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Case Report
Valvuloplasty of a Stenosed Mitral Valve Bioprothesis
June 2010
ABSTRACT: An 86-year-old female patient was admitted to our hospital with a stenosed biological mitral valve prothesis (orifice area 0.75 cm2). Additional cardiac surgery was refused by the patient and her physician. Therefore, balloon valvuloplasty of the mitral valve bioprothesis was planned. Valvulopasty was successfully and safely performed using a standard mitral valve valvuloplasty protocol. Positioning of the Inoue-balloon was facilitated using a wire that was inserted into the left ventricle and simultaneous transthoracic echocardiography. The Inoue balloon was inflated twice (26 mm). After valvuloplasty, echocardiography was repeated, showing a reduction in mean pressure gradient (5 mmHg) and increased orifice area (1.2 cm2) without relevant mitral valve regurgitation.
J INVASIVE CARDIOL 2010;22:E97–E98
Key words: Inoue balloon, balloon valvuloplasty
Case Report. An 86-year old female patient was admitted to our hospital suffering from severe dyspnea on mild exertion (NYHA III). Her past medical history included coronary artery disease and severe mitral valve regurgitation. Nine years previously, she had received combined aortocoronary bypass surgery and mitral valve replacement using a pericardial bioprothesis (31 mm). Initial follow-up examinations showed a good surgical result without any mitral prothesis dysfunction. In addition, the patient suffered from mild pulmonary hypertension (systolic pulmonary artery pres- sure of 40 mmHg), atrial fibrillation and moderate chronic obstructive pulmonary disease. Transthoracic and transesophageal echocardiography revealed degeneration of the mitral valve bioprothesis with significant stenosis (mean pressure gradient 9 mmHg and orifice area of 0.75 cm2) and grade I regurgitation. Additional cardiac surgery was refused by the patient and her attending physicians. Therefore, balloon valvuloplasty of the mitral valve bioprothesis was planned. The patient was informed about specific risks of this procedure and of worldwide limited experience with bioprothesis valvuloplasties.
Valvulopasty was successfully performed using a standard mitral valve valvuloplasty protocol. An Inoue-balloon catheter (12 Fr, 26 mm) was inserted into the left atrium via transseptal puncture. Balloon positioning was facilitated using a wire that was inserted into the left ventricle and simultaneous transthoracic echocardiography (Figure 1). The Inoue-balloon was inflated twice with an inflation diameter of 26 mm. After valvuloplasty, left atrial pressure curves did not demonstrate relevant mitral regurgitation. This was confirmed by left ventricular angiography, still showing grade I regurgitation. Next day, echocardiography was repeated, showing a reduction in mean pressure gradient (5 mmHg) and increased orifice area (1.2 cm2). The patient recovered quickly from this procedure with some hematoma at the puncture site. No relevant postprocedural complications were noted, and the patient was discharged from our hospital two days after valvuloplasty in good condition. A telephone interview after three months confirmed our initial success with a reduction of the required diuretics and an improvement of dyspnea to NYHA II.
Discussion. This case report describes a rare but feasible procedure that may become more important in the future. In the last decade the absolute number of implanted bioprotheses and the ratio to mechanical protheses has increased. Looking at data from the German institute for prospective payment (InEK), the total number of implanted protheses between 2003 and 2007 has nearly doubled and the percentage of bioprotheses has increased from 53% to 72%. This phenomenon is partly due to the aging population and improved outcome of valve surgery, even in elderly patients. In consequence, it is very likely that interventional cardiologists will be confronted with an in- creasing number of degenerated bioprotheses in the future, since overall life expectancy in this population will further increase. Therefore, new interventional strategies will become relevant.
Reviewing the literature, we found many controversial opinions on this topic. Some authors have warned against performing valvuloplasty of mitral valve protheses,1 others have discussed this technique as feasible but associated with high risks.2 Most single case reports describe it as safe.3,4 Due to these varying opinions and limited experience, we believe that more case reports are needed to establish a base for future expert recommendation. In this single case experience, probing of the mitral valve prothesis with the Inoue-balloon was surprisingly more difficult technically than we would normally experience with native stenosed mitral valves. Thus, we used a wire to guide the balloon, in contrast to the general recommendations for native mitral valves. This new and safe aspect should be considered for valvuloplasty of mitral valve bioprostheses.
Valvulopasty was successfully performed using a standard mitral valve valvuloplasty protocol. An Inoue-balloon catheter (12 Fr, 26 mm) was inserted into the left atrium via transseptal puncture. Balloon positioning was facilitated using a wire that was inserted into the left ventricle and simultaneous transthoracic echocardiography (Figure 1). The Inoue-balloon was inflated twice with an inflation diameter of 26 mm. After valvuloplasty, left atrial pressure curves did not demonstrate relevant mitral regurgitation. This was confirmed by left ventricular angiography, still showing grade I regurgitation. Next day, echocardiography was repeated, showing a reduction in mean pressure gradient (5 mmHg) and increased orifice area (1.2 cm2). The patient recovered quickly from this procedure with some hematoma at the puncture site. No relevant postprocedural complications were noted, and the patient was discharged from our hospital two days after valvuloplasty in good condition. A telephone interview after three months confirmed our initial success with a reduction of the required diuretics and an improvement of dyspnea to NYHA II.
Discussion. This case report describes a rare but feasible procedure that may become more important in the future. In the last decade the absolute number of implanted bioprotheses and the ratio to mechanical protheses has increased. Looking at data from the German institute for prospective payment (InEK), the total number of implanted protheses between 2003 and 2007 has nearly doubled and the percentage of bioprotheses has increased from 53% to 72%. This phenomenon is partly due to the aging population and improved outcome of valve surgery, even in elderly patients. In consequence, it is very likely that interventional cardiologists will be confronted with an in- creasing number of degenerated bioprotheses in the future, since overall life expectancy in this population will further increase. Therefore, new interventional strategies will become relevant.
Reviewing the literature, we found many controversial opinions on this topic. Some authors have warned against performing valvuloplasty of mitral valve protheses,1 others have discussed this technique as feasible but associated with high risks.2 Most single case reports describe it as safe.3,4 Due to these varying opinions and limited experience, we believe that more case reports are needed to establish a base for future expert recommendation. In this single case experience, probing of the mitral valve prothesis with the Inoue-balloon was surprisingly more difficult technically than we would normally experience with native stenosed mitral valves. Thus, we used a wire to guide the balloon, in contrast to the general recommendations for native mitral valves. This new and safe aspect should be considered for valvuloplasty of mitral valve bioprostheses.
References
1. Lin PJ, Chang JP, Chu JJ, et al. Balloon valvuloplasty is contraindicated in stenotic mitral bioprostheses. Am Heart J 1994;127:724–726. 2. Waller BF, McKay C, VanTassel J, Allen M. Catheter balloon valvuloplasty of stenotic porcine bioprosthetic valves: Part II: Mechanisms, complications, and recommendations for clinical use. Clin Cardiol 1991;14:764–772. 3. Hurst FP, Caravalho J Jr, Wisenbaugh TW. Prosthetic mitral valvuloplasty. Catheter Cardiovasc Interv 2004;63:503–506. 4. Babic UU, Grujicic S, Vucinic M. Balloon valvoplasty of mitral bioprosthesis. Int J Cardiol 1991;30:230–232.
_________________________________________________ From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany. The authors report no conflicts of interest regarding the content herein. Manuscript submitted October 15, 2009, provisional acceptance November 3, 2009, final version accepted November 9, 2009. Address for correspondence: Raffi Bekeredjian, MD, Department of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany. E-mail: raffi.bekeredjian@med.uni-heidelberg.de
