1. Treatment of Mitral Stenosis

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

3.  Percutaneous MV Comissurotomy (PMC)  Percutaneous MV Replacement ? ( new technique ) Interventional Valvotomy

4.  Balloon commissurotomy  Metallic commissurotomy Percutaneous Mitral Valve Commissurotomy ( PMVC )

5.  Antegrade ( Teansseptal )  Single balloon ( Inoue )  Double balloon  Retrograde ( Transatrial ) Balloon Commissurotomy

6.  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

7.  When transseptal approach is contraindicated or impossible Retrograde PMVC

8.  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

9.  Symptomatic patients  Asymptomatic patients Indication of Valvotomy ( most be individualized )

10.  Sever MS ( MVA ≤ 1 cm 2 )  Moderate MS ( MVA ≤ 1.5 cm 2 )  Functional class II  PA pressure > 60 mmHg  Mean PCWP > 25 mmHg during exercise Indication of Valvotomy in Symptomatic Patients, if:

11.  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

12.  Patients who indicated for valvotomy + good MV scoring (≤ 8 ) Indication of PMVC

13.  Mobility ( 1-4 )  Subvalvular thickening ( 1-4 )  Leaflet thickening ( 1-4 )  Calcification ( 1-4 ) Mitral Valve Scoring

14.  LA thrombosis  Floating in LA  Attached to interatrial septum  Severe scoliosis  IVC obstruction  Major abnormalities of interatrial septum Contraindication of PMVC

15.  Percutaneous  Local anesthesia  Good hemodynamic result  Good long-term outcome Advantages of BMVC

16.  No direct visualization of valve  Only feasible with flexible & non calcified valves  Contraindicated if MR> 2+ or LA clot is present Disadvantages of BMVC

17.  Patient’s height  Body surface area  Diameter of Mitral annulus Balloon Size

18.  Cerebral emboli (1%)  Cardiac Perforation (1%)  Development of severe MR ( 2% need to surgery )  Residual small ASD (5%) Complication of PMVC

19.  Valvotomy  Closed MV commissurotomy ( CMVC)  Open MV commissurotomy ( OMVC )  MV replacement  Metallic  Biologic Surgical treatment of MS

20.  Advantages :  Off pump  Inexpensive  Relatively simple  Good hemodynamic result  Good long-term outcome Closed MV commissurotoimy

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

22.  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

23.  Disadvantages :  Surgical procedure with general anesthesia  Best results with flexible / non calcified valve Open MV commissurotoimy

24.  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 70 mmHg Indications of MVR

25.  Bioprosthetic  Mechanical :  Caged ball ( starr – Edwards)  Tilting disc:  Monoleaflet ( Bjork – shiley )  Bioleaflet ( St. jude ) Prosthetic Mitral valve

26.  durability Advantage of mechanical valve

27.  Thromboembolism  Valvular thrombus  Valvular failure  Valvular infection  Pregnancy ( none of the 3 available anticoagulants have been effective ) Disadvantage of mechanical valve

28.  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)

29.  Lt. posterolateral thoracotomy in 4 th 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

30.  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

31. 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