Emergency mitral valve replacement for traumatic mitral insufficiency following balloon mitral valvotomy: an early...

Acute severe mitral insufficiency may occur during percutaneous transvenous balloon mitarl valvotomy. Urgent surgical intervention in the form of mitral valve repair or replacement may be necessary in these patients. The haemodynamic measurements at various stages in these patients were obtained and compared with those of patients undergoing elective mitral valve replacement for chronic mitral regurgitation. Between September 1995 and December 1947, urgent mitral valve replacement was performed in 14 patients out of a total of 1688 patients who underwent balloon mitral valvotomy. Haemodynamic measurements could be obtained in 7 of these patients and they constituted group I. Eight other patients undergoing elective mitral valve replacement during the same period for chronic mitral regurgitation constituted group II. Standard haemodynamic measurements were obtained at the following stages: (1) Baseline- 20-30 min after endotracheal intubation; (2) stage 1- 20-30 min after termination of the cardiopulmonary bypass: (3) stage 2- four hours after the patient was transferred to ICU and (4) stage 3-30 min after extubation. All the patients were suffering from severe pulmonary hypertension. However, the indices of pulmonary artery hypertension such as mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance as well as right ventricular systolic and end-diastolic pressures did not decrease after surgery in group I. In contrast, in group II, there was significant decrease in mean pulmonary artery pressure (p<0.05), pulmonary capillary wedge pressure (p<0.05), right ventricular systolic (p<0.001) and end-diastolic pressures (p<0.05) at stage 1. These changes persisted throughout the study period. Pulmonary vascular resistance showed a decreasing trend, but attained statistical significance at stage 1 only. Two patients died; one of intractable cardiac failure and another from septicaemia and multiple organ failure in group I, but there were no deaths in group II. Reactive pulmonary hypertension secondary to acute mitral regurgitation may not recover immediately following mitral valve replacement and may be responsible for poor outcome in these patients.