Download - Treatment of Mitral Stenosis. Medical Valvotomy Interventional Surgical Treatment of Mitral Stenosis
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Treatment ofMitral Stenosis
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Medical Valvotomy
Interventional Surgical
Treatment of Mitral Stenosis
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Percutaneous MV Comissurotomy (PMC) Percutaneous MV Replacement ?
( new technique )
Interventional Valvotomy
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Balloon commissurotomy Metallic commissurotomy
Percutaneous Mitral Valve Commissurotomy ( PMVC )
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Antegrade ( Teansseptal ) Single balloon ( Inoue ) Double balloon
Retrograde ( Transatrial )
Balloon Commissurotomy
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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
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When transseptal approach is contraindicated or impossible
Retrograde PMVC
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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
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Symptomatic patients Asymptomatic patients
Indication of Valvotomy( most be individualized )
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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:
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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
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Patients who indicated for valvotomy + good MV scoring (≤ 8 )
Indication of PMVC
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Mobility ( 1-4 ) Subvalvular thickening ( 1-4 ) Leaflet thickening ( 1-4 ) Calcification ( 1-4 )
Mitral Valve Scoring
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LA thrombosis Floating in LA Attached to interatrial septum
Severe scoliosis IVC obstruction Major abnormalities of interatrial septum
Contraindication of PMVC
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Percutaneous Local anesthesia Good hemodynamic result Good long-term outcome
Advantages of BMVC
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No direct visualization of valve Only feasible with flexible & non calcified
valves Contraindicated if MR> 2+ or LA clot is
present
Disadvantages of BMVC
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Patient’s height Body surface area Diameter of Mitral annulus
Balloon Size
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Cerebral emboli (1%) Cardiac Perforation (1%) Development of severe MR ( 2% need to
surgery ) Residual small ASD (5%)
Complication of PMVC
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Valvotomy Closed MV commissurotomy ( CMVC) Open MV commissurotomy ( OMVC )
MV replacement Metallic Biologic
Surgical treatment of MS
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Advantages : Off pump Inexpensive Relatively simple Good hemodynamic result Good long-term outcome
Closed MV commissurotoimy
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Disadvantages : No direct visualization of valve Only feasible with flexible / non calcified valves Contraindicated if MR>2+ Need to general anesthesia
Closed MV commissurotoimy
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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
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Disadvantages : Surgical procedure with general anesthesia Best results with flexible / non calcified valve
Open MV commissurotoimy
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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
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Bioprosthetic Mechanical :
Caged ball ( starr – Edwards) Tilting disc:
Monoleaflet ( Bjork – shiley ) Bioleaflet ( St. jude )
Prosthetic Mitral valve
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durability
Advantage of mechanical valve
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Thromboembolism Valvular thrombus Valvular failure Valvular infection Pregnancy ( none of the 3 available anticoagulants have
been effective )
Disadvantage of mechanical valve
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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)
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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
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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
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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