Timing of Intervention in Mitral Stenosis Ted Feldman, M.D., FSCAI FACC FESC Evanston Hospital CRT Cardiovacular Research Technologies Washington, D.C. February 23 – 26, 2013

Ted E. Feldman, MD Consulting: Abbott Laboratories Boston Scientific Corporation Edwards Lifesciences, LLC

Indications for Percutaneous Mitral Balloon Valvotomy CLASS Indication I A Symptomatic, MVA ≤1.5cm2, MR≤2, no LA clot C Asymptomatic, PASP>50mm Rest/60mm exercise IIa Calcified valve, NYHA III–IV, and are either not candidates or high risk for surgery IIb Asymptomatic with new onset of atrial fibrillation Symptomatic, MVA>1.5 , PASP>60 mmHg, PCW≥25 mm, mn MV gradient >15mm Hg exercise Alternative to surgery with mod-severe MS, calcified valve, NYHA III–IV III Mild MS, moderate to severe MR or left atrial clot JACC 52, 2008:e1–142

Indications for Percutaneous Mitral Balloon Valvotomy CLASS Indication I A Symptomatic, MVA ≤1.5cm2, MR≤2, no LA clot C Asymptomatic, PASP>50mm Rest/60mm exercise IIa Calcified valve, NYHA III–IV, and are either not candidates or high risk for surgery IIb Asymptomatic with new onset of atrial fibrillation Symptomatic, MVA>1.5 , PASP>60 mmHg, PCW≥25 mm, mn MV gradient >15mm Hg exercise Alternative to surgery with mod-severe MS, calcified valve, NYHA III–IV III Mild MS, moderate to severe MR or left atrial clot JACC 52, 2008:e1–142

ECHO Score Mobility Subvalvular Thickening Calcium 1 tips restricted minimal thickening nl (4-5mm) single area 2 mid & base nl 1/3 chordal length leaflet margins 5-8mm scattered 3 valve moves forward thick to distal chords entire leaflet 5-8mm mid leaflets 4 barely mobile extensive to paps >8-10mm thick extensive Br Heart J 60:299,1988

Spectrum of Valve Deformity LA Mild Moderate Severe LV LA LV LA

Left Atrial Smoke

Left Atrial Thrombus Resolution After Warfarin Therapy PRE PRE Post 4 months warfarin 80% of thrombi resolve after 2 months of anticoagulation AHJ 140:150,2000

Organized Left Atrial Thrombus 65F, CABG 6 months prior, Stroke 2 months prior Coumadin 8 for weeks, Successful PTMC

Leaflet Lesion Recent TIA

Mitral Stenosis & Mitral Annular Calcification

Calcific Mitral Stenosis Dialysis

Bioprosthetic Mitral Stenosis 88YO female with atrial fibrillation & bioprosthetic aortic and mitral valve replacement, TV repair in 2009

Bioprosthetic Stenosis 24mm PTMC