The lowest mitral valve area successfully treated by PTMC: a rare case

We present a detailed case of a 39-year-old male patient with severe, symptomatic rheumatic mitral stenosis who was successfully treated with percutaneous transvenous mitral commissurotomy (PTMC) at Milad Hospital in Isfahan, Iran. The patient presented with chronic dyspnea on exertion (New York Heart Association class III) and fatigue, and pre-procedural two-dimensional and three-dimensional echocardiography confirmed a critically low mitral valve area (MVA) of 0.36 cm \({}²\) (3D planimetry with multiplanar reconstruction) and a challenging valve morphology, as assessed by a high Wilkins score of 10 and a 3D echocardiographic score of 8. The PTMC procedure, performed with an Inoue balloon, was uneventful and resulted in a marked improvement in valve function, with the MVA increasing to \(0.6 cm²\) and the systolic pulmonary artery pressure decreasing from 45 mmHg to 30 mmHg. Mitral regurgitation remained trivial/mild (grade 1+) throughout. At one-month follow-up, the patient was in NYHA class II and the MVA remained stable. This case highlights that PTMC remains a highly effective and safe intervention for severe mitral stenosis, even in patients with high-risk valve morphology, when performed by experienced operators in a specialized tertiary care center and guided by a multidisciplinary Heart Team.