Percutaneous Balloon Dilatation of Mitral Valve Stenosis and Aortic Coarctation

Association of coarctation of aorta and rheumatic mitral stenosis is rare and makes the simultaneous surgical approach of both lesions difficult. We present a case of the successful dilatation of aortic coarctation and mitral stenosis, peformed in the same intervention. Case Report. A 19-year-old woman, who presented with dyspnea on exertion and high blood pressure, was admitted for evaluation and treatment of arterial hypertension. Physical examination revealed symmetrical blood pressure of 180/180 mmHg in both upper limbs and absence of pulses in the lower limbs, where systolic pressure measured 80 mmHg (Doppler assay). On auscultation, heart sounds were regular at a rate of 70 beats/minute, with a 3/6 midcardiac systolic murmur as well as mild diastolic and interscapular systolic murmurs. Electrocardiography detected left atrium hypertrophy and non-specific ST-T changes in the lateral leads. Echocardoigraphy showed left ventricular hypertrophy with 14 mm wall thickness and, surprisingly, a 1 cm2 mitral stenosis with non-calcific valves, minimal valvular and subvalvular thickening, and a mean Doppler gradient of 12 mmHg. The transisthmic gradient was assessed with difficulty and was approximated at 74 mmHg. Transesophageal echocardiography excluded the congenital nature of the mitral stenosis, the lack of thrombi in the left atrium, and the typical aspect of rheumatic deformation of the mitral valve (Figure 1). Under these circumstances, cardiac catheterization was performed, excluding a left-to-right shunt, revealing a 50/35/20 mmHg pressure in the pulmonary artery, a 0.9 cm2 mitral area and a 72 mmHg aortic transisthmic gradient. Angiographies confirmed a tight isthmic coarctation with well-developed collateral circulation, an efficient left ventricle and competent mitral and aortic valves. In the same intervention, the mitral valve was initially dilated via the Inoue technique using a 28 Toray balloon at a nominal value of 28 mm. The mean gradient decreased from 14 mmHg to 4 mmHg without the occurrence of mitral regurgitation (Figure 2). Afterward, the isthmic aorta was dilated with a 14-mm diameter, 4-cm long Tyshac-Braun balloon (Figure 3). The final gradient was 11 mmHg (Figure 4), with a satisfactory angiographic aspect of the isthmic aorta (minimal dissection) (Figure 5). The patient was discharged normotensive, with a unitary ankle index at the Doppler examination and a 2.1 cm2 mitral valve area on cardiac ultrasound (using the planimetric method). The patient returned for evaluation 2 years after the procedure. She was 3 months pregnant, with a blood pressue of 150/80, tachycardia of 95 beats/minute, transisthmic gradient of 10 mmHg and a 2 cm2 mitral area. Under sodium restrictoin, moderate rest and beta-blocker during the last trimester of pregnancy, the outcome was favorable and the patient gave birth at term through Cesarean section without complications for the mother or the newborn. Discussion. Despite the fact that there is nothing new from a technical perspective in this report, we think that it is interesting because the clinical case is so unusual (the patient had both congenital and rheumatic heart defects) and the patient was well served with a single interventional catheterization. Dilatation of multiple valves in the same intervention has been sporadically reported, especially for associated congenital malformations.1 In this case, the peculiarity consisted of the association of a rheumatic juvenile stenosis with a coarctation of the aorta (the latter usually associates with congenital mitral stenosis, which was excluded in our patient by ultrasound and the excellent outcome post-dilatation.)2-4 This rare association raised an extra therapeutic impediment; the surgical intervention in adults is sequential, imposing two thoracotomies or a median sternotomy with graft interposition for aortic coarctation, between the ascending aorta and proximal abdominal aorta.5 The role of the balloon dilatation in mitral stenosis and in coarctation of the aorta is well known, so that their complement can only confer the same good prognosis, needing only isthmic aorta evaluation to detect any possible aneurysm.6

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