Catheterization and Cardiovascular Diagnosis 21 :239-244 (1990)

Case Reports

Mitral Valve Disruption Following Percutaneous Balloon Valvuloplasty

Angelo Ramondo, MD, Fabio Chirillo, MD, Maurizio Dan, MD, Carlo Sorbara, MD, Alberto Fracasso, MD, Alessandro Mazzucco, MD, Carlo Rampazzo, MD,

Giambattista Isabella, MD, and Raffaello Chioin, MD

Two cases of massive mitral regurgitation due to mitral valve disruption following per- cutaneous balloon valvuloplasty are reported. This severe complication occurred in two elderly women with recurrent mitral stenosis after previous surgical commissurotomy. Due to their unstable hernodynamic and clinical condition, both patients underwent emer- gency valve replacement. At surgery, the cornrnissures appeared fused and heavily cal- cified; the chordae tendineae thickened, shortened, and fused; and the leaflets presented a large tear with sheared edges. Because the technical aspects of both procedures were unremarkable, the anatomic features of the mitral valve seemed to affect the occurrence of severe mitral regurgitation. Percutaneous balloon valvuloplasty should be therefore applied carefully to patients with prior surgical valvotomy, in whom the structural alter- ations of the mitral apparatus may predispose to severe valvular damage.

Key words: mitral stenosis, mitral commissurotorny, acute mitral regurgitation

INTRODUCTION

Percutaneous balloon mitral valvuloplasty (PBMV) has been recently introduced as a nonsurgical approach to the treatment of patients with rheumatic mitral stenosis [ 1-31. Since its introduction, PBMV has been more and more frequently applied to patients with rigid or even calcific stenosis and to patients in whom a restenosis has developed after surgical valvotomy [4]. This larger ap- plication has been encouraged by the excellent short- and mid-term hemodynamic and clinical results and also by the low rate of complications [ 5 ] . Mitral regurgitation has been reported to develop or worsen in 30% to 53% of patients undergoing PBMV [6,7]. However, severe mi- tral regurgitation due to leaflet tearing and chordae rup- ture has been rarely reported [8,9]. In this report, we describe two cases in which massive mitral regurgitation occurred following PBMV and required emergency sur- gery.

CASE REPORTS Case 1

A 63-year-old female was hospitalized for congestive heart failure. She had had rheumatic fever in childhood. At age 34 years, she had undergone close-heart surgical valvotomy. From the age of 40, she was in permanent

0 1990 Wiley-Liss, Inc.

atrial fibrillation and had remained in good general con- dition until 3 years ago, when she experienced progres- sive exertional dyspnea and fatigue.

She underwent cardiac catheterization, which docu- mented severe mitral restenosis. Two-dimensional echo- cardiography showed a hugely dilated left atrium, mark- edly reduced diastolic excursion of the mitral leaflets, which appeared slightly calcified, and a moderate fibro- sis of the subvalvular apparatus. Treatment options were discussed with the patient, and the recommendation for PBMV was accepted; informed consent was given by the patient.

At catheterization, initial hemodynamic findings con- firmed the severity of mitral stenosis: The mean mitral gradient was 10 mm Hg, and the calculated mitral valve area resulted 0.7 cm2. Left ventriculography revealed no mitral regurgitation (Fig. 1 A). After prevalvuloplasty

From the Cardiac Catheterization Unit, Department of Cardiology, Institute of Anaesthesiology, and Institute of Cardiovascular Surgery, University of Padova, Padova, Italy.

Received February 26, 1990; revision accepted June 5, I Y Y O .

Address reprint requests to Angelo Ramondo, MD, Servizio di emo- dinamica-cardiologia. Policlinico Universitario, Via N. Giustiniani 2, 35121 Padova, Italy.

240 Rarnondo et al.

FIG. 1. End-systolic frame from left ventriculography before (A) percutaneous balloon mitral valvuloplasty showing absence of mitral regurgitation; immediately after the procedure (B) a massive mitral regurgitation is evident (black wedges).

FIG. 2. Left ventricular and left atrial pressure before (A) and immediately after (B) percutaneous balloon mitral valvulo- plasty. The mean mitral gradient before the procedure was 10 mm Hg, and there was no evident v-wave. After valvuloplasty

measurements were made, transeptal catheterization was accomplished with a 8F Mullins transeptal sheath and dilatator (USCI, Billerica, MA) and Brockenbrough needle. After puncture of the atrial septum, at the fossa ovalis level, a 7F balloon floatation catheter was ad- vanced from the left atrium to the left ventricle. A 0.038 inch, 300 crn long Teflon-coated guide wire was then positioned through this catheter to allow removal of the balloon catheter and advancement of a small (8 mm) dilation catheter (Cook Inc, Bloomington, IN) for en- largement of the opening made in the interatrial septum.

(B) a giant v-wave (60 mm Hg) was present in the left atrial pressure tracing, whereas peak systolic left ventricular pres- sure slightly decreased and end diastolic pressure increased to 23 mm Hg.

This step was required to facilitate passage of the larger valvuloplasty balloon through the atrial septum.

After removal of this catheter, a 9F balloon dilation catheter with a 3 X 15 trefoil balloon (Mansfield Scien- tific, Mansfield, MA) was advanced across the septum t o the left ventricle and positioned across the stcnotic mitral valve. The balloon was subsequently inflated twice for 20 and 40 sec, respectively, by hand pressure. After valvuloplasty all of the hemodynamic measurements were repeated. A giant (60 mm Hg) v-wave appeared in the left atrial pressure recording, as illustrated in Figure

Complications of Mitral Valvuloplasty 241

FIG. 3. Pathological specimen of the excised mitral anterior leaflet. The leaflet is thickened and fibrotic, but not calcified. There is a severe alteration of the subvalvular apparatus with short- ening and fusion of the chordae tendineae, and involvement of the tip of the papillary muscles. A group of ruptured chordae tendineae is indicated by the arrow.

2. Mean right atrial pressure increased to 15 mm Hg and systolic pulmonary artery pressure to 60 mm Hg. Repeat ventriculography showed massive mitral regurgitation (Fig. I B).

The patient’s clinical and hernodynamic condition did rapidly worsen, and she was transferred in emergency to the operation room. At surgery, the mitral leaflets were found to be moderately thickened and focally calcified. The commissures were totally fused, and a massive cal- cific dcposition was found in the commissural and para- commissural areas. There was no commissural splitting. There was a severe alteration of the subvalvular appara- tus with shortening and fusion of the chordae tendineae, and involvement of the tip of both papillary muscles. A large tear with sheared edges was seen in the posterior leaflet, along with rupture of one group of chordae tendineae of the anterior leaflet in proximity to the pos- terior commissure (Fig. 3). The anterior leaflet was re- moved by the surgeon by cutting the papillary muscles, whereas the posterior leaflet was not removed in order to reduce the cardiopulmonary bypass time. The valve was replaccd with a 3 1 mm Sorin Allcarbon prosthesis. After closure of the left atrium, cardiopulmonary bypass was discontinued without problems. Postoperative recovery was satisfactory, and the patient was discharged from hospital 20 days later.

Case 2 A 75-year-old woman had close-heart mitral valvot-

omy because of a severe rheumatic mitral stenosis when

she was 41. She was in atrial fibrillation from the age of 50, and she remained quite well until 1988, when she suffered from a cerebral transient ischemic attack, with full recovery. At that time, she underwent echocardi- ography, which showed a severe mitral restenosis (mitral valve area 0.7 cm2) and an enlarged left atrium with evidence of thrombi within the left atrial appendage. Shc was given oral anticoagulants in addition to the diuretics and digitalis she had already been assuming for 25 years. In the following months, the patient’s clinical condition worsened rapidly, with progressive dyspnea, orthopnea, and fatigue. Respiratory functional tests revealed a se- vere chronic obstructive lung disease. She underwent cardiac catheterization, which documented a severe mi- tral restenosis with severe pulmonary hypertension and poor biventricular function.

The patient was addressed to surgery, but she was not considered suitable for mitral valve replacement due to her poor clinical condition, unstable hemodynamic find- ings, and severe respiratory failure. The patient gave informed consent for percutaneous mitral valvuloplasty after being informed of the risk and potential complica- tions of the procedure. In order to make a stressful and potentially very long procedure more tolerable, and to get a better control of the patient’s hernodynamic and respiratory condition, the patient was intubated, and PBMV was carried out under general anesthesia. This allowed continuous transesophageal echocardiographic monitoring. Transesophageal echocardiography (TEE) was performed using a 5 MHz phased array transducer

242 Ramondo et al.

FIG. 4. A: Transesophageal echocardiographic four-chamber view immediately after mitral valvuloplasty. There is no coapta- tion of the mitral leaflets. The posterior leaflet is partially free floating in the left atrium during systole. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. B: End-systolic

transesophageal echocardiographic two-chamber view. Color Doppler reveals a wide and central turbulent jet reaching the top of the left atrium, indicating the presence of massive mitral re- gurgitation. LA, left atrium; LV, left ventricle.

with incorporated color-coded Doppler (64 elements, maximal sector angle 90, Hewlett Packard model 21362A) mounted at the tip of a modified gastroscope. Initially, left atrial thrombi were searched for, but the whole left atrial cavity was thrombus free. Subsequently, the mitral apparatus was visualized. The mitral leaflets showed a reduced diastolic excursion, and a trivial mitral regurgitation was detected by color Doppler.

PBMV was accomplished via a transeptal approach according to the technique above described in case 1 . A triadat (Mansfield Scientific, Mansfield, Massachusetts) 15-18 mm balloon was inflated three times for 10, 15, and 10 sec, respectively, by hand pressure. After with- drawing the balloon from the mitral orifice, TEE dem- onstrated a total loss of coaptation of the mitral leaflets. The posterior leaflet was partially free floating in the left

Complications of Mitral Valvuloplasty 243

FIG. 5. Operative view. Via a lefl atriotomy, the atrial aspect of the mitral valve is disclosed. A large tear in the posterior leaflet is evident (black solid arrow) alongside of two ruptured chor- dae tendineae (solid black wedges).

atrium during systole (Fig. 4a). Color Doppler revealed a massive mitral regurgitation with a central and wide jet reaching the top of the left atrium (Fig. 4b). Pressure tracings revealed a giant v-wave (50 mm Hg) and a sig- nificant increase in pulmonary artery pressure. Because of the patient’s deteriorating hemodynamic and clinical condition, she was immediately transferred to the oper- ating room. At surgery, the valve looked severely dam- aged, with a large tear in the posterior leaflet and the rupture of two chordae tendinae in proximity to the pos- terior commissure (Fig. 5 ) . The commissures were fused and heavily calcified. The chordae tendinae were thick- ened, fused, and most of them focally calcified. The valve was totally removed and replaced with a 29 mm Sorin Pericarbon prosthesis. After closure of the left atrium, the cardiopulmonary bypass was discontinued in the presence of major arrhythmic problems. Acidosis and hypotension unresponsive to pressors caused death that occurred 3 hr after operation.

DISCUSSION

Although an increasing number of patients is currently undergoing mitral balloon valvuloplasty , the value, safety, and feasibility of this procedure in patients with rheumatic mitral stenosis is still under active clinical in- vestigation. Valve disruption represents a potential com-

plication of this procedure. Although an increase in mi- tral regurgitation after PBMV has been reported by many investigators [5,9, lo], the occurrence of massive mitral regurgitation seems to be a rare event.

In our experience, two cases of mitral valve disruption occurred after 19 successful procedures. In our institu- tion, the initial indications for PBMV were very restric- tive, and only patients with no calcific lesions, with no prior surgical commissurotomy and without involvement of the subvalvular apparatus, were treated with PBMV. The excellent short- and mid-term clinical and hemody- namic results, along with the absence of major compli- cations, encouraged a more extensive application of mi- tral balloon valvuloplasty. However, as soon as balloon dilation was performed in older patients who had previ- ously undergone surgical mitral valvotomy, massive mi- tral regurgitation complicated the procedure. No techni- cal reasons seemed to affect the occurrence of massive mitral regurgitation, as no oversized balloons were used, and the other technical aspects of both procedures were unremarkable. In our opinion, according to previous studies [ 10-121, the anatomic features of the stenotic mitral valve represent the major determinant of the result of balloon dilation. In fact, although separation of the fused commissures is the main mechanism of successful valvuloplasty in patients with rheumatic mitral stenosis, this condition cannot be always achieved in patients with mitral restenosis after surgical commissurotomy .

244 Ramondo et al.

Our two cases presented a severe fibrocalcific distro- phy in the commissural and paracommissural areas, which may represent a greater resistance site that on the one hand hinders the commissural splitting and on the other hand delivers the balloon pressure on less resistant structures (such as fibrotic but not calcified leaflets). Moreover, the severe fusion, thickening, and shortening of the chordae tendineae, in association with a distorted mitral architecture, may have led to valve disruption by transmitting balloon pressure in an abnormal direction.

Our experience seems to be rather different from that of Rediker et al. [4], who, in a larger series, have re- ported excellent results of mitral valvuloplasty in patients with prior surgical commissurotomy. However, their best results were achieved in younger patients who had sinus rhythm and less echocardiographic evidence of rheumatic mitral valve damage. The older age of our patients and the longer time (29 and 34 years) elapsed after surgical valvotomy, compared with that of Redik- er’s patients, could partly explain the failure of balloon dilation in our cases. The “natural” progression (due to a “wear-and-tear’’ process) of the rheumatic mitral dis- ease may overlap with time the fibrocicatricial alterations induced by surgical commissurotomy, and they may both contribute toward making the mitral apparatus more dis- torted than in patients with more recent surgery. Due to a deeply modified mitral anatomy, the balloon pressure may be transmitted in an absolutely unpredictable way and may produce severe valve damage. In conclusion, mitral valvuloplasty may be quite safely recommended in younger patients without calcific mitral stenosis, whereas its application to elderly patients with prior sur- gical commissurotomy should be carefully evaluated, as the potential risk of mitral valve disruption is not negli- gible in this particular group of patients.’

‘Sincc this article was submitted, we have performed balloon mitral valvuloplasty in an additional 19 patients with satisfactory hernody- namic results and no additional complications.

ACKNOWLEDGMENTS

This work was supported by Associazione per lo Stu- dio dell’Emodinamica e della Cardiologia, Padova, It- aly.

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