Author + information
- Ilya Karagodin, MD∗ (, )ilya_tweets,
- Eric Kruse, RDCS,
- John E.A. Blair, MD,
- Atman P. Shah, MD and
- Roberto M. Lang, MD
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
- ↵∗Address for correspondence:
Dr. Ilya Karagodin, University of Chicago Medical Center, 5758 South Maryland Avenue, MC 9067, Chicago, Illinois 60637.
A 50-year-old man with severe rheumatic mitral stenosis was deemed too high risk for surgery and was referred for percutaneous balloon valvuloplasty. The valvuloplasty was successful in reducing the transmitral gradient and improving the patient’s symptoms; however, it was complicated by a tear in the posteromedial commissure and moderate mitral regurgitation. (Level of Difficulty: Beginner.)
A 50-year-old man with a past medical history of severe rheumatic mitral stenosis began to experience increased dyspnea on exertion. The patient’s Wilkins score was 14 on the basis of limited valve mobility, extensive valvular and subvalvular thickening, and severe calcification, as assessed by transesophageal echocardiography (TEE) (Figure 1A) (1). Because of the presence of severe pulmonary hypertension and severely reduced right ventricular function, the patient was deemed to be a high-risk surgical candidate after multidisciplinary discussion between the cardiology and cardiothoracic surgery departments. The decision was made to proceed with percutaneous balloon mitral valvuloplasty.
On initial intraprocedural evaluation, 3D TEE with transillumination showed a heavily calcified, rheumatically deformed mitral valve with a small orifice of 0.8 cm2 (Figure 1B, blue arrow, Video 1) (2). Next, TEE was used to guide the mitral balloon valvuloplasty procedure with a 28-mm Inoue balloon (Toray, New York, New York) that was inflated to 28 mm across the mitral valve (Figure 1C, blue arrow, Video 2). TEE post-valvuloplasty (Figure 1D, yellow arrow) showed an increased area of the mitral valve orifice of 1.9 cm2 (Figure 1E, blue arrow, Video 3) with color Doppler showing moderate mitral regurgitation (Figure 1F, Video 4). The transmitral gradient decreased from 24.3 to 7.1 mm Hg. Although the patient had significant improvement in his degree of mitral stenosis post-valvuloplasty, the asymmetric calcification near the anterolateral commissure likely resulted in the nonuniform expansion of the mitral valve and a tear in the posteromedial commissure, ultimately causing moderate mitral regurgitation.
At 2 weeks following the mitral valvuloplasty procedure, the patient was able to return to work after reporting improvement in his dyspnea and an increased walking distance. A follow-up transthoracic echocardiogram showed reduction in right ventricular systolic pressure from 101.1 to 42.7 mm Hg with significant improvement in right ventricular systolic function.
This case illustrates the challenges associated with balloon valvuloplasty in the setting of severe, rheumatically deformed mitral stenosis with a high Wilkins score.
Dr. Lang has received a research grant from Philips Healthcare for other unrelated studies. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Informed consent was obtained for this case.
- Abbreviation and Acronym
- transesophageal echocardiogram
- Received September 25, 2019.
- Revision received October 25, 2019.
- Accepted October 28, 2019.
- 2019 The Authors
- Wilkins G.T.,
- Weyman A.E.,
- Abascal V.M.,
- et al.
- Genovese D.,
- Addetia K.,
- Kebed K.,
- et al.