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Severe Rheumatic Mitral Stenosis Treated with Percutaneous Mitral
Valvuloplasty using Modified Technique

- Operator : Myeong-Ki Hong, MD, Korea

Case Presentation
A 63 year-old female was admitted for exertional dyspnea, NYHA functional class III. The electrocardiogram showed atrial fibrillation with controlled ventricular rhythm. The echocardiogram revealed thickening and motion limitation of mitral valve leaflets. Pre-procedure MVA (2D/PHT) was 1.1/1.2 cm2, and pressure gradient was 16/6mmHg on echocardiographic exam. Trivial mitral regurgitation and severe tricuspid regurgiatation were found with color Doppler technique and the Echo-score was 10 (mobility: 2, thickening: 3, subvalvular structure: 3, calcification: 2) ( Figure 1, Figure 2). There was no thrombus in the left atrium and left atrial appendage on transesophageal echocardiography. Calculated body surface area was 1.46. Thus operator planned to perform PMV with 28 mm Inoue balloon.
An 7 Fr sheath was inserted through right femoral vein and 6 Fr sheath was inserted through right femoral artery. Pig-tailed catheter was placed into the posterior cusp of aortic valve through right femoral artery. Right femoral vein sheath was exchanged for a Mullin sheath and dilator, which is advance over 0.032 inch guidewire into the superior vena cava. The guidewire is removed, and Brockenbrough needle was gently advanced to within a few milimeters of the tip of the dialtor, and needle is flushed and connected to a manufolder for continuous pressure monitoring. With fluoroscopic guidance (RAO 45?, interatrial septum was punctured at the site of fossa ovalis (Figure 3) (intended point of septal puncture is halfway between the posterior boundary of the atrial and an imaginary line drawn through the posterior aortic wall, and approximately 1 to 3 cm below an imaginary horizontal line drawn through the aortic valve). Mullin sheath was advanced into the left atrium after the puncture, and LA pressure and pressure gradient were measured after advancement of pigtail catheter into LV (Figure 4). After septal punture, under frontal fluoroscopic view, the stainless steel wire was placed into the left atrium until the coiled tip touches the superior wall of the left atrium. And then Mullin sheath was removed and Inoue balloon was introduced over the wire into left atrium (Figure 5). The stainless steel wire was removed after successful placement of the balloon. The Inoue balloon was optimally positioned to the mitral opening with inner stylet wire and gently advanced through the mitral opening to the left ventricle and then inner stylet wire was removed. The distal balloon is partially inflated and then pulled back and anchored in the mitral valve; full balloon inflation is completed to dilate the mitral valve (Figure 6). After deflating the balloon, left atrial pressure is measured. LA pressure and pressure gradient were remeasured (Figure 7).
Before and after the procedure, left atrial and left ventricular pressures were traced. The transmitral pressure gradient was dropped to the upper normal range after the procedure. Post-procedure MVA (2D/PHT) was 1.7/1.7 cm2, and pressure gradient was 13/5mmHg on echocardiographic exam ( Figure 8, Figure 9)., but moderate MR and persistent TR were observed on the echocardiographic exam. The patient was discharged uneventfully two days after.
Take home message
It has been demonstrated moderate to severe TR did not resolve, not even in a subgroup of patients in whom right ventricular systolic pressure fell by 10 mm Hg (as much as 41 mm Hg) regardless of the success of the procedure which can be a major drawback of PMV in the treatment of severe MS with moderate to severe TR. However, recently published study by Song et al. reported data on 71 patients who underwent PMV for severe MS with significant functional TR, they reported that TR was resolved on the follow-up echocardiography in 23 of the 71 patients with significant TR before PMV (32%). The TR jet area before PMV (P < 0.05) and the late decrement of peak transmitral pressure gradient (P <0 .01) were independent determinants of resolution. TR was resolved in only 6.7% of patients (1/15) with an unsuccessful long-term PMV result, but was resolved in 39% of patients (22/56) with a successful long-term result (P < 0.05). Therefore, TR could be diminished when the transmitral pressure gradient was sufficiently relieved with PMV. (Am Heart J 2003;145:371-376.)
reda abu elatta2005-12-18
reda mahfouz2010-07-04
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