Asymmetric Calcification in Rheumatic Mitral Stenosis and Implications for Balloon Valvuloplasty.

A 50 year-old male with severe rheumatic mitral stenosis was deemed too high risk for surgery and referred for percutaneous balloon valvuloplasty. The valvuloplasty was successful in reducing the trans-mitral gradient and improving the patient's symptoms, however was complicated by a tear in the posteromedial commissure and moderate mitral regurgitation.

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.

Figure 1

Mitral Balloon Valvuloplasty Imaging Panel

(A) Pre-procedural transesophageal echocardiogram showing a heavily calcified, rheumatically deformed mitral valve with a small orifice (yellow arrow). (B) A 3-dimensional echocardiogram with transillumination (2) (Philips, Amsterdam, the Netherlands) was used to highlight the small mitral valve orifice (0.8 cm2) with severe, asymmetrical calcification near the anterolateral commissure (blue arrow). (C) Next, transesophageal echocardiography was used to guide the mitral balloon valvuloplasty procedure with an Inoue balloon that was inflated to 28 mm across the mitral valve (blue arrow). (D) Transesophageal echocardiography post-valvuloplasty showed increased area of the mitral valve orifice (yellow arrow). (E) A 3-dimensional echocardiogram with transillumination highlighted the enlarged mitral valve area post-valvuloplasty (1.9 cm2) with a tear in the posteromedial commissure (blue arrow). (F) Transesophageal echocardiography with color Doppler showed moderate mitral regurgitation post-valvuloplasty. See Videos 1, 2, 3, and 4.

Online Video 1

Online Video 2

Online Video 3

Online Video 4

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.

Severe Rheumatic Mitral Stenosis Pre-Valvuloplasty

This 3-dimensional transesophageal echocardiogram with transillumination from the left atrial perspective (surgeon’s view) highlights the small mitral valve orifice pre-procedure with asymmetrical calcification near the anterolateral commissure and significantly reduced leaflet excursion secondary to severe rheumatic mitral stenosis.

Inflation of Balloon Across Mitral Valve

This intraprocedural 3-dimensional transesophageal echocardiogram from the left ventricular perspective demonstrates the real-time inflation of a 28 mm Inoue balloon (Toray, New York, New York) across the mitral valve.

Improved Excursion of Mitral Valve Leaflets Post-Valvuloplasty

This 3-dimensional transesophageal echocardiogram with transillumination from the left atrial perspective (surgeon’s view) highlights the enlarged mitral valve orifice post-procedure with significantly improved leaflet excursion and a tear in the posteromedial commissure.

Mitral Regurgitation Post-Valvuloplasty

This 2-dimensional color Doppler image on a transesophageal echocardiogram demonstrates a moderate, anteriorly directed jet of mitral regurgitation following mitral valvuloplasty.

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.