Mitral valve injury after radiofrequency ablation for Wolff-Parkinson-White syndrome.

A 39-year-old athletic female with symptomatic Wolff-Parkinson-White syndrome underwent an electro-physiological study and subsequent ablation of orthodromic reentrant tachycardias using left lateral, posterolateral, and posteroseptal accessory pathways. Ablation was performed with 7F medium-and large-curl Safire catheters using the retrograde aortic approach. Eighteen radiofrequency lesions were delivered at the mitral valve annulus (50 W, 60°, 10–60 seconds), and 8 were delivered in the coronary sinus, with weak persistence of antegrade conduction through the pos-teroseptal pathway. Two weeks later, she presented to the emergency room with a new episode of supraventricular tachycardia, She had been having dyspnea since the ablation procedure. A transthoracic echocardiogram revealed severe mitral regurgitation with a regurgitant volume of 66 ml and estimated regurgitant orifice of 39 mm 2 (Figure [C, F, and G]); the left atrium was enlarged with a volume index of 36 ml/m 2. Transesophageal echocardiogram revealed a ruptured chord to the anterior leaflet adjacent to the postero-medial commissure (Figure [E]). Given the symptoms and severity of the mitral valve regurgitation, the decision was made to proceed with surgical intervention. The patient was taken to the operating room. An intraoperative transesopha-geal echocardiogram confirmed severe mitral regurgitation with small flail segment at the posteromedial commissure and an ejection fraction of 65%. Median sternotomy and standard aortic and right atrial cannulation with a 2-stage venous cannula were performed. Cardiopulmonary bypass was initiated, and the heart was arrested with antegrade cardioplegia. On opening of the left atrium and exposure of the mitral valve, it was clear that there was a ruptured chord to the anterior leaflet corresponding to the medial (A3) scallop at the level of the posteromedial commissure. Additionally, there were reddened thickened excoriated areas along the posteromedial mitral annulus and the posterior mitral leaflet (Figure [H]). The quality of the tissue was rather poor and appeared to be partially necrotic. Therefore, we were concerned about anchoring neochords at this location. Instead, we plicated the posteromedial commis-sure using 2 pledgeted 4-0 polypropylene sutures and placed a 63-mm posterior annuloplasty band anchored between left and right fibrous trigones (Figure [I]). The cross-clamp was released after a total of 43 minutes. A transesophageal echo-cardiogram showed trivial mitral regurgitation and a transmi-tral mean gradient of 3 mm Hg at a heart rate of 50 bpm. The patient was dismissed from the hospital on postoperative day 5. Dismissal transthoracic echocardiogram confirmed trivial mitral regurgitation, no evidence of systolic anterior motion of …