Sequential Single-Stage Percutaneous Balloon Dilatation of an Inferior Vena Cava Obstruction with Rheumatic Mitral Stenosis Nakul Sinha 1 , Aditya Kapoor 1 , Sudeep Kumar 1 , Nagaraja Moorthy 1 , Vikas Singh 2 , Rajendra V. Phadke 2 Departments of 1 Cardiology and 2 Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India While rheumatic mitral stenosis (MS) continues to be a major problem in developing countries, percuta- neous balloon mitral valvotomy (PBMV) has evolved as an effective alternative therapeutic modality for patients with MS, with excellent short- and intermedi- ate-term results. The presence of inferior vena cava (IVC) obstruction, however, may preclude the conven- tional transfemoral approach of the Inoue technique. Case report A 26-year-old male presented with a history of short- ness of breath and easy fatigability of four years’ dura- tion. At presentation, the patient had NYHA class II dyspnea, while a clinical examination was consistent with findings typical of severe rheumatic MS, without evidence of systemic venous congestion. The electro- cardiogram revealed sinus rhythm with a frontal QRS axis of +1200 and left atrial overload, while chest radi- ography revealed a normal cardiothoracic ratio, left atrial enlargement, and evidence of severe pulmonary venous hypertension. Transthoracic two-dimensional echocardiography confirmed severe MS with a trans- valvular mean gradient of 16 mmHg, a mitral valve area of 0.9 cm 2 , and valve morphology amenable to balloon dilatation. Femoral vein access was obtained from both groins, while left femoral artery access was utilized for hemo- dynamic studies and pressure monitoring. While attempting to pass a 6 Fr Swan-Ganz catheter through the IVC to the right atrium, however, the suprahepatic portion of the IVC was found to be totally blocked with extensive collateral formation (Fig. 1). An injec- tion from the right subclavian vein revealed a patent superior vena cava draining into the right atrium. Abdominal ultrasonography confirmed a diagnosis of IVC obstruction that was localized to the suprahep- atic portion, but there was no evidence of any extrinsic compression surrounding the IVC. A work-up for anti- cardiolipin antibodies, lupus anticoagulant levels and paroxysmal nocturnal hemoglobinuria yielded nega- tive results. The decision was taken to relieve the IVC obstruction by balloon dilatation and, sequentially, to attempt to perform a balloon mitral valvotomy. At a second sitting, the patient underwent successful percutaneous balloon dilatation of the IVC. The proxi- mal cap of the membranous obstruction was penetrat- ed using the stiff end of a 0.035-in (0.9 mm) Crosswire™ guidewire (Terumo Inc., Japan), after which serial balloon dilatations were performed using a 4 × 20 mm Tyshak balloon catheter (NuMed, Cornwall, Ontario, Canada) followed by a final dilata- tion with a 10 × 20 mm Tyshak balloon catheter (NuMed) (Fig. 2A) until the waist disappeared. A sat- isfactory flow was restored across the IVC, draining into the right atrium. A successful PBMV was then performed using the Address for correspondence: Dr. Aditya Kapoor MD, DM, FSCAI, FACC, Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India 226014 e-mail: akapoor65@gmail.com © Copyright by ICR Publishers 2011 The case is reported of severe rheumatic mitral steno- sis (MS) associated with asymptomatic inferior vena cava (IVC) occlusion, detected incidentally while performing percutaneous balloon mitral valvotomy (PBMV). The patient successfully underwent a sin- gle-stage balloon dilatation of the membranous obstruction in the IVC, followed by PBMV using the Inoue technique. The case represents a rare, inciden- tal concurrence of IVC obstruction and severe rheu- matic MS. This rare hybrid percutaneous sequential balloon dilatation is the first of its type to be report- ed, and highlights the growing experience of percu- taneous interventional techniques in the management of such complex cases. The Journal of Heart Valve Disease 2011;20:237-239