Our patient did well post mitral balloon valvuloplasty. Her mitral valve gradient was markedly reduced on pressure tracings immediately following the procedure. She was maintained on medications to control her residual atrial arrhythmia and she gradually became asymptomatic and resumed a normal lifestyle.
The following mitral balloon valvuloplasty procedure is presented through the courtesy of Dr. Peter C. Block, and was carried out at the Massachusetts General Hospital. Our plan today is to do a percutaneous balloon mitral valvotomy using the double balloon technique to open her stenotic mitral valve. At the present time, we have a catheter in her right internal jugular vein, which will be used for a swan-ganz line to measure cardiac output and we have done a right femoral venous puncture and a small wire guide is in place in the superior vena cava, having been threaded up. So, we will move right ahead to the transseptal procedure, and Dr. Palacios and I will perform that. Pressure is monitored constantly on the zero-to-forty scale on the pressure monitor as we do this procedure… and the position is very excellent. Rob, one is yours, one is for me. Should be able to see a waist in these as we inflate them, and we always tell the patient that they may feel a little funny, because the blood pressure does drop. One, two, three, go. The balloons are coming up. The position is very good… there is the waist and I think we got it. Deflate. Blood pressure dropped to around 60 with rate… slight slowing, but the rate now is good and the blood pressure is coming back. I think we should advance just a little more if we can. Ehem… we are going to try to advance these balloons just a little bit now that we have opened the valve a little. That is a better position, and we are ready to go again. Ready? One, two, three, inflate… and deflate.
Although this procedure was performed using a double balloon technique, recent advances now permit this to be done with a single balloon. These are the left ventricular and left atrial pressure curves obtained pre and post balloon valvuloplasty. They clearly show a markedly diminished post valvuloplasty gradient, typical of a successful result.
The following open commissurotomy is presented through the courtesy of Drs. Robert Hall and Denton Cooley, and was carried out at the Texas Heart Institute. Open mitral commissurotomy is most often the procedure of choice when balloon valvuloplasty is unsuccessful or contraindicated, and valve replacement is not required. A special atrial retractor is used to expose the badly diseased mitral valve. The anterolateral and posteromedial commissures are fused and the mitral valve orifice is markedly stenotic. It is well seen in the central portion of the valvular area. Incision of the commissures and dissection of the papillary muscles and chordae will next be carried out to mobilize the leaflets. Scissors are used to divide the anterolateral commissure, followed by subvalvular dissection of the papillary muscles and the chordae tendineae. Note that releasing the anterolateral commissure has significantly increased the size of the orifice. A scalpel is next used to incise the posteromedial commissure and the markedly thickened chordae tendineae are well seen. The left ventricular chamber is seen beneath the valve plane. Although there is residual disease with thickening of the mitral leaflets and some calcification, the valve is now moderately pliable and the mitral valve orifice has been markedly increased.