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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 76-77

Calcific severe rheumatic mitral valve stenosis disguising as a “pseudoprosthesis”: An imaging vignette


Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission14-Aug-2020
Date of Acceptance11-Feb-2021
Date of Web Publication24-Apr-2021

Correspondence Address:
Ankit Kumar Sahu
Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_80_20

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  Abstract 


We present an interesting cardiac fluoroscopic image representing a severe rheumatic mitral restenosis with heavily calcific mitral valve leaflets having a striking resembling to the valve leaflets of bileaflet mechanical valve on cineangiography with respect to size, shape, motion, and position.

Keywords: Bileaflet mechanical prosthetic valve, calcific mitral valve, mitral stenosis


How to cite this article:
Ahmed A, Sahu AK, Kapoor A. Calcific severe rheumatic mitral valve stenosis disguising as a “pseudoprosthesis”: An imaging vignette. J Pract Cardiovasc Sci 2021;7:76-7

How to cite this URL:
Ahmed A, Sahu AK, Kapoor A. Calcific severe rheumatic mitral valve stenosis disguising as a “pseudoprosthesis”: An imaging vignette. J Pract Cardiovasc Sci [serial online] 2021 [cited 2021 Jun 22];7:76-7. Available from: https://www.j-pcs.org/text.asp?2021/7/1/76/314477




  Introduction Top


Long-standing mitral valve stenosis often develops calcification in varying degrees, ranging from a small calcific nodule at tip of valve leaflet to extensive calcification involving mitral annulus, valve leaflets, chordae tendineae, and even papillary muscles. Moderate-to-heavy calcium over mitral valve involving subvalvular apparatus or commissures compromises the safety, procedural success, and durability of percutaneous balloon mitral valvotomy. In most of such cases, surgical repair is also futile, thereby leaving mitral valve replacement (MVR) surgery as the only viable option. Herein, we discuss one such mitral stenosis case in which native mitral valve had quite a unique appearance on fluoroscopy.


  Case Report Top


A 50-year-old nondiabetic, nonhypertensive female presented with progressively increasing exertional dyspnea for the past 6 months with the background of having undergone percutaneous balloon mitral valvotomy 20 years ago for rheumatic mitral valve stenosis. On examination, the patient had irregular low volume pulse, loud S1, loud P2, and a long mid-diastolic murmur at apex. Twelve-lead electrocardiogram showed atrial fibrillation with controlled ventricular rate. Chest X-ray showed straightening of left heart border, left atrial appendage enlargement, and small linear tubular radiopacities, suggestive of calcified mitral valve [Figure 1]. A transthoracic echocardiography revealed severe rheumatic mitral valve restenosis (MVA = 1.0 cm2, PG/MG = 41/18 mmHg), densely calcific mitral leaflets [Figure 2] and [Videos 1 and 2], commissural calcium with severe subvalvular pathology, trivial mitral regurgitation, moderate tricuspid regurgitation, and moderate pulmonary arterial hypertension (RVSP = 56 mmHg). In view of heavily calcified mitral valve restenosis, MVR was planned and patient was taken up for coronary angiography before MVR. Coronaries were unremarkable; however, during fluoroscopy, special note was taken for two mobile, linear, 5-mm thick, wedge-shaped densities oriented parallel to each other in left anterior oblique view [Video 3]. Similar densities were seen moving in anteroposterior caudal view [Video 4] in a fashion reminiscent of prosthetic mechanical valve in mitral position [Figure 3]. The patient subsequently underwent MVR with 29 mm St Jude bileaflet mechanical valve and had an uneventful recovery.
Figure 1: Chest roentgenogram in the posteroanterior and lateral view showing calcified mitral valve leaflets (small arrowheads).

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Figure 2: Two-dimensional transthoracic echocardiogram in parasternal long-axis view showing thick, calcified tips (hollow arrows) of anterior and posterior mitral leaflets in systole (left panel) and diastole (right panel).

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Figure 3: Still fluoroscopic image showing two linear radiodense opacities oriented parallel to each other depicting calcified mitral valve leaflets in left anterior oblique (left panel) and anteroposterior caudal view (right panel), respectively.

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  Discussion Top


Probably, heavy calcification of the mitral valve leaflets and the adjacent parts of the chordae mimicked the linear mobile shadows of the occluders of a bileaflet mechanical prosthetic mitral valve. In the background of clinical diagnosis of severe mitral stenosis, visualization of calcification in chest roentgenogram or fluoroscopy should overtly preclude any attempt to perform balloon mitral valvuloplasty. Moreover, in such cases, surgeons should desist themselves from attempting any type of repair without valvular replacement.


  Conclusion Top


This brief clinical imaging report provides a unique opportunity to have a spatial and dynamic visualization of native mitral valve leaflets in situ. The classical position and movement of valve leaflets is also reminiscent of the actual mobility of prosthetic bileaflet mechanical valve implanted in the mitral position, thereby underlining the importance of clinical, surgical, and radiological anatomy in patients with mitral valve disease requiring valve replacement surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.




    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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