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(Circulation. 1998;98:2095-2097.)
© 1998 American Heart Association, Inc.

Images in Cardiovascular Medicine

Acute Mitral Regurgitation Due to Leaflet Tear After Balloon Valvotomy

Jong-Won Ha, MD; Namsik Chung, MD; Byung-Chul Chang, MD; Yangsoo Jang, MD; Won-Heum Shim, MD; Seung-Yun Cho, MD; ; Sung-Soon Kim, MD

From the Cardiology Division and Division of Cardiovascular Surgery (B.-C.C.), Cardiovascular Center, Yonsei University, Seoul, Korea.

Correspondence to Jong-Won Ha, MD, Cardiology Division, Cardiovascular Center, Yonsei University College of Medicine, CPO Box 8044, Seoul, Korea. E-mail jwha{at}yumc.yonsei.ac.kr

Percutaneous mitral balloon valvotomy (PMV) has evolved into an effective method for the treatment of patients with symptomatic mitral stenosis. An increase in mitral regurgitation can occur in 45% of patients undergoing PMV. Severe mitral regurgitation can be caused by rupture of chordae or of a papillary muscle. Noncommissural tearing of the mitral leaflet is also an important mechanism of severe regurgitation after PMV.

A 35-year-old woman presented with exertional dyspnea that had been present for 3 months. Physical examination revealed a chronically ill-looking appearance with malar flush and accentuated first heart sound, opening snap, and diastolic rumble at the apex. The ECG revealed normal sinus rhythm with left atrial enlargement. Transthoracic echocardiography revealed severe mitral stenosis with trivial mitral regurgitation. The echo score according to Wilkins et al was 8 (mobility, 2; thickening, 2; subvalvular, 2; and calcification, 2). Balloon mitral valvotomy was performed with a 28-mm Inoue balloon catheter. The effective balloon dilating area was 6.52 m². After 1 dilatation, the patient complained of chest tightness and dyspnea, with a markedly elevated v wave in the left atrial pressure tracing. Transesophageal echocardiography revealed severe eccentric mitral regurgitation toward the anterior wall of the left atrium, with suspicious tearing of the posterior mitral leaflet. These findings were confirmed at subsequent mitral valve replacement surgery with a prosthetic valve. The patient subsequently recovered and was uneventfully discharged days later.

View larger version (28K): [in this window] [in a new window]   Figure 1. Left atrial pressure tracing before and after balloon mitral valvotomy. A, Before valvotomy, there was a significant diastolic pressure gradient between left atrium (LA) and left ventricle (LV) suggestive of significant mitral stenosis. B, After severe mitral regurgitation, systolic LV pressure was decreased from 135 to 113 mm Hg, and mean LA pressure was increased from 20 to 48 mm Hg. The v wave reached 80 mm Hg.

View larger version (117K): [in this window] [in a new window]   Figure 2. Top, Multiplane transesophageal long-axis view (137°) shows fluttering echogenic density at posterior mitral leaflet indicative of tearing of leaflet. Bottom, Color flow imaging corresponding to top panel shows eccentric severe mitral regurgitation toward anterior wall of left atrium.

View larger version (86K): [in this window] [in a new window]   Figure 3. Operative finding revealed tearing of mid scallop of posterior mitral leaflet (arrows).

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ha, J.-W. Articles by Kim, S.-S. Search for Related Content PubMed PubMed Citation Articles by Ha, J.-W. Articles by Kim, S.-S.