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J Thorac Cardiovasc Surg 2006;131:927
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Severe mitral regurgitation after percutaneous transmitral commissurotomy: Underestimated subvalvular disease

Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India

To the Editor:

We read with interest the article by Varma and associates ¹ in which the authors describe 23 cases of severe acute mitral regurgitation (MR) after percutaneous transmitral commissurotomy (PTMC). Tearing of either the anterior (n = 20) or posterior (n = 3) mitral leaflet was responsible for production of acute MR. The authors also found that the majority of these patients had significant subvalvular disease, which was underestimated on transthoracic echocardiography.

We had a similar experience, as reported earlier. ² Acute, severe MR developed in 25 of 752 patients undergoing PTMC and necessitated emergency mitral valve replacement or repair. The most common lesion responsible for acute MR was a radial tear in either the anterior (n = 16) or posterior (n = 2) mitral leaflet. Three patients had rupture of one or more chordae. In the remaining 4 patients, creation of a pseudo-orifice in the mitral apparatus was responsible for acute MR. Moderate-to-severe commissural fusion was present in all cases, and commissural fracture was seen in only 1 case, suggesting very serious commissural fusion. The most interesting finding was the presence of moderate (n = 14) or severe (n = 5) subvalvular fusion as against pre-PTMC transthoracic echocardiographic findings of no subvalvular disease in 13 patients, mild disease in 7 patients, and moderate disease in 5 patients.

We believe the presence of undiagnosed, significant subvalvular disease may lead to either faulty transmission of balloon pressure forces leading to leaflet tear or improper engagement of the balloon leading to chordal rupture or pseudo-orifice creation. Thus, the presence of subvalvular disease plays a major role in the production of these lesions. Unfortunately, transthoracic echocardiography may not be a sensitive tool to evaluate subvalvular disease, as it was missed in most of our patients.

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1. Varma PK, Theodore S, Neema PK, Ramachandran P, Sivadasaanpillai H, Nair KK, et al. Emergency surgery after percutaneous transmitral comissurotomy. operative versus echocardiographic findings, mechanisms of complications, and outcomes. J Thorac Cardiovasc Surg. 2005;130:772-776.[Abstract/Free Full Text]
   
2. Choudhary SK, Bhan A, Sharma R, Airan B, Das B, Kumar AS, et al. Pathology of severe mitral regurgitation following balloon valvuloplasty. Asian Cardiovasc Thorac Ann. 1997;5:25-30.[Medline]
   

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 Add to Personal Folders Download to citation manager Author home page(s): Shiv Kumar Choudhary Sachin Talwar Panangipalli Venugopal Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Choudhary, S. K. Articles by Venugopal, P. Search for Related Content PubMed PubMed Citation Articles by Choudhary, S. K. Articles by Venugopal, P. Related Collections Related Article