire transseptal set was advanced into the aorta andwithdrawn, and onset of tamponade was delayed in theother case in which only the needle and tip of the dilatorentered the aorta. These findings indicate the followingsequence of events. When the ‘‘catch’’ offered by thelimbic ledge is minimal or absent (as often happens whenthe left atrium is enlarged), the transseptal set may slipsuperiorly along the atrial septum until it encounters thecrista terminalis (Fig. 2). At this point, resistance tofurther advancement of the transseptal set may be mis-taken for the limbic ledge. Advancing the needle in thiscase will lead to perforation of the right atrial wall and theroot of the aorta. Needle perforation alone of the aorticroot should not result in cardiac tamponade. Failure toidentify aortic pressure (in a range of 0–40 mm Hg, theaortic pressure tracing will not be seen) may result inadvancement of the transseptal set into the aorta, thereby

TABLE II. Major Complications of Balloon Mitral Valvuloplasty

Complication N (%)

Number of procedures 903Inhospital death 8 (0.9)Cardiac tamponade 10 (1.1)Severe mitral regurgitation 28 (3.1)Mitral valve replacement within 30 d 16 (1.8)Cerebrovascular accident 5 (0.6)Infective endocarditis 2 (0.2)Any major complication 47 (5.2)

140 Joseph et al.

enlarging the perforation. Once this has happened, with-drawal of the transseptal set will lead to cardiac tampon-ade.

Left Ventricular Perforation by Straight-TippedBalloon Catheter

A linear rent was seen at the left ventricular apex inthree patients who rapidly developed cardiac tamponadeafter mitral valve dilatation with balloon catheters withstraight tips. In all three patients, most of the balloonlength was beyond the mitral valve at the time ofinflation, and the waist produced by the stenotic valvewas at the proximal shoulder of the balloon, whichresulted in harpooning of the balloon catheter distallythrough the left ventricular apex, taking the curlicue ofguidewire along (Fig. 3).

Left Ventricular Perforation by Guidewire

Small apical left ventricular perforations were seen intwo patients who developed cardiac tamponade shortly

after completion of mitral valve dilatation. Review ofvideotape recordings of the procedures revealed that theballoon-tipped wedge pressure catheter was wedged inthe left ventricular apex at the time of valvuloplastyguidewire introduction. These wires have tremendous‘‘push,’’ and despite having curved, soft tips, they perfo-rate the myocardium when unable to curl around in theleft ventricular cavity (Figs. 4, 5). The pigtail tip of theballoon valvuloplasty catheter, which was introducedover the wire perforating the myocardium, also mighthave tracked through the myocardium, thereby enlargingthe perforation. Withdrawal of the wire and ballooncatheter, after completion of mitral dilatation, led to onsetof cardiac tamponade.

Right Atrial Perforation

The site of perforation in two patients was in theposterior aspect of the heart, close to the inferior venacava–right atrial junction. In one patient, the perforation wasseen extending into the coronary sinus. In the other

TABLE III. Cardiac Tamponade in Balloon Mitral Valvuloplasty: Clinical Features *

PatientAge/Sex

BMVNo.

Weight(kg)

LASize(mm)

ValveArea(cm2)

ValveScore

LAMean

(mm Hg)Time to

Presentation

MitralValve

Dilation Surgery Outcome

Statusat 6-mo

Follow-up

Aortic root perforation

1 37/M 2 56 50 0.6 7 15 1 h Completed Aortic rootrepair

Full recovery Class I NYHA

2 22/F 68 35 38 0.7 7 a ,5 min Not done Aortic root andRA repair,closed sur-gical val-votomy

Hypoxicencepha-lopathy

Residual neuro-logic deficits

Left ventricle apical perforation by straight-tip balloon catheter

3 52/F 47 42 48 1.0 7 15 ,5 min Completed LV repair Hypoxicencepha-lopathy

Residual neuro-logic deficits

4 46/M 97 38 44 0.6 8 27 ,2 min Completed LV repair Full recovery Class I NYHA5 48/F 759 40 41 0.7 7 25 ,2 min Completed LV repair Full recovery Class I NYHA

Left ventricle apical perforation by guidewire

6 40/M 314 67 49 1.0 7 26 10 min Completed LV repair Full recovery Class I NYHA7 60/F 348 55 51 1.1 6 28 ,5 min Completed LV repair Full recovery Class I NYHA

Right atrial perforation

8 52/F 467 34 45 0.8 9 13 ,5 min Not done RA repair,mitral valvereplacement

Full recovery Class I NYHA

9 35/F 864 35 50 0.6 9 17 ,5 min Completed afteronset of tam-ponade

Decompression,evacuation,exploration

Massive airembolism,death

—

Right ventricular perforation

10 13/F 78 31 33 0.6 8 17 30 min Completed RV repair Full recovery Class I NYHA

*BMV no., series case number; LA, left atrium; LA mean, left atrial mean pressure; NYHA, New York Heart Association functional classification; RA,right atrium; LV, left ventricle; RV, right ventricle.aData not recorded.

Cardiac Perforation in Mitral Valvuloplasty 141

patient, the perforation extended longitudinally down theposterior aspect of inferior venacava. In both patients,transseptal catheterization had been uneventful; the leftatrium was entered and guidewires were introduced intothe left ventricle without evidence of hemodynamicinstability. However, cardiac tamponade rapidly followeddilatation of the track through the interatrial septum. Inboth patients, prominent left atrial enlargement waspresent, and a low site of septal puncture had beendeliberately selected. However, the puncture site was tooclose to the inferior limit of the atrial septum, andsubsequent balloon dilatation resulted in tear into the freewall of the right atrium and contiguous structures (Fig. 6).

Right Ventricular Perforation

Right ventricular apical perforation adjacent to the leftanterior descending coronary artery was seen in onepatient who developed cardiac tamponade 30 min aftersuccessful BMV. A 6-French temporary pacing catheter

Fig. 2. Needle puncture of the aortic root resulting from thetransseptal set sliding up the atrial septum to the crista termina-lis (right anterior-oblique view).

Fig. 3. Harpooning of straight-tip balloon catheter through theleft ventricular apex, taking the curlicue of guidewire along. Thewaist on the balloon is at its proximal shoulder.

Fig. 4. Myocardial perforation by valvuloplasty guidewire intro-duced through a balloon-tipped catheter wedged in the leftventricular apex.

Fig. 5. Appropriate position of catheter, allowing tip of valvulo-plasty guidewire to curl within the left ventricular cavity duringintroduction.

142 Joseph et al.

had been used in this patient, with its tip positioned in theright ventricular apex. This catheter had probably perfo-rated the right ventricular wall at the time of its introduc-tion, but bleeding into the pericardial space did not occuruntil its removal after completion of BMV.

Change in Profile of Cardiac PerforationMechanisms

Five of 10 cardiac perforations that led to tamponade inthis series occurred within the first 100 cases (Table III).The rest were spread over the subsequent 800 cases.Associated with this marked fall in incidence of cardiactamponade was a change in profile of mechanismsleading to perforation. The early cases of tamponade wererelated mostly to left ventricular perforation by straight-tip balloon catheters and aortic perforation during trans-septal puncture. The abrupt decline in incidence oftamponade toward the end of the first 100 cases coincidedwith the introduction of pigtail-tip balloon catheters andthe use of right anterior oblique-view septal puncturewith catheter landmarking of the aorta. Subsequent casesof tamponade were related mostly to guidewire perfora-tion of the left ventricle and right atrial tears after lowseptal punctures.

Results of Multivariate Analysis

Total experience at the center versus operatorexperience.Two of 15 variables studied with multivari-ate logistic regression analysis were significantly relatedto cardiac perforation (Table IV). One variable was theseries case number, associated with an odds ratio of,1,indicating diminishing probability of cardiac perforationas the total experience at the center increased. Individualoperator experience was not significantly related toperforation in the multivariate model, even though it wasin the univariate analysis: 11 of 15 cardiac perforationsencountered in this series occurred when individualoperator experience was,100 cases, indicating inverserelationship (x2, P , 0.001) (Table V). A similar inverserelationship (univariate) was also seen with the totalexperience at the center: 10 of the 15 perforationsoccurred within the first 300 procedures done at the center(x2, P 5 0.008). When considered together in themultivariate model, total experience at the center emergedas the overriding variable.

Patient age and left ventricular perforation. Thesecond variable significantly related to cardiac perfora-tion in the multivariate model was patient age. Theassociated odds ratio was.1, indicating increased likeli-

Fig. 6. Low septal puncture close to the inferior limit of theatrial septum. Proximity to the atrial free wall and contiguousinferior venacava and coronary sinus can lead to a tear extend-ing into these structures.

TABLE IV. Predictors of Cardiac Perforation: Results ofLogistic Regression Analysis *

VariableOddsRatio

95% ConfidenceInterval P

Series case number 0.996 0.993–0.999 0.022Age 1.076 1.022–1.130 0.008

*Other variables included in the analysis but not significantly related to theoutcome were sex, weight, duration of symptoms, New York HeartAssociation class of symptoms, cardiac rhythm, left atrial size, mitral valvemorphologic score, mitral valve calcification, mitral valve area, pastsurgical valvotomy, operator experience, and technique used.

TABLE V. Influence of Operator Experience and TotalExperience at the Center on Incidence of Cardiac PerforationDuring BMV *

Tercile of Cases(300 BMVs Each) 1 2 3

Total(N 5 900)

Cardiac perforations 10 3 2 15Tamponade producing perforations 5 3 2 10Cardiac perforations in cases in

which operator experience was,100 BMVs 8 3 0 11

No. of procedures done by operatorswith experience of,100 BMVs 133 128 0 261

Incidence (per 100 BMVs) of cardiacperforation in operators with

Experience,100 BMVs (%) 6.0 2.3 NA 4.2Experience.100 BMVs (%) 1.2 0.0 0.7 0.6All operators (%) 3.3 1.0 0.7 2.5

*Data represent total numbers unless specified as incidence per 100 cases(%). BMV, balloon mitral valvuloplasty; NA, not applicable.

Cardiac Perforation in Mitral Valvuloplasty 143

hood of cardiac perforation in older patients. Analysis ofsubgroups of patients with cardiac perforation (Table VI)showed that this effect was largely the result of leftventricular perforations having occurred exclusively inolder patients. The other subgroups did not differ amongthemselves or with the entire patient population withrespect to age.

DISCUSSION

Our results indicate that cardiac perforation duringBMV occurs at specific sites in the heart, at characteristicpoints during the procedure, with distinct mechanismsoperating at each location. Awareness of these mecha-nisms has led us to appropriately modify the equipmentand technique used in BMV and to take specific precau-tions during certain steps of the procedure. The result hasbeen a marked reduction in incidence of cardiac perfora-tions and a smoother learning phase for new operators.

Precautions and Procedural Modifications

Aortic perforation occurs during transseptal punctureand can be avoided by keeping the transseptal set leftwardand posteriorly directed, staying away from a pigtailcatheter placed in the noncoronary aortic sinus. Theneedle must not be allowed to slide up the septum or pointanteriorly during transseptal puncture. If needle punctureof the aorta does occur, tamponade can be prevented ifaortic pressure is recognized and the transseptal set is notadvanced. Conversely, left atrial puncture must be con-firmed by the characteristic left atrial pressure tracing andby contrast injection before advancing the transseptal setinto the left atrium. Right atrial angiography with levo-phase left atrial imaging, as described by Inoue and Hung[28,29], is helpful in selecting a safe puncture site,particularly in patients with distorted atrial anatomy dueto markedly enlarged atria. Biplane fluoroscopy addsgreatly to the ability to position precisely the transseptalset in such situations [29,30]. Single-plane fluoroscopy,

limited to the straight anteroposterior or right anterior-oblique view, does not completely describe the positionand orientation of the needle tip.

Perforation of the left ventricular apex by straight-tipballoon catheters can be avoided by using pigtail-tipballoon catheters or self-positioning balloons such as theInoue balloon instead. Having a loop of guidewire in theleft ventricle distal to the balloon tip and holding theballoon back during mitral valve dilatation are notsufficient protection against harpooning of straight-tipballoon catheters through the left ventricular apex. It isdifficult to predict balloon movement during inflation,and the forces generated are sufficient to drive a straight-tip balloon catheter and a soft guidewire loop through themyocardium. Positioning the guidewire tip in the descend-ing aorta with the stiff shaft forming a loop at the leftventricular apex [1] may protect against apical perfora-tion by straight-tip balloon catheters. Guidewires werethus positioned in seven patients who underwent uncom-plicated BMV procedures early in this series. However,the practice was abandoned because positioning guidewiretips in the left ventricle is clearly more expeditious.

Guidewire perforation of the left ventricular apexoccurred despite the wire having a soft curved tip becauseof straitjacketing of the wire within a catheter wedged inthe cardiac apex. Ensuring that the catheter tip is approxi-mately half way between the mitral valve and the apex atthe time of wire introduction has eliminated this problem(Fig. 5).

Right atrial perforations were seen after we began tochoose lower and more posterior sites for septal puncturein patients with large left atria. In these patients, such apuncture site makes it easier to cross the mitral valve [28]and obtain a more stable position of wire and ballooncatheter. Too low a puncture is obviously hazardous, andseptal puncture more than 2 cm below the level of the pigtailcatheter at the aortic valve should be avoided. If theanatomyis distorted, atrial angiography and biplane fluoroscopyshould be utilized in selecting a safe septal puncture site.

Perforation of the right ventricular free wall by stifftemporary pacing catheters is well known [31,32] but hasnot been reported with BMV procedures. Use of balloon-tipped pacing catheters can eliminate this problem.

Perforation at Other Sites and With OtherTechniques

The sites and mechanisms of cardiac perforationdescribed in the present report are characteristic ofconventional transseptal double balloon mitral valvulo-plasty, which was the predominant technique used. Leftatrial perforation during transseptal puncture also hasbeen reported with this technique [33] but was notencountered in this series. Transseptal puncture-related car-diac perforation and tamponade also are features of theInoue

TABLE VI. Age Comparison Between Patients with LeftVentricular Perforation and Others

Patient Subgroup nMean Age

(yr)SD(yr)

Range(yr) P*

Left ventricular perfora-tions 5 49.2 7.4 40–60 —

Other tamponade pro-ducing perforations 5 31.8 14.9 13–52 0.048

All non–left ventricularperforations 10 31.2 11.5 13–52 0.007

Entire patient population 903 30.7 10.3 8–77 0.0001

*P values were derived by using tests of significance to compare the leftventricular perforation subgroup with others.

144 Joseph et al.

balloon technique [28]. However, left ventricular perfora-tions do not occur because guidewires are not introducedinto the left ventricle and the dumbbell shape of theballoon locks it into position during inflation, therebykeeping it away from the cardiac apex. The Babic retrogradetransarterial mitral valvuloplasty technique[34] has beenassociated with left ventricular perforation and tampon-ade, which is related to manipulation of balloon cathetersfrom the left ventricle to left atrium [18]. However, twostudies using the retrograde nontransseptal techniquehave not reported this complication [35,36].

Predictors of Cardiac Perforation

In the present series, multivariate analysis showed asignificant inverse relationship between the total experi-ence at the center and the incidence of cardiac perfora-tion. This relationship is not unexpected, given that therewas progressive refinement in technique and equipmentused, resulting in safer procedures as the series pro-gressed. Operator experience was not a significant predic-tor of perforation in the multivariate model, even thoughit had a highly significant association in univariateanalysis. This dominance of total experience at the centerover operator experience is consistent with the premisethat establishment of sound protocol based on the experi-ence in the center and transmission of relevant technicalinformation to new operators effectively minimizes car-diac perforation in BMV. Conversely, even with exten-sive experience of individual operators, occurrence ofcardiac perforation is not eliminated entirely.

The emergence of patient age as a significant predictorof cardiac perforation in the multivariate model led toidentification of left ventricular perforation as a complica-tion occurring exclusively in older patients (.40 yr)undergoing BMV. Pooling of data from published casereports and series [14–16,18–19] describing a total ofeight cases of left ventricular perforation complicatingBMV revealed a mean age of 586 9 yr, with a range of47–71 yr. In six other patients with left ventricularperforation during BMV, reported by Ruiz et al. [37], fivewere older than 60 yr of age. Although these reports arebased on procedures in older patient populations ascompared with our series, they are consistent with ourfinding that left ventricular perforation occurs only inpatients.40 yr of age. Our series, with mean age of 30610 yr, exposes this association and enables age differ-ences to reach statistical significance. Left ventricularmass has been found to be reduced in isolated rheumaticmitral stenosis, and chronic left ventricular underfillingmay lead to progressive myocardial atrophy [38]. Thisand other age-related factors may predispose older pa-tients to left ventricular perforation during BMV.

Limitations of the Study

There are several important limitations to this study.First, the mechanisms of cardiac perforation described inthe present report are not necessarily applicable to othertechniques of BMV such as the Inoue balloon techniqueand the retrograde transarterial technique. Second, evenwith the conventional double balloon technique, consider-able procedural variation can occur from center to center,resulting in differences in sites and mechanisms ofperforation. Thus, generalization of these results andcomparison with results of other centers must be guarded.Third, the precise location of perforations not resulting intamponade could not be determined because these pa-tients did not undergo surgery. Hence, other mechanismsof perforation may exist, which are not described in thisstudy.

CONCLUSIONS

The incidence of cardiac perforation and tamponadecomplicating BMV can be greatly reduced if the underly-ing mechanisms are clearly understood and if appropriatemodifications are made in equipment and technique.Establishment of sound protocol with emphasis on specificprecautions makes the procedure safer and the learning phasefor new operators smoother. The specifics may be differentfrom center to center, depending on the local experienceand BMV technique utilized. Safeguards such as echocar-diographic guidance, atrial angiography, and surgicalstandby are advisable early in the experience of anycenter or individual operator, when incidence of cardiacperforation is relatively high. Predisposition of olderpatients to left ventricular perforation makes precautionsrelating to balloon selection and guidewire use especiallyimportant in this category of patients.

ACKNOWLEDGMENTS

We thank Dr. Jayaseelan L. for statistical help; John K.Murthy, Lewis Sampath Kumar, Glory Doss, and AnnePriyalatha for technical support in the cardiac catheteriza-tion laboratory; and Meenakshi M. for secretarial assis-tance.

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