Rescue percutaneous mitral balloon valvuloplasty for iatrogenic critical mitral stenosis after open mitral valve repair for rheumatic mitral regurgitation

Abstract

Mitral valve repair is a feasible option in rheumatic heart disease with reasonable long-term results. 1 , 2 Early mitral stenosis is a very rare complication of mitral valve repair. Percutaneous balloon mitral valvuloplasty (PBMV) can serve as a bailout procedure if reoperation is a very high risk. Here, we report a patient who underwent successful PBMV due to iatrogenic critical mitral stenosis. A 14-year-old Asian male underwent mitral valve repair after he presented with exertional dyspnoea (New York Heart Association Class II/III). He was a known case of severe rheumatic mitral regurgitation for 7 years. His transoesophageal echocardiography (TOE) showed mildly thickened leaflets and flail P3 scallop (Carpentier type II and IIIa) (Supplementary material online, Video S1). The valve was repaired using the annuloplasty Physio ring (32 mm), new chord to the anterior mitral leaflet, and plication of both commissures. There was no residual mitral regurgitation on intraoperative echocardiogram, but a higher mean gradient (5 mmHg). The next day, he was extubated but reintubated again due to signs of acute pulmonary oedema, desaturation, and significant hypotension. Echocardiography showed significant diastolic flow acceleration across the repaired mitral valve with a mean gradient of 19 mmHg (heart rate 134 b.p.m.) and the mitral valve area (MVA) of 0.42 cm2 (measured by 3D TOE) and both commissures were fused ( Figure 1 , Supplementary material online, Video S2, Image S1). The patient was at high risk for redo surgery due to significant hypotension (89/54 mm/Hg) despite ionotropic support, so the next morning, he underwent PBMV. Multiple balloon inflations ( Figure 2 ) were done using Inoue-Balloon, which resulted in a significant increase in MVA up to 1.5 cm2 with open commissures and the mean gradient dropped to 5 mmHg (Supplementary material online, Videos S3–S5). There was only mild mitral regurgitation which gradually regressed on follow-up. Percutaneous mitral balloon valvotomy can be considered for iatrogenic mitral stenosis after mitral valve repair. Figure 1 Three-dimensional transoesophageal echocardiography showing severe mitral stenosis with a mitral valve area of 0.42 cm2 and commissural fusion (arrowheads). Annuloplasty ring can also be seen (white arrow). Figure 2 Two-dimensional transoesophageal echocardiography showing inflated Inoue-Balloon (white arrow) in the repaired mitral valve using an annuloplasty ring (arrowheads). Supplementary material Supplementary material is available at European Heart Journal - Case Reports online. Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance. Conflict of interest: none declared. Supplementary Material ytaa345_Supplementary_Data Click here for additional data file.