|
|
| (4 intermediate revisions by the same user not shown) |
| Line 1: |
Line 1: |
| {{SI}}
| |
| {{CMG}}
| |
|
| |
|
| '''Associate Editor-In-Chief:''' {{CZ}} ; Joanna J. Wykrzykowska, MD Contact at [mailto:jwykrzyk@bidmc.havard.edu]; Phone: 617-767-5343 and Roger J. Laham, MD Contact at [mailto:rlaham@bidmc.harvard.edu]
| |
|
| |
| {{Editor Help}}
| |
|
| |
|
| |
| == Surgery and Device Based Therapy ==
| |
|
| |
| === Indications for Mitral Valvuloplasty ===
| |
|
| |
| ====Patient selection====
| |
| * [[Mitral stenosis]] due to rheumatic disease is becoming less common in the US but is very prevalent worldwide
| |
| * Symptoms of [[shortness of breath]] and valve area or less than 1.5 cm2 are indications for commissurotomy
| |
| * Unlike with the surgical approach, elevated pulmonary pressures or depressued LV function are not contraindications
| |
| * Wilkins score that describes valve anatomy is the best predictor of procedural success: it assigns points for leaflet mobility, valvular and subvulvular thickening and calcification degree (score of < 8 makes the patient a favorable candidate); Thus good quality echocardiogram is essential before qualifying the patient for the procedure
| |
| * Contraindications include presence of left atrial appendage clot, moderate to severe mitral regurgitation or other indications for open heart surgery
| |
|
| |
| ====Technique====
| |
| * Transvenous transeptal technique is most commonly used with the Inoue balloon system
| |
| * [[Fossa ovalis]] lies usually at 1-7 o’clock but this orientation can be distorted in the presence of mitral stenosis where the interatrial septum becomes more flat, horizontal and lower
| |
| * For the femoral vein approach a 70 cm Brockenbrough needle should be used or an 8 Fr Mullins sheath and advanced under fluoroscopic guidance with pressure monitoring
| |
| * The latter is necessary to monitor for puncture into adjacent structures such as aorta
| |
| * Further catheter manipulation may be necessary to direct the catheter into the left ventricle through the mitral valve rather than towards one of the pulmonary veins
| |
| * The Mullins sheath is exchanged for a solid-core coiled 0.025 inch guidewire over which a 14 Fr dilator is placed
| |
| * This is exchanged for the Inoue balloon (24-30 mm) which inflates in three stages allowing for balloon self-positioning with the last inflation resulting in commissural splitting
| |
|
| |
| ====Hemodynamic and Clinical Outcomes====
| |
| * Results of the commissurotomy should be assessed with hemodynamics and echocardiography
| |
| * If second inflation is needed mitral regurgitation should be assessed
| |
| * In general increasing valve area to greater than 1 cm2/m2 is an acceptable result
| |
| * Usually the valve area doubles and the pulmonary pressures degrease immediately
| |
| * 5 year survival is in the 90% range
| |
|
| |
|
| |
| == Factors favouring successful percutaneous mitral valvuloplasty ==
| |
|
| |
| Mitral stenosis is amenable to percutaneous mitral valvuloplasty if the echocardiography demonstrates :
| |
|
| |
| * Thickening confined to valve tips
| |
| * Good mobility of Anterior mitral valve leaflet
| |
| * Little chordal involvement
| |
| * not more than trivial [[mitral regurgitation]]
| |
| * no left atrial thrombus
| |
| * no commissural calcification.
| |
|
| |
| === Wilkins score ===
| |
|
| |
| A scoring system exists to grade the morphological changes in the mitral valve during assessment with echocardiography. This takes into account 4 characteristics: leaflet mobility, leaflet thickening, valve calcification and involvement of the subvalvular apparatus. The involvement is graded from 0-4. A total score of more than 8 is predictive of a low success post percutaneous mitral valvuloplasty.<ref>Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IF. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988;60:299–308. doi: 10.1136/hrt.60.4.299 </ref>
| |
|
| |
|
| |
| ==References==
| |
| {{Reflist}}
| |
|
| |
| [[Category:Valvular heart disease]]
| |
| [[Category:Cardiology]]
| |
| {{WikiDoc Help Menu}}
| |
| {{WikiDoc Sources}}
| |