Use of three-dimensional transesophageal echocardiography to evaluate mitral valve morphology for risk stratification prior to mitral valvuloplasty

Mitral stenosis is often managed percutaneously with an interventional procedure such as balloon commissurotomy. Although this often results in an increased mitral valve area and improved clinical symptoms, this procedure is not benign and may have serious complications including the development of hemodynamically significant mitral valve regurgitation. Multiple scoring systems have been developed to attempt to risk stratify these patients prior to their procedure. Case: A 64-year-old patient underwent an emergent mitral valve replacement after having percutaneous mitral balloon commissurotomy complicated by development of severe mitral regurgitation. Prior to valvuloplasty, her mitral valve was evaluated by traditional methods including calculation of a Wilkins score. Her mitral valve was evaluated after valvuloplasty and preoperatively with three-dimensional transesophageal echocardiography. This examination demonstrated heterogeneous distribution of calcification affecting the mitral valve commissures more than the leaflets, which is consistent with the noncommissural leaflet tearing that occurred during her procedure, causing severe mitral regurgitation. In the future, careful 3D evaluation of mitral valve morphology including leaflets, annular calcification, and subvalvular apparatus may help risk stratify patients prior to intervention.