Surgical and investigational approaches to management of mitral stenosis
- Mackram F Eleid, MD
Mackram F Eleid, MD
- Associate Professor of Medicine
- Department of Cardiovascular Medicine
- Mayo Clinic
- Bongani Mayosi, MBChB, PhD, FCP(SA)
Bongani Mayosi, MBChB, PhD, FCP(SA)
- Professor of Medicine and Dean: Faculty of Health Science
- University of Cape Town
- Section Editors
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Jeroen J Bax, MD, PhD
Jeroen J Bax, MD, PhD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Cardiology
- Leiden University Medical Center, The Netherlands
Mitral stenosis (MS) is a condition caused most commonly by rheumatic heart disease and characterized by obstruction of blood flow across the mitral valve (MV) from the left atrium to the left ventricle. The mechanical obstruction leads to increases in pressure within the left atrium, pulmonary vasculature, and right side of the heart. If untreated, symptomatic MS leads to progressive symptoms (eg, dyspnea and fatigue) and serious complications (eg, pulmonary edema, systemic arterial embolism, pulmonary hypertension, and death). Medical therapy can alleviate symptoms, but surgical or percutaneous intervention is required to relieve the obstruction to flow. (See "Clinical manifestations and diagnosis of mitral stenosis" and "Medical management and indications for intervention for mitral stenosis".)
Surgical and investigational approaches to management of MS are reviewed here. Issues directly related to the indications for intervention and choice of percutaneous mitral balloon valvotomy versus surgery and the medical management of MS are discussed separately. (See "Percutaneous mitral balloon valvotomy for mitral stenosis" and "Medical management and indications for intervention for mitral stenosis".)
Assessment of valve pathology — Preprocedural imaging of the mitral valve (MV) includes echocardiography as well as multidetector computed tomography (MDCT), when available. Echocardiography (initial transthoracic, complemented by transesophageal if needed) is used primarily for the hemodynamic (functional) assessment of valve pathology while MDCT is essential for precise preoperative anatomical delineation of MV apparatus anatomy and pathology including delineation of whether calcium is limited to the leaflet, involves the subvalvular apparatus, or even extends into the left ventricle beyond the mitral annulus.
Transthoracic echocardiography is the initial test of choice for assessment of MV pathology and hemodynamic (functional) severity of disease. In selected cases in which transthoracic echocardiographic assessment is incomplete, transesophageal echocardiography is useful for further characterization of pathology including the presence/extent of calcification and assessment of mitral regurgitation. When available, MDCT is used for precise anatomical delineation of abnormalities/pathology of the MV apparatus.
The feasibility of percutaneous or surgical commissurotomy is assessed based upon the type and severity of pathologic change involving the valve and subvalvular apparatus. For percutaneous commissurotomy, this is most commonly assessed using the Wilkins score, as discussed separately. Assessment for open MV surgery includes more extensive evaluation of all rheumatic pathology including the leaflets (to determine need for surgical delamination and augmentation with pericardium ), commissures, and subchordal/chordal (elongation, splitting, chordal transfer or insertion) and papillary muscle pathologies. (See "Percutaneous mitral balloon valvotomy for mitral stenosis" and "Percutaneous mitral balloon valvotomy for mitral stenosis", section on 'Echocardiography'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Zühlke L, Engel ME, Karthikeyan G, et al. Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study). Eur Heart J 2015; 36:1115.
- Zühlke L, Karthikeyan G, Engel ME, et al. Clinical Outcomes in 3343 Children and Adults With Rheumatic Heart Disease From 14 Low- and Middle-Income Countries: Two-Year Follow-Up of the Global Rheumatic Heart Disease Registry (the REMEDY Study). Circulation 2016; 134:1456.
- Abramowitz Y, Jilaihawi H, Chakravarty T, et al. Mitral Annulus Calcification. J Am Coll Cardiol 2015; 66:1934.
- Ben Farhat M, Ayari M, Maatouk F, et al. Percutaneous balloon versus surgical closed and open mitral commissurotomy: seven-year follow-up results of a randomized trial. Circulation 1998; 97:245.
- Reyes VP, Raju BS, Wynne J, et al. Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med 1994; 331:961.
- Lau KW, Ding ZP, Hung JS. Percutaneous transvenous mitral commissurotomy versus surgical commissurotomy in the treatment of mitral stenosis. Clin Cardiol 1997; 20:99.
- Cohn LH, Allred EN, Cohn LA, et al. Long-term results of open mitral valve reconstruction for mitral stenosis. Am J Cardiol 1985; 55:731.
- Kim JB, Kim HJ, Moon DH, et al. Long-term outcomes after surgery for rheumatic mitral valve disease: valve repair versus mechanical valve replacement. Eur J Cardiothorac Surg 2010; 37:1039.
- Khan MN. The relief of mitral stenosis. An historic step in cardiac surgery. Tex Heart Inst J 1996; 23:258.
- Wheeler EO, Wilkins GT, Reynolds TR, et al.. Rheumatic mitral valve disease and tricuspid valve disease. In: The Practice of Cardiology, 2nd ed, Eagle KA, Habe E, DeSanctis R, Austen WG (Eds), Little, Brown, and Company, Boston 1989. p.655.
- Pavankumar P, Venugopal P, Kaul U, et al. Closed mitral valvotomy during pregnancy. A 20-year experience. Scand J Thorac Cardiovasc Surg 1988; 22:11.
- John S, Bashi VV, Jairaj PS, et al. Closed mitral valvotomy: early results and long-term follow-up of 3724 consecutive patients. Circulation 1983; 68:891.
- Sharma KH, Jain S, Shukla A, et al. Patient profile and results of percutaneous transvenous mitral commissurotomy in mitral restenosis following prior percutaneous transvenous mitral commissurotomy vs surgical commissurotomy. Indian Heart J 2014; 66:164.
- Coutinho GF, Branco CF, Jorge E, et al. Mitral valve surgery after percutaneous mitral commissurotomy: is repair still feasible? Eur J Cardiothorac Surg 2015; 47:e1.
- Eleid MF, Foley TA, Said SM, et al. Severe Mitral Annular Calcification: Multimodality Imaging for Therapeutic Strategies and Interventions. JACC Cardiovasc Imaging 2016; 9:1318.
- Mayosi BM, Commerford PJ, Levetan BN. Anticoagulation for prosthetic valves during pregnancy. Clin Cardiol 1996; 19:921.
- Appelbaum A, Kouchoukos NT, Blackstone EH, Kirklin JW. Early risks of open heart surgery for mitral valve disease. Am J Cardiol 1976; 37:201.
- Feldman T. Rheumatic Mitral Stenosis. Curr Treat Options Cardiovasc Med 2000; 2:93.
- Magne J, Mathieu P, Dumesnil JG, et al. Impact of prosthesis-patient mismatch on survival after mitral valve replacement. Circulation 2007; 115:1417.
- Song H, Kang DH, Kim JH, et al. Percutaneous mitral valvuloplasty versus surgical treatment in mitral stenosis with severe tricuspid regurgitation. Circulation 2007; 116:I246.
- Lansing AM, Elbl F, Solinger RE, Rees AH. Left atrial-left ventricular bypass for congenital mitral stenosis. Ann Thorac Surg 1983; 35:667.
- Wright JS, Thomson DS, Warner G. Mitral valve bypass by valved conduit. Ann Thorac Surg 1981; 32:294.
- Said SM, Schaff HV. An alternate approach to valve replacement in patients with mitral stenosis and severely calcified annulus. J Thorac Cardiovasc Surg 2014; 147:e76.
- Guerrero M, Dvir D, Himbert D, et al. Transcatheter Mitral Valve Replacement in Native Mitral Valve Disease With Severe Mitral Annular Calcification: Results From the First Multicenter Global Registry. JACC Cardiovasc Interv 2016; 9:1361.
- PRE-PROCEDURE ASSESSMENT
- Assessment of valve pathology
- Risk assessment
- Preoperative coronary angiography
- CHOICE OF PROCEDURE
- Rheumatic MS
- Mitral annular calcification
- Congenital MS
- MITRAL VALVE INTERVENTIONS
- Mitral valve commissurotomy
- - Percutaneous mitral balloon valvotomy
- - Open commissurotomy and valve repair
- - Closed surgical commissurotomy
- - Repeat commissurotomy
- Mitral valve replacement
- - Use
- - Choice of valve
- - Outcomes
- - Prosthetic valve-patient mismatch
- Concurrent surgical procedures
- - Left atrial appendage ligation
- - Management of atrial fibrillation
- - Tricuspid valve repair
- Investigational approaches
- - Mitral valve bypass
- - Transcatheter mitral valve replacement
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS