Treatment of Mitral Stenosis. Medical Valvotomy Interventional Surgical Treatment of Mitral...

Treatment ofMitral Stenosis

Medical Valvotomy

Interventional Surgical

Treatment of Mitral Stenosis

Percutaneous MV Comissurotomy (PMC) Percutaneous MV Replacement ?

( new technique )

Interventional Valvotomy

Balloon commissurotomy Metallic commissurotomy

Percutaneous Mitral Valve Commissurotomy ( PMVC )

Antegrade ( Teansseptal ) Single balloon ( Inoue ) Double balloon

Retrograde ( Transatrial )

Balloon Commissurotomy

Most common procedure is Inoue balloon MVA become slightly more larger in double

balloon catheter than Inoue balloon Risk of perforation is greater in double

balloon procedure than Inoue balloon Suitable , when interatrial thrombosis is not

present

Antegrade PMVC

When transseptal approach is contraindicated or impossible

Retrograde PMVC

Uses a device similar to the tubes dilator Efficacy similar to BMVC More demanding for operator than BMVC Advantage is that dilator is reusable

Metalic Commissurotomy

Symptomatic patients Asymptomatic patients

Indication of Valvotomy( most be individualized )

Sever MS ( MVA ≤ 1 cm2 ) Moderate MS ( MVA ≤ 1.5 cm2 )

Functional class II PA pressure > 60 mmHg Mean PCWP > 25 mmHg during exercise

Indication of Valvotomy in Symptomatic Patients , if:

Women with sever MS who wish to become pregnant

Who experience recurrent thromboembolie events

Who have sever pulmonary hypertension Atrial fibrillation ( persistent or recurrent )

Indication of Valvotomy in Asymptomatic Patients

Patients who indicated for valvotomy + good MV scoring (≤ 8 )

Indication of PMVC

Mobility ( 1-4 ) Subvalvular thickening ( 1-4 ) Leaflet thickening ( 1-4 ) Calcification ( 1-4 )

Mitral Valve Scoring

LA thrombosis Floating in LA Attached to interatrial septum

Severe scoliosis IVC obstruction Major abnormalities of interatrial septum

Contraindication of PMVC

Percutaneous Local anesthesia Good hemodynamic result Good long-term outcome

Advantages of BMVC

No direct visualization of valve Only feasible with flexible & non calcified

valves Contraindicated if MR> 2+ or LA clot is

present

Disadvantages of BMVC

Patient’s height Body surface area Diameter of Mitral annulus

Balloon Size

Cerebral emboli (1%) Cardiac Perforation (1%) Development of severe MR ( 2% need to

surgery ) Residual small ASD (5%)

Complication of PMVC

Valvotomy Closed MV commissurotomy ( CMVC) Open MV commissurotomy ( OMVC )

MV replacement Metallic Biologic

Surgical treatment of MS

Advantages : Off pump Inexpensive Relatively simple Good hemodynamic result Good long-term outcome

Closed MV commissurotoimy

Disadvantages : No direct visualization of valve Only feasible with flexible / non calcified valves Contraindicated if MR>2+ Need to general anesthesia

Closed MV commissurotoimy

Advantages : Risk of dislodging thrombi from the atrium or

calcium from valve s low Visualization of valve allows direct valvotomy Concurrent annuloplasty for MR is feasible

Open MV commissurotoimy

Disadvantages : Surgical procedure with general anesthesia Best results with flexible / non calcified valve

Open MV commissurotoimy

Combined MS + moderate to severe MR Extensive commissural calcification Severe fibrosis Subvalvular fusion Previous valvotomy Whose valves are not suitable for valvotomy :

MVA < 1.5 cm2 + Fc III-IV MVA < 1 cm2 + Fc II + PAP>70 mmHg

Indications of MVR

Bioprosthetic Mechanical :

Caged ball ( starr – Edwards) Tilting disc:

Monoleaflet ( Bjork – shiley ) Bioleaflet ( St. jude )

Prosthetic Mitral valve

durability

Advantage of mechanical valve

Thromboembolism Valvular thrombus Valvular failure Valvular infection Pregnancy ( none of the 3 available anticoagulants have

been effective )

Disadvantage of mechanical valve

Double-crowned valved stent:1. Ventricular stent ( fixation of device to the

Mitral annulus )2. Atrial stent ( holds in place the homograft

sutured on the prosthesis ) The grocre between the two crowns is

placed at the level of the Mitral annulus Self-expandable artificial heart valve

Off pump MVR ( new technique)

Lt. posterolateral thoracotomy in 4th intercostal space

The atrium was punctured with a needle and a guide wire was inserted into it before a short 9-F sheath was introduced

Ivus was inserted in order to measure the diameter and Mitral valve area

Position of annulus was confirmed as well under the guidance of fluoroscopy

An incision of 1 cm was made on left atrium, centralled by the purse strings

Approach to off pump MVR

Mild peravalvular regurgitation due to mismatch between native annulus + valve size

LVOT obstruction due to protrusion of valved stents into the LV + push anterior of the MV towards the LVOT ( similar to SAM)

Complication of off pump MVR

Patients with : MR who no candidate for open heart surgery Severe CHF Hepatic failure Renal failure Restenosis of MV after PMC

Indication of off pump MVR