Author + information
- Received April 17, 2014
- Accepted April 25, 2014
- Published online November 1, 2014.
- ∗Department of Medicine, Emory University, Atlanta, Georgia
- †Division of Cardiology, Emory University, Atlanta, Georgia
- ↵∗Reprint requests and Correspondence:
Dr. Joseph T. Knapper, Emory University School of Medicine, 116 Ponce de Leon Avenue NE, #2314, Atlanta, Georgia 30308.
An 89-year-old woman was admitted to the hospital with dyspnea, renal failure, and atrial fibrillation with rapid ventricular response. Transthoracic (Figure 1A, Online Video 1) and transesophageal echocardiograms (Figures 1B to 1D, Online Videos 2 and 3) showed severe mitral annular calcification (MAC), calcification of the leaflet bases, and shortening of the subvalvular apparatus—all consistent with severe nonrheumatic mitral stenosis (MS). Mean gradient was 18 to 22 mm Hg, with a valve area of 0.7 to 0.9 cm2 by pressure half-time. Attempts were made to improve her low-output state, but intermittent hypotension limited beta-blocker up-titration, and atrioventricular nodal ablation with VVI pacing at 55 beats/min provided no clinical benefit. Her comorbid conditions precluded surgical valve intervention. After extensive discussion with family, the decision was made to pursue balloon mitral valvuloplasty (BMV) despite her unfavorable valve anatomy.
Transfemoral BMV was performed using a 26-ml Inoue balloon (Toray, Tokyo, Japan) (Figure 1E, Online Videos 4 and 5). Following balloon inflation, systolic blood pressures rapidly increased from the 90s to the 130s. Intraprocedural echocardiogram showed a decrease in the mean gradient from 22 to 9 mm Hg (Figure 1F), with no increase in mitral regurgitation. Her symptoms significantly improved, and after several days of physical therapy, the patient walked out of the hospital under her own power. She died the following month in home hospice care.
This is the second reported case of BMV in nonrheumatic MS (1), and the first via the transfemoral approach. BMV is typically avoided because of prior research suggesting that calcification is linked to worse outcomes in rheumatic MS (2). Though such hesitation is understandable, this case suggests that BMV may be an option for palliative treatment in poor surgical candidates with severe nonrheumatic MS. Transcatheter mitral valve replacement may provide more durable results (3,4) and should be an area for future research.
For the supplemental videos, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 17, 2014.
- Accepted April 25, 2014.
- American College of Cardiology Foundation
- Tuzcu E.M.,
- Block P.C.,
- Griffin B.,
- Dinsmore R.,
- Newell J.B.,
- Palacios I.F.
- Hasan R.,
- Mahadevan V.S.,
- Schneider H.,
- Clarke B.