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A rare combination of rheumatic mitral and tricuspid stenosis treated by percutaneous balloon valvuloplasty
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 3 2 e3 4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jicc
Case Report
A rare combination of rheumatic mitral and tricuspid stenosis treated by percutaneous balloon valvuloplasty Biplab Paul*, Pranab Kumar Biswas, Biswajit Majumder Department of Cardiology, RG Kar Medical College, Kolkata, West Bengal 700004, India
article info
abstract
Article history:
Rheumatic heart disease is still a leading cause of morbidity and mortality in developing
Received 28 May 2014
countries. Rheumatic mitral stenosis is almost always associated with other valvular
Accepted 24 October 2014
lesion; however, combination of rheumatic mitral stenosis nad tricuspid stenosis is very
Available online 25 November 2014
rare. We encountered a patient of rheumatic MS & TS and planed to treat both the valves with balloon valvuloplasty. We performed balloon valvuloplasty of both the valves with
Keywords:
26 mm size Akura balloon in same setting. Post-procedure and one year follow-up data was
Echocardiography
excellent.
Cardiovascular examination
Copyright © 2014, Indian College of Cardiology. All rights reserved.
Mitral stenosis Tricuspid stenosis Valvuloplasty
1.
Introduction
Learning objective Although Rheumatic heart disease is very common in our country, combination of pure mitral and tricuspid stenosis without other valve involvement is rare. Balloon valvuloplasty is the procedure of choice in case of MS, but whether, TS can be treated in similar manner or with same balloon is not clear. Here, we performed both valvuloplasty with same balloon in same sitting and just want to share our experience with the reader of your popular journal.
Percutaneous balloon mitral valvuloplasty (BMV) has been established as the procedure of choice for symptomatic mitral stenosis with suitable valve morphology. It has replaced surgery for the treatment of mitral stenosis (MS) in selected patients since its introduction by Inoue et al in 1984.1 It affords an event-free survival rate greater than 90% at 5e7 years.1,2 Acute and long-term results of balloon mitral valvuloplasty is comparable to open surgical commissurotomy and better than closed mitral commisurotomy and are occasionally associated with complications such as death in 0e1% of cases, moderate or severe valvular regurgitation in 3e5% of cases, and systemic
* Corresponding author. Tel.: þ91 9674941651. E-mail address: [email protected] (B. Paul). http://dx.doi.org/10.1016/j.jicc.2014.10.006 1561-8811/Copyright © 2014, Indian College of Cardiology. All rights reserved.
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 3 2 e3 4
33
valvuloplasty using Inoue techniques (Akura balloon) as a single stage procedure with good results and recovery.
2.
Fig. 1 e Echocardiography: continous wave Doppler across mitral valve (upper part) and across tricuspid valve (lower part) showing severe stenotic gradient.
embolization in 1e3% of cases.1 Similarly, tricuspid stenosis (TS) can also be successfully dilated by means of balloon valvotomy. Although combined mitral and tricuspid stenoses are rarely seen, when they exist together without significant tricuspid regurgitation, concurrent percutaneous balloon valvuloplasty3 can be an alternative to surgical treatment in suitable cases. However, experience of valvuloplasty for patients with combined MS and TS is very limited. We report the immediate and intermediate follow-up results of this particular patients with rheumatic tricuspid and mitral valve stenosis who were successfully treated by double
Case report
A 26 year old female presented with exertional fatigue for last 10 years, exertional dyspnea for last 10 years, swelling of the lower limbs for last 5 years with past history suggestive of acute rheumatic fever at her age of 8 years, but was without any penicillin prophylaxis. On examination pulse was 80/min, regular and BP was 100/80 mm Hg, on JVP a wave prominent with blunted y discent. On examination of the cardiovascular system, Apex beat was present in 5th ICS just inside midclavicular line, tapping in character, diastolic thrill in left parasternal area: S1 was loud, S2 was normal. Opening snap was present, low pitch mid-diastolic rumbling murmur with pre-systolic accentuation was present in mitral area which increased on expiration. Another low pitch mid-diastolic murmur was present in lower left parasternal area which increased on inspiration. On examination of abdomen hepatomegaly and mild ascites was present and chest was bilaterally clear. ECG showed biatrial enlargement and sinus rhythm. Chest X-ray shows massive right and also marginal left atrial enlargement with clear lung fields. Echocardiography shows severe mitral stenosis, with MVA of 0.90 cm2 and mean gradient of 9.0 mm Hg with Willkin score of 8 (Fig. 1). Tricuspid valve also shows TVA of 1 cm2 and mean gradient of 4.5 mm Hg (Fig. 1) and also trivial tricuspid regurgitation and mild aortic regurgitation as a consequences of Rheumatic Heart Disease. We planned to perform Percutaneous balloon valvuloplasty of mitral and tricuspid valve with 26 mm size Akura balloon through antegrate approach. Patient's height was 143 cm and weight was 41 kg; Although for BMV, ideally we needed a balloon to be inflated with 25 ml contrast, we initially used 24 ml of contrast to dilate mitral valve (Fig. 2). After measuring post BMV hemodynamics, we proceeded to tricuspid valve which was inflated with the same balloon but with 26 ml contrast (Fig. 2). Post valvuloplasty gradient for mitral and tricuspid valve decreased to 2 mm Hg and 1 mm Hg respectively. MVA and MVA and TVA was 2.04 cm2 and
Fig. 2 e Rao Angiographic View Akura balloon of 26 size inflated inside mitral (left panel) and tricuspid valve (right panel).
34
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 3 2 e3 4
3.14 cm2 respectively without any increase of tricuspid regurgitation and without development of any mitral regurgitation. After 1 year follow-up, patient was symptom free and mean gradient across mitral and tricuspid valve was 3 mm Hg and 1 mm Hg respectively and MVA and TVA was 2.02 cm2 and 3.04 cm2 respectively.
3.
valvuloplasty can be cost effective and non-invasive in patients with combined mitral and tricuspid stenoses with favorable valve morphology. Both the lesion can be addressed in the same sitting with the same balloon which reduces patient discomfort as well as cost. Although long term outcome of mitral balloon valvuloplasty is excellent, the long term outcome of tricuspid balloon valvuloplasty is not known due to rarity of the condition.
Discussion
Isolated rheumatic TS is uncommon, but generally accompanies mitral valve disease. In many patients with TS, the aortic valve is also involved (i.e., trivalvular stenosis is present). TS is found at autopsy in about 15% of patients with rheumatic heart disease but is of clinical significance in only about 5%. Organic tricuspid valve disease is more common in India, Pakistan, and other developing nations near the equator than in North America or Western Europe.4 However, many of the times, tricuspid stenosis is associated with tricuspid regurgitation making it unsuitable for balloon valvuloplasty. Here, we encountered a patient of rheumatic mitral stenosis along with tricuspid stenosis and valve morphology are suitable for balloon valvuloplasty and without any significant TR. Although procedure of balloon mitral valvuloplasty including appropriate balloon sizing are elaborated in different text books, knowledge regarding tricuspid valvuloplasty is very limited in literature, so we tried to perform tricuspid valvuloplasty procedure with same balloon (Akura balloon) with Inoue technique, but with slightly higher contrast material. Concurrent percutaneous balloon
Conflicts of interest All authors have none to declare.
references
1. Ashraf T, Pathan A, Kundi A. Percutaneous balloon valvuloplasty of coexisting mitral and tricuspid stenosis: single-wire, double-balloon technique. J Invasive Cardiol. 2008;20:E126eE128. 2. Sancaktar O, Kumbasar SD, Semiz E, Yalc¸inkaya S. Late results of combined percutaneous balloon valvuloplasty of mitral and tricuspid valves. Cathet Cardiovasc Diagn. 1998 Nov;45(3):246e250. 3. Yunoki K, Naruko T, Itoh A, et al. Percutaneous transcatheter balloon valvuloplasty for bioprosthetic tricuspid valve stenosis. Circulation. 2006;114:e558ee559. 4. Bonow RO, Mann Dl, Zipes DP, Libby P. Braunwald's HEART DISEASE-a textbook of cardiovascular medicine. 9th ed. Elsevier (Saunders); 1490e1516.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jicc
Case Report
A rare combination of rheumatic mitral and tricuspid stenosis treated by percutaneous balloon valvuloplasty Biplab Paul*, Pranab Kumar Biswas, Biswajit Majumder Department of Cardiology, RG Kar Medical College, Kolkata, West Bengal 700004, India
article info
abstract
Article history:
Rheumatic heart disease is still a leading cause of morbidity and mortality in developing
Received 28 May 2014
countries. Rheumatic mitral stenosis is almost always associated with other valvular
Accepted 24 October 2014
lesion; however, combination of rheumatic mitral stenosis nad tricuspid stenosis is very
Available online 25 November 2014
rare. We encountered a patient of rheumatic MS & TS and planed to treat both the valves with balloon valvuloplasty. We performed balloon valvuloplasty of both the valves with
Keywords:
26 mm size Akura balloon in same setting. Post-procedure and one year follow-up data was
Echocardiography
excellent.
Cardiovascular examination
Copyright © 2014, Indian College of Cardiology. All rights reserved.
Mitral stenosis Tricuspid stenosis Valvuloplasty
1.
Introduction
Learning objective Although Rheumatic heart disease is very common in our country, combination of pure mitral and tricuspid stenosis without other valve involvement is rare. Balloon valvuloplasty is the procedure of choice in case of MS, but whether, TS can be treated in similar manner or with same balloon is not clear. Here, we performed both valvuloplasty with same balloon in same sitting and just want to share our experience with the reader of your popular journal.
Percutaneous balloon mitral valvuloplasty (BMV) has been established as the procedure of choice for symptomatic mitral stenosis with suitable valve morphology. It has replaced surgery for the treatment of mitral stenosis (MS) in selected patients since its introduction by Inoue et al in 1984.1 It affords an event-free survival rate greater than 90% at 5e7 years.1,2 Acute and long-term results of balloon mitral valvuloplasty is comparable to open surgical commissurotomy and better than closed mitral commisurotomy and are occasionally associated with complications such as death in 0e1% of cases, moderate or severe valvular regurgitation in 3e5% of cases, and systemic
* Corresponding author. Tel.: þ91 9674941651. E-mail address: [email protected] (B. Paul). http://dx.doi.org/10.1016/j.jicc.2014.10.006 1561-8811/Copyright © 2014, Indian College of Cardiology. All rights reserved.
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 3 2 e3 4
33
valvuloplasty using Inoue techniques (Akura balloon) as a single stage procedure with good results and recovery.
2.
Fig. 1 e Echocardiography: continous wave Doppler across mitral valve (upper part) and across tricuspid valve (lower part) showing severe stenotic gradient.
embolization in 1e3% of cases.1 Similarly, tricuspid stenosis (TS) can also be successfully dilated by means of balloon valvotomy. Although combined mitral and tricuspid stenoses are rarely seen, when they exist together without significant tricuspid regurgitation, concurrent percutaneous balloon valvuloplasty3 can be an alternative to surgical treatment in suitable cases. However, experience of valvuloplasty for patients with combined MS and TS is very limited. We report the immediate and intermediate follow-up results of this particular patients with rheumatic tricuspid and mitral valve stenosis who were successfully treated by double
Case report
A 26 year old female presented with exertional fatigue for last 10 years, exertional dyspnea for last 10 years, swelling of the lower limbs for last 5 years with past history suggestive of acute rheumatic fever at her age of 8 years, but was without any penicillin prophylaxis. On examination pulse was 80/min, regular and BP was 100/80 mm Hg, on JVP a wave prominent with blunted y discent. On examination of the cardiovascular system, Apex beat was present in 5th ICS just inside midclavicular line, tapping in character, diastolic thrill in left parasternal area: S1 was loud, S2 was normal. Opening snap was present, low pitch mid-diastolic rumbling murmur with pre-systolic accentuation was present in mitral area which increased on expiration. Another low pitch mid-diastolic murmur was present in lower left parasternal area which increased on inspiration. On examination of abdomen hepatomegaly and mild ascites was present and chest was bilaterally clear. ECG showed biatrial enlargement and sinus rhythm. Chest X-ray shows massive right and also marginal left atrial enlargement with clear lung fields. Echocardiography shows severe mitral stenosis, with MVA of 0.90 cm2 and mean gradient of 9.0 mm Hg with Willkin score of 8 (Fig. 1). Tricuspid valve also shows TVA of 1 cm2 and mean gradient of 4.5 mm Hg (Fig. 1) and also trivial tricuspid regurgitation and mild aortic regurgitation as a consequences of Rheumatic Heart Disease. We planned to perform Percutaneous balloon valvuloplasty of mitral and tricuspid valve with 26 mm size Akura balloon through antegrate approach. Patient's height was 143 cm and weight was 41 kg; Although for BMV, ideally we needed a balloon to be inflated with 25 ml contrast, we initially used 24 ml of contrast to dilate mitral valve (Fig. 2). After measuring post BMV hemodynamics, we proceeded to tricuspid valve which was inflated with the same balloon but with 26 ml contrast (Fig. 2). Post valvuloplasty gradient for mitral and tricuspid valve decreased to 2 mm Hg and 1 mm Hg respectively. MVA and MVA and TVA was 2.04 cm2 and
Fig. 2 e Rao Angiographic View Akura balloon of 26 size inflated inside mitral (left panel) and tricuspid valve (right panel).
34
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 3 2 e3 4
3.14 cm2 respectively without any increase of tricuspid regurgitation and without development of any mitral regurgitation. After 1 year follow-up, patient was symptom free and mean gradient across mitral and tricuspid valve was 3 mm Hg and 1 mm Hg respectively and MVA and TVA was 2.02 cm2 and 3.04 cm2 respectively.
3.
valvuloplasty can be cost effective and non-invasive in patients with combined mitral and tricuspid stenoses with favorable valve morphology. Both the lesion can be addressed in the same sitting with the same balloon which reduces patient discomfort as well as cost. Although long term outcome of mitral balloon valvuloplasty is excellent, the long term outcome of tricuspid balloon valvuloplasty is not known due to rarity of the condition.
Discussion
Isolated rheumatic TS is uncommon, but generally accompanies mitral valve disease. In many patients with TS, the aortic valve is also involved (i.e., trivalvular stenosis is present). TS is found at autopsy in about 15% of patients with rheumatic heart disease but is of clinical significance in only about 5%. Organic tricuspid valve disease is more common in India, Pakistan, and other developing nations near the equator than in North America or Western Europe.4 However, many of the times, tricuspid stenosis is associated with tricuspid regurgitation making it unsuitable for balloon valvuloplasty. Here, we encountered a patient of rheumatic mitral stenosis along with tricuspid stenosis and valve morphology are suitable for balloon valvuloplasty and without any significant TR. Although procedure of balloon mitral valvuloplasty including appropriate balloon sizing are elaborated in different text books, knowledge regarding tricuspid valvuloplasty is very limited in literature, so we tried to perform tricuspid valvuloplasty procedure with same balloon (Akura balloon) with Inoue technique, but with slightly higher contrast material. Concurrent percutaneous balloon
Conflicts of interest All authors have none to declare.
references
1. Ashraf T, Pathan A, Kundi A. Percutaneous balloon valvuloplasty of coexisting mitral and tricuspid stenosis: single-wire, double-balloon technique. J Invasive Cardiol. 2008;20:E126eE128. 2. Sancaktar O, Kumbasar SD, Semiz E, Yalc¸inkaya S. Late results of combined percutaneous balloon valvuloplasty of mitral and tricuspid valves. Cathet Cardiovasc Diagn. 1998 Nov;45(3):246e250. 3. Yunoki K, Naruko T, Itoh A, et al. Percutaneous transcatheter balloon valvuloplasty for bioprosthetic tricuspid valve stenosis. Circulation. 2006;114:e558ee559. 4. Bonow RO, Mann Dl, Zipes DP, Libby P. Braunwald's HEART DISEASE-a textbook of cardiovascular medicine. 9th ed. Elsevier (Saunders); 1490e1516.