Mitral Stenosis: Ahmad Adityawarman

Mitral Stenosis
Ahmad Adityawarman
Introduction
• MS remains a major cause of valve disease worldwide
• Most of MS in the world results from rheumatic heart disease (RHD)
• Nonrheumatic calcific MS is found with ↑ frequency in the elderly
population in high-income countries
• Rheumatic MS is low in high-income countries & slowly ↓ in low- and
middle-income countries
2020 ACC-AHA guideline for the management of patients with valvular heart disease
Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018.
Epidemiology
• RHD is one of the leading noncommunicable diseases in developing
countries, global prevalence > 19.6 million (2005) & 282,000 new
cases/year
• + 2/3 of rheumatic MS cases are female
• The clinical presentation of rheumatic MS varies:
• high disease prevalence: presenting at a young age (teen years to age 30) with
commissural fusion but pliable noncalcified valve leaflets
• low disease prevalence: more often in older patients (age 50 to 70 years),
present decades after the initial rheumatic fever (RF)

Anatomy
Mitral apparatus
• Left atrial wall
• Annulus
• Commissures
• Leaflets: anterior (aortic/septal) & posterior (ventricular/mural)
• Zone: anterior  rough & clear zone; posterior  rough, clear, & basal zone
• Segmental classification: anterior  A1, A2, A3; posterior  P1, P2, P3
• Chordae tendineae: marginal (free edge-commissural), strut (rough zone), basal;
primary, secondary
• Papillary muscles: anterolateral, posteromedial
• Left ventricular wall
Kouchoukos NT et al. Kirklin/Barrat Boyes cardiac surgery 4th edition. 2013
Kanjanauthai S. Mitral valve anatomy. 2018. https://emedicine.medscape.com/article/1878301-overview#a2
Anderson RH et al. Wilcox’s surgical anatomy of the heart 4th edition. 2013
Sellke F et al. Atlas of cardiac surgical technique. 2010
Pathophysiology
Mechanism of Valve Obstruction
• Rheumatic: Commissural fusion, posterior leaflet thickening & restriction,
thickening & rigidity of anterior leaflet &/or subvalvular apparatus
• Degenerative mitral annular calcification: significant stenosis seldom
occurs & related to restriction of both leaflets dt extensive calcification
without commissural fusion
• Congenital MS: consequence of abnormalities of the subvalvular
apparatus
• Inflammatory disease (SLE), infiltrative dis., carcinoid dis., drug-induced
valve dis.: predominance of leaflet thickening & restriction, seldom with
fusion of commissures
Otto CM, Bonow RO. Valvular heart disese a companion to Braunwald’s Heart Disease, 4th ed. Philapdelphia : Elsevier. 2014
Severity of commissural fusion in RHD:
• Grade I—partial fusion of the commissures with chordal
preservation
• Grade II—complete fusion of the commissure with preserved
delineation between the anterior & the posterior leaflets
• Grade III—complete fusion of the commissures with absence of
leaflet delineation & calcium deposition
Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

Doty DB, Doty JR. Cardiac surgery operative technique, 2nd ed. Philadelphia : Elsevier. 2012
Hemodynamic Consequences of MS
1. Mitral gradient: ↑ in pressure gradient (in the beginning)
• For a given valve area, mean mitral gradient ↑ when CO ↑ or
when tachycardia ↓ duration of diastolic filling
• Atrial contraction contributes to the increase of transmitral flow in
end-diastole  mitral gradient ↑
• Severe MS  low mitral gradient (low CO), particularly in chronic
AF
2. Left Atrium
• Mitral gradient  ↑left atrial pressure (LAP)  enlargement of LA  AF
• MS  blood stasis in LA  ↓ systolic pulmonary vein flow
• AF  impaired blood stasis & LA appendage flow velocities 
thrombosis  LA thrombus
3. Pulmonary Circulation
• ↑ LA pressure  ↑ pulmonary artery pressure
• Pulmonary hypertension (PH) worsened by an increase in pulmonary
vascular resistance (PVR), which determines a gradient larger than 10
mm Hg between diastolic pulmonary pressure and left atrial pressure
• ↑ PVR involves vasoconstriction & structural changes of the pulmonary
arterial wall  persistent PH after intervention in MS
4. Right Heart
• Chronic PH  RVH, RV dilation  TR, Right HF
5. Left Ventricle
• LV size generally normal or moderately reduced
• Impaired diastolic filling, ↑ contribution of LA contraction
(hemodynamics are severely impaired when AF disturbs atrial
contraction)
• ↓stroke volume
Natural History of Rheumatic Heart Disease
• Early stage acute RF  pancarditis & valvulitis  mitral regurgitation (MR) in
very young patients (< 10 years)  patients get older  mixed mitral & aortic
valve diseases in 2nd decade of life  rheumatic MS increases in prevalence
• Pattern of MV pathology among different endemic regions is variably
• Characteristic: Progression of the disease over many years after acute RF
• MVA will decrease about 0.1–0.3 cm2 per year depending on the individual risk
• Risk factors for progression: severity of carditis, recurrences of RF, low mother
socioeconomic level, relevant impairment of the MV anatomy (Wilkins score ≥
8), peak mitral gradient ≥ 10 mmHg
• MV orifice area > 1.5 cm2  generally asymptomatic & good 10-year survival
2019 Rheumatic Mitral Valve Stenosis Diagnosis and Treatment Options

Clinical Presentation
History
• Dyspnea/paroxysmal dispnea
• Paroxysmal cough/hemoptysis
• Fatigue
• Asthenia & abdominal pain
• Hoarseness
• Palpitation
• Embolic events
Physical Examination
• Loud S1, opening snap in early
diastole just after S2, followed by a
holodiastolic rumbling murmur that
decreases in intensity with time &
increases in end-diastole in patients
with sinus rhythm
• Arrhythmia
• Pulmonary rales
• Hepatomegaly, peripheral edema,
jugular distension
• “Mitral facies”
Otto CM, Bonow RO. Valvular heart disese a companion to Braunwald’s Heart Disease, 4th ed. 2014
Workup
Chest Radiography
• LAE: LA double density, prominence
of the LA appendage
• PH  dilation of PA trunk & branches
• Early stage: normal heart size
• Severe chronic MS  RV & RA
enlargement, cardiomegaly
• Elevated LA pressure  pulmonary
vascular redistribution  interstitial
edema
• Decompensation  alveolar edema
Electrocardiography
• Early stage: LAE
• Advanced disease with severe and/or longstanding PH: RAE, RVH,
RAD, RBBB
• Atrial arrhytmias: frequent atrial premature beats, AF
(transient/persistent), atrial flutter/tachycardia (less common)
Echocardiography
• Diagnostic features:
leaflet thickening &
decreased mobility,
commissural fusion,
involvement of the
subvalvular apparatus
• Assess the
• Severity
• Morphology
Echocardiography (TTE)
• PLAX: doming characteristic
• PSAX
• Planimetry: measure the MVA, useful for BMV monitoring & evaluation, can
be difficult in irregular & heavily calcified area or poor echogenity
• Assesses commissural fusion (diagnostic of RHD, feasibility of balloon/surgical
valvotomy)
• Pressure half-time (4CAV): widely used; may be misleading in AR,
abnormal compliance of cardiac chambers, & immediately after BMV
• PISA (the proximal isovelocity surface area)  M-mode
• Mean mitral gradient (pulsed or continuous wave Doppler)
MVA = 220/PHT
Echocardiography made easy

The practice of clinical echocardiography
• The severity of valvular & subvalvular
involvement is described by a combined
score (Wilkins & Cormier Score)
• Limitations: lack of a detailed location of
calcification & leaflet thickening, particularly
in relation to commissural areas; tend to
underestimate the weight of subvalvular
apparatus impairment
Cardiac Catheterization
• Seldomly used
• Indication:
• Discordance between the clinical & echo finding
• Older patients: other factors contributing to symptoms may need to be
further sorted out, such as concomitant diastolic dysfunction, LA
noncompliance, or intrinsic pulmonary vascular disease.
• MVA calculation
Bojar RM. 2011. Manual of perioperative care in adult cardiac surgery 5th edition.
Management & Treatment
Medication
• Secondary prophylaxis of RF: for patients with previous episodes of RF
or in those with evidence of RHD
• Treatment for AF: anticoagulant, negative dromotropic agents (B-
blocker/ivabradine), cardioversion
• Treatment for HF: diuretic
2019 Rheumatic Mitral Valve Stenosis Diagnosis and Treatment Options
Percutaneous Mitral Balloon
Commissurotomy
• PMBC is performed by advancing one/more balloon catheters across
the MV & inflating them, thereby splitting the commissures
• The most common techniques are the transseptal approaches, using
either a double-balloon or the Inoue balloon system (most commonly
used)
• Favorable valve morphology consists of mobile and relatively thin
valve leaflets, which are free of calcium, in the absence of significant
subvalvular fusion
• 70% to 80% of patients free of recurrent symptoms at 10 years, and
30% to 40% are free of recurrent symptoms at 20 years
Nunes MCP, et al. Update on percutaneous mitral commissurotomy. Heart 2016
ACC-AHA 2020 guideline for the management of patients with valvular heart disease
Percutaneous Mitral Balloon
Commissurotomy
• Indication: • Contraindication
• Symptomatic patients (NYHA class • Wilkin score > 8 (relative?)
II-IV) • MR moderate – severe
• Asymptomatic: PASP > 50 mmHg, • LA thrombus
new onset AF
• Severe rheumatic MS (mitral valve
area < 1.5 cm2 , Stage D) with
favorable valve morphology
• MVA > 1.5 cm2 but PAWP > 25
mmHg/mean MV gradient >
15mmHg at exercise
Bashore, T.. “VALVULAR HEART DISEASE PERCUTANEOUS BALLOON VALVULOPLASTY 322.” (2004).
Immediate Result of Complications of
PMBC PMBC
• Indicator of success: > 50% • Severe MR (1,5-7,5%)
increase in MVA or MVA > 1.5 • Cardiac tamponade
cm2 without significant increase
in MR (MR < 3) • Embolic event
• Procedural success rates: 65 – • Bleeding
80%
Nunes MCP, et al. Update on percutaneous mitral commissurotomy. Heart 2016

History of MV Surgery
• 1923: first successful MV surgery (commissurotomy) by Elliott Cutler
through LV apex with a tenotomy knife on a young girl
• 1925: Souttar performed digitally enlargement of MV opening
• 1951: Harken reported results in 86 patients, 71 of whom had
undergone simple “finger fracture valvuloplasties”
• 1948: Closed commissurotomy by Bailey
• 1950s: Invention of CPB machine
• 1984: Kanji Inoue invented balloon valvuloplasty
Weisse AB. The surgical treatment of mitral stenosis: the first heart operation. Am J Cardiol 2009
Indication for Surgery
• Severely symptomatic (NYHA class III or IV)
• Severe rheumatic MS (mitral valve area < 1.5 cm2 , Stage D
• Not candidates for PMBC
• Failed a previous PMBC
• Require other cardiac procedures
• No access to PMBC
Surgery
• MVr
• Commissurotomy
• Leaflet Resuspension (Subvalvular
Techniques) • MVR
• Leaflet Augmentation with a • Bioprosthetic
Gluteraldehyde-fixed Autologous • Mechanical valve
Pericardial Patch
• Decalcification Techniques
Pre-operative
• Optimization of cardiac output
• AF control (ß-blocker/CCB, digoxin)
• Adjust preload (fluid balance) judiciously
• Many patients with long-standing MS are cachectic & at ↑ risk for respiratory
failure. Aggressive preoperative diuresis and nutritional supplementation may
reduce morbidity in the early postoperative period
• Anticoagulation
• Stop Warfarin 4 days before surgery.
• In high risk of embolization, outpatient LMWH may be prescribed, but stopped 18–24
hours before surgery.
• Admission for UFH the day before surgery may be considered once the international
normalized ratio (INR) falls below the therapeutic range
Bojar RM. 2011. Manual of perioperative care in adult cardiac surgery 5th edition.
Surgical Approach
• Open sternotomy
• Left atriotomy (entry through Sondergaard’s groove)
• Left atrial dome
• Trans septal – modified trans septal – superior septal – extended vertical trans
septal (Guiraudon)
• Left thoracotomy
• Minimally invasive/robotic
• Trans aortic
• Mitral valve surgery through left ventriculotomy
Sultan I et al. Surgical approaches to the mitral valve: variable paths to the same destination. Indian J Thorac Cardiovasc Surg. 2017
Vertical left atriotomy
• After a median sternotomy, incise the pericardium longitudinally and firmly suspend
the right side to the pectoralis fascia, the drapes, or the retractor, while leaving the
left side unsuspended. This allows elevation of the heart, and the rotation of the apex
of the heart posteriorly improves the ease of mitral valve visualization.
• Institute total CPB through aortic and bicaval venous cannulation.
• Insert antegrade and retrograde cardioplegia cannulas, dissect the intrapericardial
caval attachments a short distance (2 to 3 cm), using care to avoid injury to the
posteriorly located azygos or hepatic veins.
• After cardioplegic arrest, apply caval tourniquets or Cooley caval clamps (Pilling Weck,
Research Triangle Park, NC).
• Anterior and leftward traction on the inferior vena caval tourniquet further improves
exposure.
Pezella AT et al. Operative approaches to the left atrium and mitral valve: an update. Op Tech Thorac Cardiovasc Surg 1998
• Initiate the vertical left atriotomy anterior to the right superior
pulmonary vein and posterior to the interatrial sulcus (Sondergaard’s
groove).
• Extend it in a “C” fashion superiorly behind the superior vena cava
(SVC), avoiding injury to the right pulmonary artery, and inferiorly into
the oblique fissure behind the inferior vena cava (NC).
• Rotate the table to the left. Exposure of the LA is accomplished with
the hand held Cooley mitral valve retractors (Pilling Weck) or the self
retaining Cosgrove (Cosgrove Mitral Valve Retractor, Kapp Surgical
Instrument, Inc, Cleveland, OH) or Carpentier (Bonchek Modified
Carpentier or Lemole-Pilling Mitral Valve Retractor Systems, Pilling
Weck) systems.
• Particularly when the IVC-pericardial reflection has been transected,
use great care to avoid excessive left atrial traction and the possible
consequence of NC avulsion. Dissection under the SVC with ligation
and division of the azygos vein allows extension of the cephalad limb
of the atriotomy onto the superior aspect of the left atrium.
• A headlight improves lighting in the tunnel-like exposure of the mitral
valve.
• A pericardial pack behind the apex of the LV increases exposure of the
anterolateral papillary muscle, whereas a pack between the inferior
diaphragm and the heart increases exposure of the posteromedial
papillary muscle.
• Pushing against difficult-to-see areas of the mitral annulus also aids in
visualization.
• Left heart venting may be achieved through the RSPV, PA, LV apex, or
the aortic root.
• Flooding the pericardial cavity with CO2 reduces the amount of
intracardiac air retention.
• Readminister cardioplegia as appropriate (usually every 10 to 15
minutes).
• After completion of the intracardiac procedure, close the left
atriotomy with a single layer 3-0 polypropylene suture, taking care to
approximate the endocardial surfaces in order to achieve maximal
closure strength and avoid an intramural atrial dissection.
Mitral Valve Repair (MVr)
• MVr is always preferred to mitral valve replacement due to
• << perioperative mortality rates,
• superior preservation of left ventricular function,
• << thromboembolic complications & risk of endocarditis (critical in patients
with deficient socio-economic conditions),
• greater long-term durability (particularly important in young patients)
• Feasible in only 50 to 75% of patients with RMVD (percentage varies
according to age, leaflet dysfunction & degree of calcification)
• Main goal: ensuring (as much as possible) leaflet mobility & pliability

Commissurotomy

Commissuroplasty

Leaflet Resuspension (Subvalvular Techniques)
• Subvalvular techniques  chordal resection & fenestration
• Excessive fibrosis & fusion of the subvalvular apparatus  split the
papillary muscle, resect the marginal chords and subsequent
replacement (neochordoplasty)
• The secondary chordae to be resected should be identified & isolated
with a nerve hook.
• The attachment to the papillary muscle is usually cut first (easier
visualization) to subsequently expose the leaflet attachment by gentle
traction.

• In severe cases (rarely amenable to
repair), marginal chordae can be also
resected as long as there is one
marginal chordae every 4 mm to
support the free edge of the leaflet
• Fused marginal chordae contributing
to subvalvular obstruction are not
resected but fenestrated
• Fenestration is usually carried down
thus spilling the corresponding
papillary muscle

Neochordoplasty
• A CV-5 double-armed polytetrafluoroethylene suture is passed and
looped through the fibrous tip of the papillary muscle
• The two ends of the artificial chord are passed through the leaflet
margin (approximately with a 3-mm distance between them) and a
two slip knots are tied
• After functional adjustment (insufflation of saline test after
remodeling annuloplasty to assess the plane of coaptation and
chordal height), a minimum of six knots are then completed to secure
the new chord.

Leaflet Augmentation
• Most commonly to the posterior leaflet
• Aim: to increase leaflet surface area in severe leaflet retraction (when
mobilization cannot be achieved with subvalvular techniques) or to
replace leaflet segments where severe calcification has led to a
significant defect after resection that cannot be closed primarily
• Pliability of the anterior leaflet is assessed by pushing the anterior
leaflet with a pair of forceps; if the leaflet rebounds into position then
fibrosis probably precludes repair techniques

Decalcification techniques
• Calcified areas can be shaved off the leaflet and the annular hinge to
facilitate leaflet excursion
• The thick fibrotic layer of tissue that accumulates on the atrial surface
of the leaflet can be peeled off
• The leaflet thinning should be always performed in leaflet areas
amenable to a potential patch augmentation (leaflet thinning may
lead to secondary windsock deformity and perforation).
• If all these techniques do not compensate for leaflet retraction and
scarring, leaflet extension is performed

MV Replacement (MVR)
• Indication in MS: significant dystrophic changes
• marked thickening & shortening of all chordae
• obliteration of the subvalvular space
• agglutination of the papillary muscles
• calcification in both annular and leaflet tissue
• For young patients, patients in chronic AF (require long-term
anticoagulation), & to minimize the chance of reoperation, a
mechanical prosthetic valve should be chosen.
• The St. Jude Medical bileaflet valve is the most widely used prosthetic
because it has good hemodynamic characteristics & easy to insert.

Preservation of Chordae Tendineae
A. The mitral valve is perforated B. Continue the incisions
through the anterior leaflet. circumferentially.
About 2 mm of the leaflet

tissue is left attached to the
annulus.
D. Only normal length

chordae tendineae should
be preserved.
C. The AML is divided through its midpoint to
facilitate working with the valve and chordae.
E. The chordae are reattached to the
mitral annulus. Favored points are the 2,
4, 8, and 10 o’clock positions.
G. Stitches used to attach the

prosthetic valve should pass
around the annulus and penetrate
the leaflet remnant retaining the
chordae tendineae.
I. New chordae
tendineae should be
created.
H. When the chordae have been

hopelessly destroyed, they must be
totally divided.
Kim WK, et al. Clinical outcomes in 1731 patients undergoing mitral valve surgery for rheumatic valve disease. Heart 2017;0:1–8
Congenital MS

Non-rheumatic Calcific MS

Mitral Stenosis: Ahmad Adityawarman

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Mitral Stenosis

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018.

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

2019 Rheumatic Mitral Valve Stenosis Diagnosis and Treatment Options

Echocardiography made easy

Nunes MCP, et al. Update on percutaneous mitral commissurotomy. Heart 2016

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018.

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

About 2 mm of the leaflet

D. Only normal length

G. Stitches used to attach the

H. When the chordae have been

Cohn LH et al. Cardiac surgery in the adult 5th edition. 2018

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