Papillary Muscle Rupture During Percutaneous Transvenous Mitral Commissurotomy: An Uncommon Scenario Exempt From Emergency Surgical Conversion

75-Year-Old Man With Chest Pain and Dyspnea

Acute severe valvular regurgitation is a surgical emergency, but accurate and timely diagnosis can be difficult. Although cardiovascular collapse is a common presentation, examination findings to suggest acute regurgitation may be subtle, and the clinical presentation may be nonspecific. Consequently, the presentation of acute valvular regurgitation may be mistaken for other acute conditions, such as sepsis, pneumonia, or nonvalvular heart failure. Although acute regurgitation may affect any valve, acute regurgitation of the left-sided valves is more common and has greater clinical impact than acute regurgitation of right-sided valves. Data to guide appropriate management of patients with acute regurgitation are sparse; there are no randomized trials, and much of the literature describes either small series or the experiences of specific centers. Despite these limitations, the available data are sufficient to allow identification of general principles as well as development of applicable guidelines from both the American College of Cardiology/American Heart Association and European Society of Cardiology. The guidelines recommend valve surgery for symptomatic patients with aortic or mitral regurgitation, including those with acute regurgitation.1–3 The data and guidelines emphasize overarching clinical principles, including the need for a high clinical suspicion of acute regurgitation, timely use of echocardiography, and, in the majority of patients, rapid progression to surgery. Causes of acute regurgitation overlap with causes of chronic regurgitation and vary depending on the valve affected (Table 1). Endocarditis may affect either the aortic or mitral valve, whereas other causes are unique to the specific valve involved. The majority of causes of acute regurgitation present as an acute or subacute event. However, acute regurgitation can occur in patients with chronic regurgitation, when regurgitant severity is exacerbated by factors such as coronary ischemia, chordal rupture, or leaflet perforation from endocarditis. Acute regurgitation of either the aortic or mitral valve may result from procedural …

Percutaneous transvenous mitral commissurotomy (PTMC) is the first-line therapy of clinically significant rheumatic mitral stenosis. While the procedure is generally safe, new onset or aggravation of mitral regurgitation (MR) may occur, mainly due to commissural splitting and, less frequently, to leaflet tear and chordal rupture. Papillary muscle rupture (PMR) is exceedingly rare in this setting. A 74-year-old woman with a history of aortic valve replacement and prior rheumatic mitral commissurotomy presented for worsening exercise intolerance and exertional dyspnoea. Transthoracic echocardiography showed a mean pressure gradient of 10 mmHg and a mitral valve area of 1.0 cm², consistent with clinically significant mitral stenosis. Subsequent PTMC was complicated by anterolateral PMR. However, the resulting MR was unexpectedly only of mild-to-moderate severity. Because of residual mitral stenosis and persisting symptoms, surgical mechanical mitral valve replacement and tricuspid annuloplasty were performed 6 weeks after PTMC. Papillary muscle rupture was confirmed during surgery. We herein describe the occurrence of PMR induced by PTMC; the resulting MR was unexpectedly of mild-to-moderate severity, as a result of extensive rheumatic lesions limiting valve mobility. This case challenges the dogma according to which PMR invariably leads to severe MR. This might not be necessarily the case when it occurs following PTMC.

Acute severe mitral regurgitation (MR) is rare, but often leads to cardiogenic shock, pulmonary edema, or both. Most common causes of acute severe MR are chordae tendineae (CT) rupture, papillary muscle (PM) rupture, and infective endocarditis (IE). Mild to moderate MR is often seen in patients with acute myocardial infarction (AMI). CT rupture in patients with floppy mitral valve/mitral valve prolapse is the most common etiology of acute severe MR today. In IE, native or prosthetic valve damage can occur (leaflet perforation, ring detachment, other), as well as CT or PM rupture. Since the introduction of percutaneous revascularization in AMI, the incidence of PM rupture has substantially declined. In acute severe MR, the hemodynamic effects of the large regurgitant volume into the left atrium (LA) during left ventricular (LV) systole, and in turn back into the LV during diastole, are profound as the LV and LA have not had time to adapt to this additional volume. A rapid, but comprehensive evaluation of the patient with acute severe MR is essential in order to define the underline cause and apply appropriate management. Echocardiography with Doppler provides vital information related to the underlying pathology. Coronary arteriography should be performed in patients with an AMI to define coronary anatomy and need for revascularization. In acute severe MR, medical therapy should be used to stabilize the patient before intervention (surgery, transcatheter); mechanical support is often required. Diagnostic and therapeutic steps should be individualized, and a multi-disciplinary team approach should be utilized.

Successful percutaneous transvenous catheter balloon mitral commissurotomy after warfarin therapy and resolution of left atrial thrombus

Percutaneous transvenous mitral commissurotomy has emerged as an effective nonsurgical technique for the treatment of patients with symptomatic mitral stenosis. This report highlights the immediate and long-term follow-up results of this procedure in an unselected cohort of patients with rheumatic mitral stenosis from a single center. It was performed in a total of 4,850 patients using double balloon in 320 (6.6%), flow-guided Inoue balloon technique in 4,374 (90.2%), and metallic valvulotome in 156 (3.2%) patients. Their age range was 6.5-72 years (mean, 27.2 +/- 11.2 years) and 1,552 (32%) patients were under 20 years of age. Atrial fibrillation was present in 702 (14.5%) patients. No patient was rejected on the basis of echocardiographic score using the Wilkins criteria. Echocardiographic score of > or = 8 was present in 1,632 (33.6%) patients, of which 103 (2.1%) had densely calcified (Wilkins score 4+) valve. A detailed clinical and echocardiographic (two-dimensional, continuous-wave Doppler and color-flow imaging) assessment was done at every 3 months for the first year and at 6-month interval thereafter. The procedure was technically successful in 4,838 (99.8%) patients but optimal result was achieved in 4,408 (90.9%) patients with an increase in mitral valve area (MVA) from 0.7 +/- 0.2 to 1.9 +/- 0.3 cm(2) (P < 0.001) and a reduction in mean transmitral gradient from 29.5 +/- 7.0 to 5.9 +/- 2.1 mm Hg (P < 0.001). The mean left atrial pressure decreased from 32.1 +/- 9.8 to 13.1 +/- 6.2 mm Hg (P < 0.001). Although there was no statistically significant difference in the MVA achieved between de novo and restenosed valves (1.9 +/- 0.3 and 1.8 +/- 0.2 cm(2), respectively; P > 0.05), or between noncalcific and calcific valves (2.0 +/- 0.3 and 1.8 +/- 0.2 cm(2), respectively; P > 0.05), on the whole MVA obtained after percutaneous transvenous mitral commissurotomy was less in restenosed and calcific valves. Ten (0.20%) patients had cardiac tamponade during the procedure. Mitral regurgitation appeared or worsened in 2,038 (42%) patients, of which 68 (1.4%) developed severe mitral regurgitation. Urgent mitral valve replacement was carried out in 52 (1.1%) of these patients. Data of 3,500 patients followed over a period of 94 +/- 41 months (range, 12-166 months) revealed MVA of 1.7 +/- 0.3 cm(2). Elective mitral valve replacement was done in 34 (0.97%) patients. Mitral restenosis was seen in 168 (4.8%) patients, of which 133 (3.8%) were having recurrence of class III or more symptoms. Thus, percutaneous transvenous mitral commissurotomy is an effective and safe procedure with gratifying results in high percentage of patients. The benefits are sustained in a majority of these patients on long-term follow-up. It should be considered as the treatment of choice in patients with rheumatic mitral stenosis of all age groups.

Improvement of exertional dyspnea occurs immediately after percutaneous transvenous mitral commissurotomy (PTMC), but the pathophysiological basis for this early symptomatic improvement has not been elucidated. Exercise hemodynamic measurement and exercise ventilatory measurement with arterial blood gas analysis were performed in 21 patients aged 50.4 +/- 9.5 years (mean +/- SD) with symptomatic mitral stenosis before and a few days after PTMC. Exercise ventilatory measurement were also performed in 14 normal control subjects aged 48.9 +/- 4.9 years. After PTMC, mitral valve area increased (from 1.0 +/- 0.3 to 1.7 +/- 0.3 cm2, P < .001), mean mitral gradient (from 12.2 +/- 5.2 to 5.2 +/- 2.2 mm Hg, P < .001), and mean left atrial pressure (from 18.7 +/- 6.1 to 12.1 +/- 4.0 mm Hg, P < .001) decreased. All patients experienced significant symptomatic improvement soon after PTMC. Comparison of hemodynamic parameters at the same ergometer work rate showed a significant decrease in pulmonary artery systolic pressure (from 77 +/- 18 to 67 +/- 14 mm Hg, P < .001) and diastolic pressure (from 36 +/- 10 to 28 +/- 7 mm Hg, P < .001) and a significant increase in cardiac output (from 6.4 +/- 1.4 to 8.1 +/- 1.9 L/min, P < .001). Despite the improvement in exercise hemodynamics and symptoms, exercise capacity determined by peak oxygen uptake (from 18.0 +/- 2.9 to 18.6 +/- 3.1 mL.kg-1 x min-1) and anaerobic threshold (from 11.7 +/- 2.4 to 12.0 +/- 2.4 mL.kg-1 x min-1) remained unchanged. Excessive exercise ventilation, as assessed by the slope of the regression line between expired minute ventilation and carbon dioxide output, decreased significantly from 37.2 +/- 6.7 to 33.9 +/- 5.8 (P < .001), but remained significantly higher than that in the normal subjects (27.9 +/- 3.6, P < .01). The ratio of total dead space to tidal volume and total dead space per breath during exercise decreased significantly after PTMC (P < .05). The change in excessive exercise ventilation after PTMC was correlated with the change in dead space to tidal volume ratio (r = .59). Significant relief of exertional dyspnea immediately after PTMC is not accompanied by an improvement in exercise capacity. A decrease in excessive ventilation due to a decrease in physiological dead space resulting from hemodynamic improvement partly contributes to the early relief of symptoms after PTMC. However, lung compliance, which was not measured in the present study, may have changed after PTMC. This change may also contribute to the symptomatic improvement.

Safety of percutaneous transvenous balloon mitral commissurotomy in patients with mitral stenosis and thrombus in the left atrial appendage

Delayed improvement in skeletal muscle metabolism and exercise capacity in patients with mitral stenosis following immediate hemodynamic amelioration by percutaneous transvenous mitral commissurotomy

Determinants of delayed improvement in exercise capacity after percutaneous transvenous mitral commissurotomy

Objective: The goal of this study is to see how often Acute Mitral Regurgitation is in patients with severe mitral stenosis who have undergone a percutaneous transvenous mitral commissurotomy (PTMC). Study Design: Cross-sectional study Pace and Duration: The study was carried out at cardiology department of Lady Reading Hospital MTI, Peshawar and PIMS hospital, Islamabad for the duration of six months from 16th August 2021 to 15th February 2021. Methods: A total of 85 patients of both genders that underwent percutaneous transvenous mitral commissurotomy (PTMC) were included in this study. A detailed demographic profile of recruited patients including age, gender and body mass index (BMI) was compiled after obtaining informed written permission from each patient. A technician with over 10 years of experience examined pre- and post-procedure mitral regurgitation using a transthoracic echocardiography (TTE). Frequency of complication was also recorded. SPSS 21.0 was used to analyze all data. Results: Among 85 patients, there were 65 (76.5%) females and 20 (23.5%) males. Mean age of the patients was 39.8 ±9.54 years and mean BMI 24.6±11.42 kg/m2. Previous commissurotomy was found in 9 (10.5%) cases. Pre-operative mean balloon size 26.5±1.88 and mitral valve area was 1.1±0.32. Frequency of severe mitral regurgitation found in 15 (17.6%) cases. 75 (88.2%) patients had no previous history of commissurotomy and the majority were females. Among 9 cases of severe MR, 4 (44.4%) had no previous history of commissurotomy. Conclusion: According to our study, few PTMC patients had significant mitral regurgitation. Procedure is safe and effective. A multiethnic, multicenter, multicity research is proposed in Pakistan to evaluate genetic, environmental, and hospital-related variables associated with post-procedural problems in patients with severe mitral regurgitation who received PTMC. Keywords: PTMC, Mitral Regurgitation, Post Percutaneous Transvenous Mitral Commissurotomy, Local Site complications, MR, Cardiac Tamponade

BackgroundThe objective of the study was to determine the long-term outcomes, including mitral restenosis and regurgitation, after successful percutaneous transvenous mitral commissurotomy (PTMC).MethodsThis cross-sectional prospective study was conducted at the cardiology department of Lady Reading Hospital, Peshawar, Pakistan, from January 2007 to December 2009. A total of 84 patients were followed up for a period of 96 months. Pre and post percutaneous transvenous mitral commissurotomy echocardiography was done on the mitral valve area (MVA) using two-dimensional (2D) and color doppler echocardiography. Patients who had successful PTMC were followed up for MVA loss, mitral regurgitation (MR), and cardiac death. SPSS Software (IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY: IBM Corp.; 2013) was used for data analysis.ResultsOf the 84 patients, 21 were male, and 63 were females. The mean age was 35 ± 11 years. After PTMC, the mean valve two-dimensional area increased from 0.84 ± 0.13 to 1.83 ± 0.49 cm2 (p value <0.001). MR was mild in 49 patients (62.8%), moderate in 27 patients (34.6%), and severe in two patients (2.6%). Good results were achieved in 60 (71.4%). Patients with good results were younger (24 ± 4), and had a relatively lower Wilkin's score, with a mean value of (8.4 ± 2.8). Follow-up events were death in six patients, mitral valve replacement (MVR) in 10 patients, and restenosis in seven patients. The Kaplan-Meier curve was used for the follow-up end points. Patient who required PTMC for mitral restenosis survived for a longer time than those requiring MVR, and those who had cardiac death due to severe pulmonary hypertension or heart failure.ConclusionPatients who had favorable Wilkin’s score and underwent PTMC for severe symptomatic mitral stenosis had better event-free survival in the long term follow-up.

Neonatal Mitral and Tricuspid Valve Repair for In Utero Papillary Muscle Rupture

Rheumatic heart disease (RHD), is a common cause of mitral stenosis (MS) in developing nations. As per current recommendation, Percutaneous Transvenous Mitral Commissurotomy (PTMC) is advised as a Class IA (I-Class Of Recommendation, COR; A-Level Of Evidence, LOE) indication in patients with symptomatic severe mitral stenosis. We aim to examine the clinical profile and in-hospital results of PTMC for mitral stenosis. A cross-sectional retrospective study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center from April 2020 to May 2022. A structured questionnaire was used to collect the data and ethical approval for conducting the study was taken from the Institutional Review Committee (IRC) of Institute of Medicine (IOM). The data was collected in Microsoft Excel (Ver. 2013). For statistical analysis, SPSS 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) Association was measured using a parametric and non-parametric test (depending upon the distribution of data) and p value<0.05 was considered significant. A total of 104 patients who met the inclusion criteria underwent PTMC during the study period. The mean age group of the patient was 41.7±12.5 years, of which 23 (22.1%) were males and 81 (78.9%) were females. Mean mitral valve area prior to PTMC was 0.98±0.19mm2 that increased to 1.69±0.19mm2 after the procedure and it was statistically significant (p=<0.001). The post PTMC MVA varied with PTMC Wilkin's score with less than or equal to 8 having favorable outcomes. Successful PTMC is highly influenced by the patients' increasing age, valve morphology (calcification, thickness, mobility), Left atrial dimensions, Pre PTMC mitral valve area, Degree of Baseline mitral regurgitation. Post procedure development of MR is usually well tolerated but rarely be severe enough requiring surgical valve replacement.

Background: The goal of this study is to investigate the factors that influence the effectiveness of redo percutaneous Transvenous Mitral Commissurotomy (PTMC) and to See how it affects MVA and echocardiographic parameters. Methods: It was a single-center, retrospective research that took place at Cardiac Center QAMC Bahawalpur from 3rd January to 31st December 2020. All patients who had Redo PTMC had their medical records reviewed. The pre- and post-procedure values for mitral valve area (MVA), left atrial pressure (LA pressure), pulmonary artery systolic pressure (PASP), and mitral regurgitation (MR) were compared. Results:. Total 78 patients were enrolled , 28(36%) males and 50(64%) females with a mean age 37.15± 2.63 enrolled age range between 25-45 years. Patients were divided into two groups, the average age of in successful (Group I) patients was 31.08±5.83 years and in un-successful (Group II) patients was 30.73±4.21. In Group-I, 18(64.3%) males and 30(60.0%) females as compare with Group-2, 10(35.7%) males and 20(40%) female’s patients were enrolled. Both groups were well matched in other demographic and echocardiographic characteristics . Findings of echocardiographic parameter showed that there is difference in Mitral Valve Area in (successful vs unsuccessful group) 1.69±0.11 vs 0.67±0.23 with p-value 0. 024.. The mean PA pressure13.25±5.19 vs 23.25±6.55 and Mean LA Pressure 13.25±5.19 vs 23.25±6.55 with p-value 0.29 between pre and post-Redo PTMC was statistically significant as p-value = 0.001. Conclusion: In patients with mitral restenosis, PTMC is a viable, safe surgery with a high success rate and tolerable morbidity. Repeat PTMC should be the procedure of choice in individuals with poor echo scores and no concomitant illnesses. Redo PTMC can be utilized as a palliative approach in patients with more severe valvular and subvalvular deformity who are at high risk of morbidity and death with MVR due to the presence of substantial concomitant conditions. Keywords: PTMC Percutaneous transvenous mitral commissurotomy, MR Mitral Stenosis Rheumatic heart disease, Valve area, Mitral stenosis PASP pulmonary artery systolic pressure