A 32-year old woman comes to the physician because of shortness of breath while walking uphill or climbing steps for the last 3 months. She immigrated with her family to the United States from Thailand 15 years ago. She is a nurse's aide and had a recent work physical performed prior to starting a new job. The physician noted "irregular heart sounds" and performed an EKG, which showed atrial fibrillation with a ventricular rate of 85 beats per minute.
A transthoracic echocardiogram showed normal left ventricular size and function with an ejection fraction of 60%. The left atrium was severely dilated and the mitral valve leaflets were thickened with restricted motion and mild focal calcification. The mitral valve area was calculated at 1.0 cm² (normal 4-6 cm²) with a moderate degree of mitral regurgitation. The aortic valve was trileaflet without stenosis or regurgitation. There was moderate tricuspid regurgitation with an estimated pulmonary artery systolic pressure of 72 mm Hg, consistent with severe pulmonary hypertension (normal < 30 mm Hg) .
Which of the following is a contraindication to percutaneous mitral balloon valvotomy in this patient?

Question

Quizplus · Accepted Answer

Based on the above findings, this patient has severe symptomatic mitral stenosis (MS) and needs further therapy to relieve the obstruction to prevent long-term complications. The decision to proceed with percutaneous mitral balloon valvotomy (PMBV) vs. surgical commissurotomy is based on the valve morphology, degree of mitral regurgitation, and the presence or absence of contraindications for PMBV. Mitral valvotomy is generally the preferred approach in all patients who have a suitable valvular morphology. It is contraindicated in patients with a moderate or severe degree of mitral regurgitation, and in patients with a left atrial thrombus that persists despite adequate anticoagulation. Surgical mitral valve repair is indicated in patients with contraindications for PMBV and with congenital MS (due to complex valve anatomy). (Choice A) The presence of atrial fibrillation alone does not preclude attempts at PMBV. A transesophageal echocardiogram should be performed in all patients to exclude left atrial thrombus prior to mitral valvotomy. (Choice B) The extent of calcification of the mitral valve leaflets is one of the factors considered in the decision making process prior to mitral valvotomy. This patient has only mild and focal calcification of the leaflets, which alone should not preclude percutaneous balloon mitral valvotomy. (Choice D) The size of left atrium is not a contraindication for percutaneous mitral balloon valvotomy. (Choice E) The presence or development of pulmonary hypertension (> 50 mm Hg at rest or > 60 mm Hg with exercise) is an indication for mitral valvotomy in asymptomatic patients with moderate or severe MS, favorable valve morphology, and absence of left atrial thrombus. Educational objective: Percutaneous mitral balloon valvotomy is preferred in patients with symptomatic moderate or severe mitral stenosis with favorable valvular morphology. It is contraindicated in patients with a moderate or severe degree of mitral regurgitation and/or left atrial thrombus. __________ References: Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). (http://www.ncbi.nlm.nih.gov/pubmed/18574274) Percutaneous mitral valve balloon valvulotomy: technique, indications and results. (http://www.ncbi.nlm.nih.gov/pubmed/7846430)

A 32-Year Old Woman Comes to the Physician Because of Shortness