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