Popping Out of BMV Balloon: A Rare Sign in Subvalvular Mitral Stenosis-A Clinical Image

Ete T, Malviya A, Kapoor K, Kumar A, Kumar U and Mishra A

Published on: 2020-03-18

Abstract

A 38 years old male presented with history of dyspnoea, orthopnoea and paroxysmal nocturnal dyspnoea for seven to eight months. Patient also had history of swelling of both lower limbs. Patient had a childhood history suggestive of inflammatory polyarthritis involving mainly the large joints of lower limbs and migratory in nature and pain got relieved on taking oral medications. Examination of the patient revealed loud S1 and mid diastolic rumbling murmur in apex. The patient also had hepatomegaly.

Keywords

Mitral stenosis; Balloon mitral valvotomy; Mitral valve

Clinical Images

A 38 years old male presented with history of dyspnoea, orthopnoea and paroxysmal nocturnal dyspnoea for seven to eight months. Patient also had history of swelling of both lower limbs. Patient had a childhood history suggestive of inflammatory polyarthritis involving mainly the large joints of lower limbs and migratory in nature and pain got relieved on taking oral medications. Examination of the patient revealed loud S1 and mid diastolic rumbling murmur in apex. The patient also had hepatomegaly. Echocardiography revealed thickened rheumatic mitral leaflets with a Mitral Valve Area (MVA) of 0.8 sq.cm, moderate to severe tricuspid regurgitation (TR) and evidence of severe pulmonary artery hypertension (PAH). Left atrial spontaneous echo contrast (SEC) was also seen in echocardiography with features suggestive of smoking mitral valve [1]. After proper counseling the patient was taken for Balloon Mitral Valvotomy (BMV). Diagnostic catheterization was carried out. The mean left atrial pressure was 28 mmHg. After septal puncture, manipulation of the balloon catheter to ?ow across the stenotic mitral valve into the left ventricle was smooth and unimpeded. The distal balloon was inflated and the catheter moved freely in the LV and then the catheter was pulled back to anchor the balloon at the stenotic mitral valve (MV). As the proximal balloon was being in?ated, the distal one was levered upwards, especially in the systolic phase. At the end of full in?ation, the balloon catheter was expelled back into the left atrium (LA) (Figure 1). As the balloon size was increased, the balloon catheter popped out more quickly and more forcefully. Each attempt at balloon dilatation ended up with the catheter popping back into the left atrium, even after advancement of the distal segment of the catheter shaft slightly after the BMV balloon attained its hourglass shape. This balloon ‘popping’ signifies enlargement of the mitral ori?ce and is usually seen in patients with pliable and noncalcified valves. In certain patients with proper anatomy it usually indicates excellent BMV results [2]. However, lifting-up of the distal balloon during in?ation of the proximal one and popping-out of the balloon catheter near the end of full in?ation can also occur in a patient with a severe subvalvular mitral stenosis and can results in a poor BMV result [3].

Figure 1:  Figure showing Balloon inflation during balloon mitral valvotomy (BMV). After inflation of the distal balloon, the balloon catheter was pulled back and anchored at the mitral valve (MV). The distal balloon was handled up during inflation of the proximal one. The balloon catheter “popped out” of the left ventricle (LV) quickly and with force.

References