Rossignon Pierre, Morra Sofia, de Hemptinne Quentin, de Cannière Didier, Unger Philippe
Department of Cardiology, CHU Saint-Pierre, Université Libre de Bruxelles, Rue aux Laines 105, 1000 Brussels, Belgium.
Department of Cardiac Surgery, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium.
Eur Heart J Case Rep. 2024 Feb 26;8(3):ytae114. doi: 10.1093/ehjcr/ytae114. eCollection 2024 Mar.
Percutaneous transvenous mitral commissurotomy (PTMC) is the first-line therapy of clinically significant rheumatic mitral stenosis. While the procedure is generally safe, new onset or aggravation of mitral regurgitation (MR) may occur, mainly due to commissural splitting and, less frequently, to leaflet tear and chordal rupture. Papillary muscle rupture (PMR) is exceedingly rare in this setting.
A 74-year-old woman with a history of aortic valve replacement and prior rheumatic mitral commissurotomy presented for worsening exercise intolerance and exertional dyspnoea. Transthoracic echocardiography showed a mean pressure gradient of 10 mmHg and a mitral valve area of 1.0 cm², consistent with clinically significant mitral stenosis. Subsequent PTMC was complicated by anterolateral PMR. However, the resulting MR was unexpectedly only of mild-to-moderate severity. Because of residual mitral stenosis and persisting symptoms, surgical mechanical mitral valve replacement and tricuspid annuloplasty were performed 6 weeks after PTMC. Papillary muscle rupture was confirmed during surgery.
We herein describe the occurrence of PMR induced by PTMC; the resulting MR was unexpectedly of mild-to-moderate severity, as a result of extensive rheumatic lesions limiting valve mobility. This case challenges the dogma according to which PMR invariably leads to severe MR. This might not be necessarily the case when it occurs following PTMC.
经皮经静脉二尖瓣交界切开术（PTMC）是具有临床意义的风湿性二尖瓣狭窄的一线治疗方法。虽然该手术一般安全，但二尖瓣反流（MR）可能会新发或加重，主要原因是交界分离，较少见的原因是瓣叶撕裂和腱索断裂。在这种情况下，乳头肌破裂（PMR）极为罕见。
一名74岁女性，有主动脉瓣置换史及既往风湿性二尖瓣交界切开术史，因运动耐量下降和劳力性呼吸困难加重前来就诊。经胸超声心动图显示平均压力阶差为10 mmHg，二尖瓣面积为1.0 cm²，符合具有临床意义的二尖瓣狭窄。随后的PTMC并发前外侧PMR。然而，由此导致的MR出人意料地仅为轻度至中度严重程度。由于二尖瓣狭窄残留且症状持续存在，在PTMC后6周进行了外科机械二尖瓣置换术和三尖瓣环成形术。手术中证实了乳头肌破裂。
我们在此描述了PTMC诱发PMR的情况；由于广泛的风湿性病变限制了瓣膜活动度，由此导致的MR出人意料地为轻度至中度严重程度。该病例挑战了PMR总是导致严重MR的教条。PTMC后发生PMR时可能未必如此。
