When should you question your wedge and use a long iron (transseptal needle) instead?

摘要

Sometimes, confidence in your data, hemodynamic data in particular, is hard to come by. There's no rule book, no on-course instruction. We learn to "lay-up" when our experience, intuition, and conflicting information suggest we need to rethink our approach to a particular patient dilemma.In this issue, Bokhari et al. [1] from Miami present a very interesting case of an elderly woman with critical aortic stenosis appearing 8 years after mitral bio-prosthetic valve replacement for prior rheumatic fever associated mitral stenosis. The echocardiographic study demonstrated critical aortic valve disease, pulmonary hypertension, and a well-functioning mitral valve prosthesis. At catheterization, the hemodynamics confirmed severe AS. As the most commonly used technique for routine mitral valve assessment, a pulmonary capillary wedge pressure was paired with the LV tracing and showed a surprise, a significant mitral gradient. The discordance of the echo and hemodynamic data prompted the astute operators to question the PCW and perform a transseptal puncture which showed that the left atrial pressure-LV gradient was only 4 mm Hg not 11 mm Hg, consistent with the echo findings.