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Percutaneous Management of Mitral Valve Disease

  • Anitha VargheseEmail author
  • Neal Uren
  • Peter F. Ludman
Chapter
  • 372 Downloads

Abstract

Almost all cases of mitral stenosis are due to cardiac disease secondary to rheumatic fever and consequent rheumatic heart disease. Uncommon causes of mitral stenosis include calcification of the mitral valve leaflets and congenital heart disease including a parachute mitral valve. The natural history of rheumatic mitral stenosis is of an asymptomatic latent phase following the initial episode of rheumatic fever. This latent period lasts an average of 16 ± 5 years. Progressive and gradual commissural fusion eventually causes the characteristic symptoms and progression to severe disability may take 9 ± 4 years. Precipitous clinical presentation may occur at the onset of atrial fibrillation causing tachycardia or thromboembolic stroke.

Keywords

Mitral Valve Mitral Regurgitation Rheumatic Fever Mitral Stenosis Mitral Valve Repair 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Supplementary material

Video 4.1

Pre-procedural TOE. Mitral valve anatomical assessment showed both mitral valve leaflets are thickened; anterior mitral valve leaflet 4 mm, posterior mitral valve leaflet 3.3 mm (Wilkins 2). There is restricted motion of valve leaflet base with bowing in diastole (Wilkins 3). The chordae are shortened and thickened (Wilkins 2), with focal calcification of the anterolateral commissure (Wilkins 2). Total Wilkins score = 9. The left atrium is dilated and demonstrates the phenomenon of spontaneous echo contrast due to slow blood flow. (AVI 852 kb)

Video 4.2

Pre-procedural TOE. Mitral valve anatomical assessment showed both mitral valve leaflets are thickened; anterior mitral valve leaflet 4 mm, posterior mitral valve leaflet 3.3 mm (Wilkins 2). There is restricted motion of valve leaflet base with bowing in diastole (Wilkins 3). The chordae are shortened and thickened (Wilkins 2), with focal calcification of the anterolateral commissure (Wilkins 2). Total Wilkins score = 9. The left atrium is dilated and demonstrates the phenomenon of spontaneous echo contrast due to slow blood flow. (AVI 535 kb)

Video 4.3

Pre-procedural TOE. Unfortunately there was evidence of thrombus in her left atrial appendage. Risk of peri-procedural thromboembolic stroke would have been increased and therefore planned PBMV was deferred to allow intensification of antithrombotic medication by increasing target INR and later, because of persistent thrombus, by addition of low dose aspirin. When the thrombus has resolved, PBMV was performed. (AVI 465 kb)

Video 4.4

Mitral valve planimetry of orifice area using three-dimensional (3 D) TOE. (AVI 792 kb)

Video 4.5

Valvuloplasty procedure. Set-up left ventriculogram to delineate position of mitral valve apparatus. (AVI 2873 kb)

Video 4.6

Valvuloplasty procedure. Correct orientation for transseptal access is confirmed by tenting of the inter-atrial septum immediately prior to puncture. (AVI 460 kb)

Video 4.7

Valvuloplasty procedure. The Inoue balloon is sized according to the patient’s height. The deflated Inoue balloon is manipulated across the stenosed mitral valve, and the tip is moved to the ventricular apex to ensure no entanglement within the chordae tendinae. Subsequently, the balloon is inflated. At first, the distal portion opens and the balloon is pulled back into position at the mitral orifice. Following further dilatation, the proximal part opens, and finally the waist, which performs the commissurotomy. Sequential and progressively larger dilatations were performed. The initial inflation was at 22 mm, then 24 mm and finally 26 mm, with assessment of the result after each inflation. (AVI 8444 kb)

Video 4.8

Valvuloplasty procedure. Live 3D TOE of the final 26 mm balloon dilatation. The deflated balloon can be seen exploring the mitral valve until the opening is found and it is then advanced into the LV. Later the atrial portion of the balloon can be seen filling. (AVI 6610 kb)

Video 4.9

Valvuloplasty procedure. Invasive haemodynamic and non-invasive TOE measurements confirmed good relief of stenosis with the transmitral gradient falling from 11 mmHg to 7 mmHg and the mitral valve area increasing to 1.3 cm2. There was no significant post-procedural mitral regurgitation. (AVI 681 kb)

Recommended Reading

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Copyright information

© Springer-Verlag London 2017

Authors and Affiliations

  1. 1.LondonUK
  2. 2.Royal Infirmary of EdinburghEdinburghUK
  3. 3.Queen Elizabeth HospitalBirminghamUK

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