Graphical abstract
Keywords: PTMC, Mitral annular tear, Rheumatic mitral stenosis, Percutaneous balloon mitral valvotomy
Highlights
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Annular tear is a rare complication to be considered in PBMV patients.
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The risk is higher with asymmetric commissural calcification.
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Consider early TEE post-PBMV when TTE findings are discrepant with clinical findings.
Introduction
Percutaneous balloon mitral valvotomy (PBMV) is the procedure of choice in a symptomatic severe rheumatic mitral stenosis (MS) with favorable morphology. However, the balloon valvotomy is associated with potential complications like commissural tear, severe mitral regurgitation (MR), and cardiac tamponade. Annular tear is a rarely reported complication of PBMV.
Case Presentation
A 72-year-old woman with rheumatic MS and history of PBMV 13 years prior presented with recurrent dyspnea. Transthoracic echocardiography (TTE) of the mitral valve (MV) showed fusion and calcification of the anterolateral commissure, doming of the anterior mitral leaflet, restricted posterior leaflet, and mild MR. The patient was diagnosed with severe MS, and the MV area was reported to be 1.0 cm2 on two-dimensional planimetry in the parasternal basal short-axis view (Figure 1). Even though the Wilkins score was 9, it was determined that the best option was to attempt another PBMV considering the patient's preference and age. Transesophageal echocardiography (TEE) was performed to evaluate for clot prior to the procedure and was used to guide the procedure along with fluoroscopy. The preprocedural TEE measured the baseline MV gradient as 11 mm Hg (Figure 2) and ruled out left atrial clots. The three-dimensional (3D) TEE en face view in dual volume layout depicts the limited opening of the MV in diastole, along with fusion and calcification of the anterolateral commissure (Figure 3). The predominant involvement of the anterolateral commissure is well visualized when seen from the ventricular aspect of the MV (Video 1). After transseptal puncture, mitral valvotomy was performed by an expandable double lumen balloon of size 23 to 26 mm (height-based formula for balloon sizing was employed). Balloon dilatation was performed in a graded 3-stage inflation, with consistent monitoring of MR and mitral inflow gradients in the TEE midesophageal 4-chamber view. Postprocedure, the patient was hemodynamically stable with an MV area of 1.5 cm2 and mild MR at the posteromedial commissure.
Figure 1.
Two-dimensional (2D) TTE, parasternal basal short-axis diastolic view, demonstrates MS (1.01 cm2 by 2D planimetry).
Figure 2.
Two-dimensional TEE, midesophageal 4-chamber view-guided continuous-wave spectral Doppler across the mitral inflow, demonstrates a stenotic profile with a mean gradient of 11 mm Hg and peak gradient of 16 mm Hg.
Figure 3.
Three-dimensional TEE, midesophageal en face short-axis diastolic view of the MV, 3D zoom, dual volume layout, demonstrates the MS with commissural calcium over the anterolateral commissure (arrows) from the left atrial (left) and the left ventricular (right) perspectives.
An hour later in the postcatheterization room, the patient experienced cardiac arrest and was intubated and resuscitated and a bedside TTE was repeated. There was mild MR and no tamponade on TTE. The patient had a heart rate of 110 beats per minute, cold extremities, and a low mean arterial pressure of 48 mm Hg; a pansystolic murmur was heard in the left infra-axillary area on auscultation. The patient was initiated on positive pressure ventilation, and hemodynamics were stabilized with 0.04 μg/kg/min of noradrenaline infusion. After stabilizing the patient, despite a mild MR as reported on TTE, the shock team decided to perform an emergent TEE, which visualized 2 distinct MR jets. In the midesophageal two-dimensional modified bicommissural view, the jet, which was quantified as mild in the TTE, was seen arising at the posteromedial commissure, and an additional larger jet was visualized originating beyond the posterior annulus (Video 2, Figure 4). A 3D full-volume acquisition with orthogonal views delineated the 2 jets; the major jet was found to originate beyond the posterior annulus (Figure 5, Video 3). A discontinuity in the annulus adjacent to posteromedial commissure was also noted in the 3D en face view of the MV (Figure 6). The patient was taken for emergent MV replacement. On opening the left atrium, a tear in the posterior leaflet was found at the posteromedial commissure extending through the posterior annulus into the left ventricular myocardium stopping just before the pericardium. The MV was replaced after excising the anterior leaflet. The tear in the posterior annulus was repaired with a patch of bovine pericardium, and a 23 mm bileaflet mechanical valve was implanted at the mitral position in view of the history of paroxysmal atrial fibrillation. The rest of the perioperative period was uneventful.
Figure 4.
Two-dimensional TEE, midesophageal long-axis (63°) zoomed, systolic view with simultaneous color-flow Doppler, demonstrates mild MR originating from the posteromedial commissure (thin white arrow) and more severe, eccentric MR from posterior to the commissure, close to the posterior annulus (thick white arrow).
Figure 5.
Three-dimensional TEE, midesophageal, simultaneous orthogonal two-dimensional cropped long-axis systolic views with color-flow Doppler and volume-rendered reconstructed full-volume display, demonstrates the MR jet originating posterior to the annulus (thick arrows) and the commissural MR (thin arrow).
Figure 6.
Three-dimensional TEE, midesophageal diastolic, zoom short-axis dual volume layout, demonstrates the posteromedial commissural tear extending to the annulus (arrows) viewed from the left atrial (left) and left ventricular (right) perspectives.
Discussion
Complications necessitating surgical interventions after percutaneous mitral valvotomies are estimated to be around 2.2%.1 Nearly one-third of these occur due to cardiac tamponade, and the others are due to acute severe MR.2,3 Annular dehiscence is rarely reported after PBMV, although its incidence after MV replacement is reported to be 10% to 30%, which is typically seen to occur in elderly women with calcified valves, commonly involving the posterior annulus.4 The recent guidelines on rheumatic heart disease enumerate the predictors of PBMV success by echocardiographic scores that assess for leaflet thickening, calcification, pliability, and subvalvar thickening. On the other hand, asymmetric commissural calcification, commissural fusion, and eccentric annular calcifications are mentioned as the predictors of PBMV-induced complications such as leaflet tear, severe valvar regurgitation, and cardiac tamponade.5,6 Retrospectively, on reviewing the images of the reference patient, immediate postprocedure 3D en face image clearly depicts a commissural calcium score of 2, involving the anterolateral commissure (as per the scoring system described by Abdelghani et al.7; Figure 3, Video 1). Bezdah et al.8 state that in patients with borderline Wilkins score, presence of commissural calcification was a predictor of poor success rate and a suboptimal commissural split after PBMV. They, however, failed to find any relation between presence of commissural calcium and development of MR, and hence they recommended a safe trial of PBMV even in borderline Wilkins score patients.8 Nunes et al.9 and Anwar et al.10 have shown that the pattern of calcification has greater implications on post-PBMV complications than the degree of calcification. Uneven calcium distribution, calcification localized at the commissures, and extension of calcification into the A1,A3 and the P1,P3 segments were marked as stronger predictors of leaflet tear and greater than grade 2 MR after PBMV even in patients with a favorable Wilkins score.9 The calcium scoring was performed using 3D TEE in both studies. Nunes et al. have curated a new score incorporating the commissural calcium patterns to guide intervention decisions in patients with intermediate Wilkins scores.9,11 Their modified scoring system emphasizes commissural inclusion, which is not captured in the traditional Wilkins score. From the above discussion, it can be deduced that patients with borderline high Wilkins score (9-11), with fused commissures, and with no commissural calcification can still be considered for PBMV to achieve reasonable immediate outcomes; however, patients with an unfavorable calcification pattern despite a favorable Wilkins score not only have suboptimal response to PBMV but also have greater complication rates. Based on the evidence from these papers, we postulate that in the reference patient, the asymmetric pathology and uneven calcification of the anterolateral commissure produced uneven distribution of balloon inflation pressure, thus tearing the more-yielding posteromedial commissure and extending the tear into the annulus. Although reported cases of annular tear after PBMV are few, this case emphasizes the importance of considering this as a complication especially in the presence of asymmetric commissural or annular calcification.
Both the intraprocedural TEE and the postprocedural TTE failed to capture the annular tear. The general anesthetics, positive pressure ventilation, and MR-induced high left atrial pressure possibly lessened the MR jet momentum, reducing the MR color jet severity on TEE. The likely explanation for the missed annular tear in the postprocedure bedside TTE is the diminished left ventricular contractile forces immediately post–cardiac arrest, producing a low momentum of MR jet underestimating the color-flow Doppler jet area. Identifying the mechanism in eccentric, posterior annular MR jets is more accurate on TEE than TTE due to the proximity of the probe to the MV. Additionally, in this patient, the tear could have been evolving over time and likewise the severity of MR. Hence, when there is a disagreement between the clinical picture and TTE findings post-PBMV, an early TEE is recommended.
Conclusion
Annular tear is a rarely reported event after PBMV and should be suspected as a possible complication in a patient with asymmetric annular or commissural calcification. Addition of a 3D TEE calcification score to the traditional Wilkins score will augment its predictability for leaflet tear, significant MR, and rare complications such as annular tear. Whenever a complication is suspected after PBMV, and the TTE does not correlate with the clinical and hemodynamic picture, an early TEE should be considered
Ethics Statement
The authors declare that the work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans.
Consent Statement
Complete written informed consent was obtained from the patient (or appropriate parent, guardian, or power of attorney) for the publication of this study and accompanying images.
Funding
The authors declare that this report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosure Statement
The authors reported no actual or potential conflicts of interest relative to this document.
Footnotes
Supplementary data related to this article can be found at https://doi.org/10.1016/j.case.2025.09.005.
Supplementary Data
Three-dimensional TEE, midesophageal 4-beat full volume acquisition, cropped to demonstrate the restricted MV opening from the left ventricular perspective, demonstrates the commissural calcium over the fused anterolateral commissure (arrow).
Two-dimensional TEE, midesophageal long-axis (63°) zoomed view with simultaneous color-flow Doppler, demonstrates mild MR originating from the posteromedial commissure (thin arrow) and more severe, eccentric MR from posterior to the commissure, close to the posterior annulus (thick arrow).
Three-dimensional TEE, simultaneous orthogonal two-dimensional cropped long-axis views with color-flow Doppler and volume-rendered reconstructed full-volume display, demonstrates the MR jet originating posterior to the annulus (arrows).
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Associated Data
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Supplementary Materials
Three-dimensional TEE, midesophageal 4-beat full volume acquisition, cropped to demonstrate the restricted MV opening from the left ventricular perspective, demonstrates the commissural calcium over the fused anterolateral commissure (arrow).
Two-dimensional TEE, midesophageal long-axis (63°) zoomed view with simultaneous color-flow Doppler, demonstrates mild MR originating from the posteromedial commissure (thin arrow) and more severe, eccentric MR from posterior to the commissure, close to the posterior annulus (thick arrow).
Three-dimensional TEE, simultaneous orthogonal two-dimensional cropped long-axis views with color-flow Doppler and volume-rendered reconstructed full-volume display, demonstrates the MR jet originating posterior to the annulus (arrows).