title: Emergency surgery after percutaneous transmitral commissurotomy: operative versus echocardiographic findings, mechanisms of complications, and outcomes.
abstract: OBJECTIVE
  This study was undertaken to determine the clinical profile of patients undergoing emergency surgery after balloon mitral valvotomy, to note operative findings and compare them with those of transthoracic echocardiography, to describe the mechanisms of complications, and to describe outcomes.
  
  
  METHODS
  A retrospective study was undertaken of patients requiring emergency surgery after percutaneous mitral valvotomy with an Inoue balloon from January 1990 to December 2003. The data analyzed included demographic variables, causes and clinical presentations of complications, and outcome. In 14 consecutive cases of mitral regurgitation, an observational study comparing the operative findings with echocardiography was also undertaken.
  
  
  RESULTS
  In 1388 cases of valvotomy, complications necessitating urgent surgery occurred in 31 cases (2.2%). Acute mitral regurgitation occurred in 23 cases (74.2%), and cardiac tamponade occurred in 8 cases (25.8%). Mitral regurgitation was due to leaflet tearing in all cases: anterior leaflet in 20 cases and posterior leaflet in 3 cases. Hypotension, orthopnea, and pulmonary edema were the clinical presentation for mitral regurgitation. Transthoracic echocardiography underestimated the severity of mitral valve pathology. Bilateral severe commissural fusion and pliable leaflet with paracommissural calcium was seen in anterior leaflet tearing. Cardiac tamponade with hemodynamic compromise occurred as a result of left atrial perforation in 6 cases, right atrial perforation in 1 case, and left ventricular perforation in 1 case. High septal puncture led to atrial perforation. Operative mortality was 9.6%, and low cardiac output developed in 29%.
  
  
  CONCLUSIONS
  Acute mitral regurgitation and cardiac tamponade were the causes of emergency surgery after balloon valvotomy. Transthoracic echocardiography underestimated the severity of valve pathology.
authors.affiliation: Division of Cardio-Vascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India. varmapk@gmail.com
authors.forename: Praveen Kerala
authors.initials: PK
authors.lastname: Varma
authors.forename: Sanjay
authors.initials: S
authors.lastname: Theodore
authors.forename: Praveen Kumar
authors.initials: PK
authors.lastname: Neema
authors.forename: Padmakumar
authors.initials: P
authors.lastname: Ramachandran
authors.forename: Harikrishnan
authors.initials: H
authors.lastname: Sivadasanpillai
authors.forename: Krishna Kumar
authors.initials: KK
authors.lastname: Nair
authors.forename: Kurur Sankaran
authors.initials: KS
authors.lastname: Neelakandhan
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D021721:Balloon Occlusion; D006348:Cardiac Surgical Procedures / Q000401:mortality; D002305:Cardiac Tamponade / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D002404:Catheterization / Q000009:adverse effects*; D002648:Child; D017548:Echocardiography, Transesophageal; D004630:Emergencies; D005260:Female; D006325:Heart Atria / Q000293:injuries; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000293:injuries*; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery; D008946:Mitral Valve Stenosis / Q000628:therapy*; D015996:Survival Rate