Percutaneous mitral valvuloplasty in an adult patient with calcific rheumatic mitral stenosis

A 75 year old man with long-standing rheumatic mitral stenosis who refused surgical intervention was treated with percutaneous balloon valvuloplasty. Prevalvuloplasty evaluation revealed a heavily calcified mitral valve, a mean transvalvular gradient of 18 mm Hg, a Fick cardiac index of 1.7 liters/min per m2, a mitral valve area of 0.6 cm2 and 1 + mitral regurgitation. After transeptal catheterization and balloon dilation of the interatrial septum with an 8 mm angioplasty balloon, a 25 mm valvuloplasty balloon was advanced over a guide wire across the interatrial septum and positioned across the mitral anulus. Subsequent balloon inflation at 3 atm pressure resulted in a reduction of the mean mitral valve gradient to 12 mm Hg, an increase in cardiac index to 2.5 liters/min per m2, an increase in mitral valve area in 1.4 cm2 and an increase in mitral regurgitation from 1 + to 2 +. Valvuloplasty was well tolerated without embolization of clot or valvular debris, and resulted in marked clinical improvement with decreased dyspnea and increased exercise tolerance. Repeat catheterization 2 months after valvuloplasty showed further resolution of pulmonary hypertension and no evidence of valvular restenosis or worsening mitral regurgitation, but detected a small atrial septal defect with a pulmonary to systemic blood flow ratio of 1.8. It is concluded that percutaneous valvuloplasty is possible in the adult patient with calcific rheumatic mitral stenosis, and may result in a significant improvement in valvular function without producing life-threatening complications.