Mitral Valve Laceration and Papillary Muscle Rupture Secondary to Percutaneous Balloon Aortic Valvuloplasty*
vanced into the left ventricle. Resting hemodynamics showed an aortic valve area of 0.65 cm2. A Berman wedge catheter was advanced across the aortic valve, and a 0.035 260 cm Andrew Farb, MD, Joel R. Galloway, MD, Richard C. Davis, MD, Allen P. extra stiff J-wire was advanced into Burke, MD, and Renu Virmani, MD the descending aorta. The interatrial septum was dilated with an 8 mm ercutaneous balloon aortic val- ported, and may have a lower inci- balloon catheter. A 20 mm balloon vuloplasty (PBAV) has been denceof bleeding and arterial dam- catheter was positioned across the usedsuccessfullyasa palliative treat- age.5 This report describes mitral aortic valve where it was inflated for ment in patients with critical aortic valve laceration and papillary muscle 15 seconds without hemodynamic stenosis.1,2These patients are often rupture associatedwith anterograde compromise, followed by deflation. elderly and are not candidates for transeptal PBAV, a complication not A second inflation was then performed for 15 seconds, and on balaortic valve replacement.3Alterna- previously reported. tively, PBAV hasbeenusedasa temA 70-year-old white man with a loon deflation, the patient developed porizing measure in patients with mass in the head of the pancreas was profound hypotension with rapid aortic stenosis and other medical referred for prelaparotomy PBAV progression to electromechanical conditions that need more urgent for critical aortic stenosis. Transthotreatment.4The procedureis typical- racic Doppler echocardiography ly performed by retrograde heart demonstrated a calcified aortic valve catheterization; however, antero- with diminished opening, left vengrade transeptal PBAV has beenre- tricular hypertrophy and normal left ventricular function. The peak inFrom the Department of Cardiovascular Pa- stantaneous aortic valve gradient thology, Armed ForcesInstitute of Pathology, was 90 to 100 mm Hg, and the calcuWashington, DC. 20306-6000,and the Divi- lated aortic valve area (continuity sion of Cardiology, FitzsimonsArmy Medical equation) was 0.5 to 0.6 cm2. No Center, Aurora, Colorado. Manuscript received September 11, 1991; revised manu- aortic regurgitation was detected. Coronary arteriography revealed script receivedDecember9, 1991, and acceptedDecember 11. minor luminal irregularities. TranbaBoon inseptal left-sided cardiac catheter- flGURE 1. VsMoplasty *The opinions and assertions contained ization was performed with an 8Fr flatedprdmaNyinkRvenbkdarcavherein are the private views of the authorsand ityWlthlKCUtt2CWlglMhOfbaloonlll are not to be construedas official or reflecting Mullin’s transeptal sheath and dilainfbwregionofleftvemtfide.Gdydisthe views of the Department of the Army or tor, with a Brockenbrough needle. A talportionofbdoonisacross eakliied the Department of Defense. 7Fr Berman wedge catheter was ad- aertlc valve (astedsk).
P
CASE REPORTS 829
dissociation. Resuscitative efforts were unsuccessful. Retrospective review of the cineangiography revealed that the balloon appeared to be acutely angled and indented as it traversed the left ventricular inflow tract to the outflow tract (Figure 1). At autopsy, the aortic valve was heavily calcified, severely stenotic and congenitally bicuspid (Figure 2A). An acute laceration was present at the anterolateral commissure between the mitral valve leaflets. Several chordae to the anterior leaflet were torn (Figure 2B). The posteromedial papillary muscle was ruptured (Figure 2, B and C). Microscopically, at the rupture sites there was a thin layer of platelets and fibrin deposition without evidence of necrosis of the adjacent myocytes (Figure 20).
Generally, most PBAV-associated complications have been described for retrograde valvuloplasty. Major complications occur in
vanced into the left ventricle. Resting hemodynamics showed an aortic valve area of 0.65 cm2. A Berman wedge catheter was advanced across the aortic valve, and a 0.035 260 cm Andrew Farb, MD, Joel R. Galloway, MD, Richard C. Davis, MD, Allen P. extra stiff J-wire was advanced into Burke, MD, and Renu Virmani, MD the descending aorta. The interatrial septum was dilated with an 8 mm ercutaneous balloon aortic val- ported, and may have a lower inci- balloon catheter. A 20 mm balloon vuloplasty (PBAV) has been denceof bleeding and arterial dam- catheter was positioned across the usedsuccessfullyasa palliative treat- age.5 This report describes mitral aortic valve where it was inflated for ment in patients with critical aortic valve laceration and papillary muscle 15 seconds without hemodynamic stenosis.1,2These patients are often rupture associatedwith anterograde compromise, followed by deflation. elderly and are not candidates for transeptal PBAV, a complication not A second inflation was then performed for 15 seconds, and on balaortic valve replacement.3Alterna- previously reported. tively, PBAV hasbeenusedasa temA 70-year-old white man with a loon deflation, the patient developed porizing measure in patients with mass in the head of the pancreas was profound hypotension with rapid aortic stenosis and other medical referred for prelaparotomy PBAV progression to electromechanical conditions that need more urgent for critical aortic stenosis. Transthotreatment.4The procedureis typical- racic Doppler echocardiography ly performed by retrograde heart demonstrated a calcified aortic valve catheterization; however, antero- with diminished opening, left vengrade transeptal PBAV has beenre- tricular hypertrophy and normal left ventricular function. The peak inFrom the Department of Cardiovascular Pa- stantaneous aortic valve gradient thology, Armed ForcesInstitute of Pathology, was 90 to 100 mm Hg, and the calcuWashington, DC. 20306-6000,and the Divi- lated aortic valve area (continuity sion of Cardiology, FitzsimonsArmy Medical equation) was 0.5 to 0.6 cm2. No Center, Aurora, Colorado. Manuscript received September 11, 1991; revised manu- aortic regurgitation was detected. Coronary arteriography revealed script receivedDecember9, 1991, and acceptedDecember 11. minor luminal irregularities. TranbaBoon inseptal left-sided cardiac catheter- flGURE 1. VsMoplasty *The opinions and assertions contained ization was performed with an 8Fr flatedprdmaNyinkRvenbkdarcavherein are the private views of the authorsand ityWlthlKCUtt2CWlglMhOfbaloonlll are not to be construedas official or reflecting Mullin’s transeptal sheath and dilainfbwregionofleftvemtfide.Gdydisthe views of the Department of the Army or tor, with a Brockenbrough needle. A talportionofbdoonisacross eakliied the Department of Defense. 7Fr Berman wedge catheter was ad- aertlc valve (astedsk).
P
CASE REPORTS 829
dissociation. Resuscitative efforts were unsuccessful. Retrospective review of the cineangiography revealed that the balloon appeared to be acutely angled and indented as it traversed the left ventricular inflow tract to the outflow tract (Figure 1). At autopsy, the aortic valve was heavily calcified, severely stenotic and congenitally bicuspid (Figure 2A). An acute laceration was present at the anterolateral commissure between the mitral valve leaflets. Several chordae to the anterior leaflet were torn (Figure 2B). The posteromedial papillary muscle was ruptured (Figure 2, B and C). Microscopically, at the rupture sites there was a thin layer of platelets and fibrin deposition without evidence of necrosis of the adjacent myocytes (Figure 20).
Generally, most PBAV-associated complications have been described for retrograde valvuloplasty. Major complications occur in
