Unusual sequelae after percutaneous mitral valvuloplasty: a Doppler echocardiographic study

Pathology of Severe Mitral Regurgitation following Balloon Valvuloplasty

This study assessed the mechanism of acute mitral regurgitation following balloon mitral valvuloplasty for the treatment of symptomatic mitral stenosis. We studied 25 patients who required mitral valve replacement for severe mitral regurgitation following balloon mitral valvuloplasty. All the mitral valves studied had features of severe mitral stenosis. Radial tear of the mitral leaflet was responsible for mitral regurgitation in 18 (72%) cases. Of these, 16 involved the anterior mitral leaflet and in 2 cases the posterior mitral leaflet was torn. Three patients (12%) had chordal rupture, whereas in 4 (16%) patients pseudo-orifices were formed. All the excised mitral valves showed significant subvalvular deformity which was underestimated in prevalvuloplasty echocardiography. No other factor was found to be associated with disruption of the valve. Hence, we conclude that cusp deformity and subvalvular pathology are responsible for faulty transmission of forces and improper engagement of the balloon, resulting in disruption of the valvular apparatus. The incidence of severe mitral regurgitation following balloon mitral valvuloplasty might be decreased by appropriate prevalvuloplasty assessment and patient selection.

Right atrium clot formation following percutaneous transmitral valvuloplasty

This case report describes a rare complication of percutaneous transmitral commissurotomy (PTMC). A patient with severe mitral stenosis developed a clot in the right atrium after an unsuccessful PTMC procedure. Because of the high risk of thromboembolism, the patient underwent urgent surgery to remove the clot and to replace the mitral valve with a mechanical prosthesis.

Emergency surgery after percutaneous transmitral commissurotomy: Operative versus echocardiographic findings, mechanisms of complications, and outcomes

OBJECTIVE

This study was undertaken to determine the clinical profile of patients undergoing emergency surgery after balloon mitral valvotomy, to note operative findings and compare them with those of transthoracic echocardiography, to describe the mechanisms of complications, and to describe outcomes.

METHODS

A retrospective study was undertaken of patients requiring emergency surgery after percutaneous mitral valvotomy with an Inoue balloon from January 1990 to December 2003. The data analyzed included demographic variables, causes and clinical presentations of complications, and outcome. In 14 consecutive cases of mitral regurgitation, an observational study comparing the operative findings with echocardiography was also undertaken.

RESULTS

In 1388 cases of valvotomy, complications necessitating urgent surgery occurred in 31 cases (2.2%). Acute mitral regurgitation occurred in 23 cases (74.2%), and cardiac tamponade occurred in 8 cases (25.8%). Mitral regurgitation was due to leaflet tearing in all cases: anterior leaflet in 20 cases and posterior leaflet in 3 cases. Hypotension, orthopnea, and pulmonary edema were the clinical presentation for mitral regurgitation. Transthoracic echocardiography underestimated the severity of mitral valve pathology. Bilateral severe commissural fusion and pliable leaflet with paracommissural calcium was seen in anterior leaflet tearing. Cardiac tamponade with hemodynamic compromise occurred as a result of left atrial perforation in 6 cases, right atrial perforation in 1 case, and left ventricular perforation in 1 case. High septal puncture led to atrial perforation. Operative mortality was 9.6%, and low cardiac output developed in 29%.

CONCLUSION

Acute mitral regurgitation and cardiac tamponade were the causes of emergency surgery after balloon valvotomy. Transthoracic echocardiography underestimated the severity of valve pathology.

[The evolution of severe postvalvuloplasty mitral insufficiency]

Percutaneous mitral valvuloplasty has become the technique of choice for mitral stenosis with favorable anatomic features. However, mitral regurgitation is an important complication of this technique that has not reduced with Inoue technique. This study reports the clinical and echocardiographic follow-up (28 +/- 20 months) of 20 patients who developed severe mitral regurgitation after percutaneous mitral valvuloplasty with Inoue technique. The patients were divided into two groups on the basis of the need for mitral valve replacement during follow-up. We analyzed variables before and after percutaneous mitral valvuloplasty using univariate analysis. Multivariate analysis was performed to identify variables as independent predictors of the need for mitral valve replacement. Ten patients needed mitral valve replacement during follow-up. Multivariate analysis showed that suboptimal result of percutaneous mitral valvuloplasty (MVA < 1.5 cm2) was the only independent predictor of the need of mitral valve replacement. We concluded that the need for MVR in patients who develop severe mitral regurgitation after percutaneous mitral valvuloplasty was related to suboptimal result of procedure.

Echocardiography can predict which patients will develop severe mitral regurgitation after percutaneous mitral valvulotomy

OBJECTIVES

Using two-dimensional echocardiography, we sought to identify features that are associated with severe mitral regurgitation after percutaneous mitral valvulotomy and combine them into a predictive score.

BACKGROUND

Severe mitral regurgitation after percutaneous mitral valvulotomy is a major complication carrying an adverse prognosis that, to date, has not been predictable in advance.

METHODS

In a consecutive series of 566 patients who underwent percutaneous mitral valvulotomy, 37 (6.5%) developed severe mitral regurgitation (assessed by angiography) after the procedure, 31 of whom had an echocardiogram available before percutaneous mitral valvulotomy. These 31 patients were matched by age, gender, mitral valve area and degree of mitral regurgitation before valvulotomy with 31 randomly selected patients who did not develop severe mitral regurgitation after percutaneous mitral valvulotomy. An echocardiographic score was developed on the basis of the pathologic studies of valves of patients who developed severe regurgitation after percutaneous mitral valvulotomy (leaflet rupture of relatively thin portions of nonhomogeneously thickened leaflets in the presence of commissural and subvalvular calcification) and evaluated uneven distribution of thickness in the anterior and posterior mitral leaflets, degree of commissural disease and subvalvular disease involvement, with each component graded from 0 to 4 (total, 0 to 16). Intraobserver and interobserver variability for score assessment were 6% and 7%, respectively.

RESULTS

The total mitral regurgitation echocardiographic score was significantly greater in the severe mitral regurgitation group (11.7 +/- 1.9 [mean +/- SD] vs. 8.0 +/- 1.2, p < 0.001). In addition, the component grades for the anterior leaflet (3.2 +/- 0.7 vs. 2.3 +/- 0.6, p < 0.001), commissures (2.6 +/- 0.7 vs. 1.6 +/- 0.6, p < 0.001) and subvalvular apparatus (3.2 +/- 0.6 vs. 2.3 +/- 0.7, p < 0.001) were also higher in the mitral regurgitation group. With a total score > or = 10 as a cutoff point for predicting severe mitral regurgitation after percutaneous mitral valvulotomy, a sensitivity of 90 +/- 5% and a specificity of 97 +/- 3% were obtained. Stepwise logistic regression analysis identified the mitral regurgitation echocardiographic score as the only independent predictor for developing severe mitral regurgitation after percutaneous mitral valvulotomy (p < 0.0001).

CONCLUSIONS

This new mitral regurgitation echocardiographic score can predict the development of severe mitral regurgitation after percutaneous mitral valvulotomy and can be useful in the selection of patients for this technique.

The value of transthoracic echocardiography during percutaneous balloon mitral valvuloplasty

Percutaneous balloon mitral valvuloplasty is a standard alternative to surgery in a selected group of patients with symptomatic dominant rheumatic mitral stenosis. With careful transthoracic and transesophageal echocardiographic selection of patients, there is a low complication and high success rate. Echocardiography has also been established as extremely useful in the long-term follow-up of patients. We present four cases that highlight our view that transthoracic echocardiography should be performed during the procedure, after each balloon inflation, and before and after the intervention. In our experience transthoracic echocardiography during balloon mitral valvuloplasty is invaluable in assessing commissural separation, increasing mitral valve area, new mitral regurgitation, and occasional unexpected anatomic sequelae of balloon inflation.

Pathology of mitral valve stenosis and pure mitral regurgitation--Part I

This two-part article examines the histologic and morphologic basis for stenotic and purely regurgitant mitral valves. In Part I, conditions producing mitral valve stenosis are reviewed. In over 99% of stenotic mitral valves, the etiology is rheumatic disease. Other rare causes of mitral stenosis include congenital malformed valves, active infective endocarditis, massive annular calcium, and metabolic or enzymatic abnormalities. In Part II, conditions producing pure mitral regurgitation will be discussed. In contrast to the few causes of mitral stenosis, the causes of pure (no element of stenosis) mitral regurgitation are multiple. Some of the conditions producing pure regurgitation include floppy mitral valves, infective endocarditis, papillary muscle dysfunction, rheumatic disease, and ruptured chordae tendinae.

Mitral valve balloon dilatation: long-term results

BACKGROUND

Although initial success rates for mitral valve balloon dilatation are currently about 85%, the procedure remains investigational and is not performed in many centers because the procedure is technically challenging and has uncertain long-term results.

AIM

The purpose of this report is to identify the predictors of long-term results after mitral valve balloon dilatation.

RESULTS

At 30-day follow-up of 738 patients treated at 24 centers (mean age 54 years), 4% of patients required mitral valve surgery, 3% had died, and 83% had their overall condition improved. At 2-month and 1-year follow-up of 17 patients treated at one center, quality of life showed sustained improvement as measured by the Sickness Impact Profile. At 5-year follow-up of 146 patients treated at a single center (mean age 59 years), overall survival was 76% and event-free survival was 51%. At 5-year follow-up of a younger group of 350 patients (mean age 46 years), overall survival was 94% and event-free survival was 85%. Predictors of survival after mitral balloon dilatation included age and baseline New York Heart Association functional class. Predictors of restenosis included the presence of valve calcification and leaflet thickening.

CONCLUSIONS

Mitral valve balloon dilatation has good long-term outcome for selected patients with mitral stenosis. The long-term outcome after this procedure can be predicted from baseline clinical and valvular characteristics.

Mechanisms and outcome of severe mitral regurgitation after Inoue balloon valvuloplasty. North American Inoue Balloon Investigators

OBJECTIVES

The purpose of this study was to assess the incidence, mechanism and outcome of severe mitral regurgitation after treatment of mitral stenosis with percutaneous mitral valvuloplasty using the Inoue balloon.

BACKGROUND

Severe mitral regurgitation occurs in up to 15% of percutaneous balloon valvuloplasty procedures for acquired mitral stenosis. The incidence and mechanism of production of mitral regurgitation with the recently introduced single-balloon Inoue technique have not been characterized.

METHODS

We examined the incidence, mechanism, predictors and outcome of severe mitral regurgitation after Inoue balloon valvuloplasty in 280 patients in the North American multicenter registry. Twenty-one patients who developed either clinically significant or angiographically severe regurgitation were identified, and their echocardiograms were reviewed to determine the mechanism of regurgitation. These patients were then compared with the remaining patients without severe regurgitation to identify predictors of this outcome.

RESULTS

The incidence of severe regurgitation in this study was 7.5%, and the mean grade of angiographic regurgitation in these patients increased from 0.9 +/- 1.0 to 2.8 +/- 0.7 (p < 0.05). The most common cause of regurgitation (43%) was rupture of chordae tendineae to the anterior or posterior mitral leaflet. Tearing of a leaflet (usually the posterior one) occurred in 30% of patients; and no recognizable structural abnormality, with wide splitting of the commissures and a central regurgitant jet, was present in five patients (26%). All patients with definite posterior leaflet tears had heavily calcified leaflets. Patients who developed severe regurgitation had fewer balloon inflations and a higher grade of preexisting mitral regurgitation but were otherwise similar to the remaining patients without severe regurgitation. During 6-month follow-up, 71% of the patients with severe regurgitation were treated surgically; the grade of regurgitation decreased in four patients (19%), and five patients (24%) have not required mitral valve replacement during 18 +/- 5 months of follow-up.

CONCLUSIONS

Severe mitral regurgitation is a relatively infrequent complication of Inoue balloon valvuloplasty and results from disruption of the valve integrity, including chordal rupture and leaflet tearing. Careful balloon positioning may help avoid chordal rupture, and heavily calcified posterior leaflets may be at greater risk of tearing. Most patients who develop severe regurgitation will require nonemergency mitral valve replacement.

Transoesophageal echocardiography in heart disease--old technologies, new tricks

Cardiac ultrasound and upper gastrointestinal endoscopy are relatively old technologies. With the introduction of new ultrasound probes and by incorporating ultrasound technology into conventional endoscopes, 'new tricks' in cardiac imaging were discovered. Posterior structures of the heart are now able to be imaged clearly by the ultrasound probe from the oesophagus. Consequently, better resolution of cardiac anatomy allows more accurate diagnosis of cardiac pathologies which is not possible using conventional transthoracic (TT) approach. Over a period of two years, 1200 cases of transoesophageal echocardiography (TOE) were undertaken in our institution. The major indications were diseases of the aorta (10%), source of cardioembolism (28%), assessment of native and prosthetic valve function (20%), suspected endocarditis and its complication (17%), pre and post percutaneous transluminal mitral valvotomy (PTMV [13%], congenital heart disease (2%) and others (10%). The greatest impact with TOE is in the diagnosis of aortic dissection and transection. TOE is superior to conventional TT approach in detecting potential source of embolism, valvular vegetations and its complication, native and prosthetic valve dysfunction and LA thrombus prior to PTMV. Observations by TOE such as spontaneous echo contrast (SEC) in the left atrium open new challenges for further research in its role in the pathogenesis of LA thrombus and its association with cardioembolic event. Other areas of interest include; reclassification of distal aortic dissection and the use of TOE in intra-operative work.