Author Affiliations: From the *Department of Cardiology A, University Hospital Ibn Sina, Rabat, Morocco, and the §Department of Cardiology B, University Hospital Ibn Sina, Rabat, Morocco. The authors report no conflicts of interest regarding the content herein. Manuscript submitted February 5, 2008, provisional acceptance given February 20, 2008, manuscript accepted March 3, 2008. Address for correspondence: Belghiti Hasnaa, MD, Department of Cardiology B, University Hospital Ibn Sina, Rabat, Morocco. E-mail: firstname.lastname@example.org
ABSTRACT: The authors report the case of a young girl with a Carpentier-Edwards annuloplasty ring for severe rheumatic mitral disease who presented 4 years later with mitral restenosis due to commissural fusion. She underwent successful percutaneous mitral commissurotomy with an Inoue balloon. Technical specificities and the safety of the procedure are briefly discussed.
J INVASIVE CARDIOL 2008;20:E281–E282 Case Report. A 30-year-old female with a severe rheumatic mitral regurgitation and moderate mitral stenosis underwent surgical commissurotomy and annuloplasty in 1999 with a Carpentier-Edwards ring (CER) n°30. Postoperatively, transthoracic echocardiography (TTE) revealed a mean mitral valve gradient (MVG) of 4 mmHg, a calculated mitral valve area (MVA) of 2.2 cm2, and no mitral regurgitation. Four years later, she presented to the emergency room with progressive dyspnea. Repeat TTE demonstrated severe mitral stenosis (MVG 25 mmHg; MVA 0.9 cm2), with no mitral regurgitation. Transesophageal echocardiography (TEE) confirmed mitral valvular restenosis due to commissural fusion and eliminated a left atrial thrombus (AUTHOR would it be correct to say: “...and elimination of a left atrial thrombus” ?). The patient’s Wilkins score was 6: mid-leaflet thickening (2), reduced mobility of the base and the mild portion of the valve (2), no valvular calcification (1), and minimal thickening of the chordal structures (1). It was decided to proceed with percutaneous mitral commissurotomy (PMC).
PMC was performed using an Inoue balloon. The transseptal puncture had to be sufficiently distant from the mitral plane to allow sufficient catheter mobility. The mitral valve was easily crossed through the prosthetic ring. The balloon was then gradually inflated at low pressure (Figure 1), but to a sufficient diameter (from 22 to 26 mm) to avoid de-insertion of the ring.
The procedure was successful with immediate clinical and hemodynamic improvement (Table 1). On TTE, the MVA was calculated at 2 cm2. There was no mitral regurgitation.
At 2-year follow up, the patient remains symptom-free with unchanged echocardiographic results (Figure 2).
Discussion. Rheumatic valvular disease continues to be endemic in developing countries where mitral stenosis is the most common valve disease.1 The first to perform PMC as an alternative to surgery in mitral stenosis was Inoue in 1982.2 The good results obtained with the technique have led to its increasing use worldwide. PMC is actually the procedure of choice for patients with appropriate characteristics, that is, young patients with favorable anatomy. Although cases of PMC have already been reported in patients following previous mitral commissurotomy3 as well as in patients with bioprosthetic valves,4 PMC for mitral restenosis through a CER remains an unusual technique.5 Is has the potential risk of accidental prosthetic ring de-insertion resulting in acute severe mitral regurgitation. Furthermore, the ring can interfere with the balloon’s inflation, resulting in only modest improvement of MVA.
Despite these inconveniences, we decided to perform percutaneous mitral commissurotomy for several reasons: the young age of the patient, the anatomy of the valve, the mechanism of restenosis due to commissural fusion, to avoid a second open-heart surgery, and to reduce the costs and duration of hospitalization.
Conclusion. PMC is technically feasible and safe for the treatment of recurrent mitral stenosis after annuloplasty if the patient’s anatomic conditions are favorable and if the interventionalists are experienced.