CASE REPORT
Improvement of the pulmonary function following percutaneous transluminal mitral commissuerotomy in a 39-year-old man exposed to sulfur mustard

Clinical history
Mustard gas causes damage to the skin, eyes, respiratory system, and gastrointestinal tract, as well as having a general effect on the body similar to that of radiation [1]. Victims of sulfur mustard gas exposure experience different types of chronic pulmonary disease, manifested as cough, sputum production and dyspnea [2-4]. Pulmonary complications are the main chronic complication of exposure to sulfur mustard (SM). More than half of the victims are known to show the complications [4]. Only a few studies report thrombocytopenia as one of hematological complications of sulfur mustard exposure [1]. Some studies show that PTMC, dramatically improves the pulmonary function [5-7], but we did not find any document indicating an improvement of the pulmonary function following PTMC in chemical weapons victims.

Material and methods
The patient referred to the department of cardiac catheterism & Intervention with Dyspnea On Exertion (DOE) with function class III and recurrent Pulmonary Edema. Echocardiography showed severe MS, mild mitral regurgitation (MR), mild pulmonary insufficiency (PI), mild tricuspid regurgitation (TR) and mild aortic valve insufficiency (AI). His Left Ventricle Ejection Fraction (LVEF) was more than 60-65%. Because of the history of chemical exposure of sulfur mustard and DOE, pulmonological examination including spirometeric studies and deep expiratory High Resolution Computerized Tomography (HRCT) was performed and the following medications were administered: Hydrocortisone 100 mg/IV/q 8 h start at 8 hours before PTMC, Atrovent spray 4 puff/q 8 h, Salbutamol spray 3 puff/q 8 h and Ceftriacsone 2 g/IV/q 12 h. Spirometric studies revealed restriction and spiral HRCT showed grand glass and bronchial wall thickening in lower lobes of both lungs [4]. Also; as ITP, hematological consultation was done and allowed heart catheterization of the patient if the platelet count was above 160x103/mm3. In such a complicated case, left heart catheterization was done via the right femoral artery (RFA) without any complication.

Results and discussion
After PTMC the following data was obtained: aortic pressure was 100/60 mmHg, left ventricular pressure was 100/0-8 mmHg (LV systolic pressure was 100 mmHg and LVEDP was 0 to 8 mmHg). Aortic root injection showed AI2+. Selective left coronary artery angiography showed no epicardial coronary artery stenosis and the right coronary artery showed non-significant irregularities. Balloon dilatation produces a commissurotomy similar to that obtained by the surgery. However, it is a percutaneous procedure, using only local anaesthesia. Several studies have shown that balloon dilatation is effective in providing sustained haemodynamic and symptomatic improvement of patients with severe mitral stenosis [8]. The degree of improvement depends principally on the valve anatomy [9-11]. Also some have shown that mitral balloon valvotomy gives an excellent result equal to that obtained with open or closed surgical valvotomy and its benefits are shown to sustain during a long term follow up [12-17]. PTMC procedure performed with Inoue Balloon NO 28 (three inflation 24 up to 28) and the gradient between the left atrium & the left ventricle diastolic pressure drop from 20 mmHg to 0 mmHg (LA mean pressure was about 30 mmHg with LVEDP about 8-10 mmHg). The patient transferred to the post catheterization ward with a desirable condition: BP: 90/50 mmHg, PR: 85 bpm, RR: 20 per min and monitored for controlling any arrhythmias. MVA increased to about 2.5-2.7 cm2 with less than 2+ MR in post PTMC echocardiography. A comparison of pre and post PTMC echocardiography are shown in Table I. Also the respiratory condition alleviated as confirmed by the Pulmonary Function Test after PTMC (Table II).

Conclusions
PTMC is the established technique for severe MS patients, also the procedure will be helpful in some complicated conditions such as pulmonary edema and ITP before improving the conditions.
References
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