Gross echocardiographic underestimation of mitral valve calcification--a near fatal experience

Acute severe mitral regurgitation is a feared complication following percutaneous balloon mitral valvuloplasty (PBMV) for the treatment of severe mitral stenosis, contributing to the 1% peri-procedural mortality rate of this procedure. Whilst there is an extensive experience with the use of the Wilkins echocardiographic score to assess patient suitability and predict long-term clinical outcomes following PBMV, catastrophic severe acute mitral regurgitation, such as that described in our patient, is a remarkably rare occurrence following PBMV in patients with favourable Wilkins echocardiographic criteria. We highlight a case of the gross underestimation of the degree of valvular calcification using trans-oesophageal echocardiography, when compared to the findings at surgery, which contributed to our patients' life-threatening mitral regurgitation following the first balloon inflation. We advocate further research into the utility of multi-detector computed tomography (MDCT) imaging for the adjunctive pre-procedural assessment of the degree mitral calcification in order to further minimise the risk of peri-procedural complications associated with PBMV. This would be particularly suitable in the elderly population who normally have greater degrees of valvular calcification that may be underestimated with echocardiography alone.