Catheter Management Of Mitral Stenosis

Mitral stenosis (MS) is a common valvular disorder. Despite advances in modern medicine, rheumatic heart disease (RHD) remains the most common cause of mitral stenosis. It usually presents in patients between 20 and 40 years of age and about 10 to 15 years after the onset of rheumatic fever. In the United States, mitral stenosis secondary to RHD most commonly presents in the immigrant population and the impoverished with limited access to healthcare. Calcific degenerative mitral valve stenosis disease (DMS) is another cause of mitral stenosis but is far less common and more often seen in the elderly.[1] Patients with symptomatic mitral stenosis usually present with symptoms of heart failure, atrial fibrillation, or thromboembolism. Risk factors for mitral stenosis include a history of rheumatic fever and/or a previously untreated streptococcus infection. Some data exists suggesting that patients on dialysis are at increased risk for mitral stenosis.[2] Physical examination may reveal prominent a wave in the jugular pulse, prominent tapping apical pulse, signs of right-heart failure, accentuation of the P2, an opening snap, and the classic low-pitched, rumbling diastolic murmur with presystolic accentuation. A chest radiograph may show prominence of the pulmonary arteries, left atrium, right ventricle, and right atrium which is a result of the build of pressure behind the valve. The electrocardiogram may show right ventricle hypertrophy along with a notched p-wave with a duration of >0.12 seconds in lead II; this is referred to a P mitrale. The diagnostic test of choice for percutaneous transcatheter mitral valve replacement (PMVR) remains to be the echocardiogram. While surgery is the procedure of choice for severe, symptomatic mitral stenosis, another option for patients not deemed candidates for open heart surgery is percutaneous transcatheter balloon mitral valvuloplasty (PBMV). However, these patients must also have suitable mitral valve anatomy on echocardiogram.[3] Other transcatheter procedures have been developed. Valves designed for transcatheter aortic valve replacement have been used to treat degenerative mitral stenosis in a procedure called percutaneous transcatheter mitral valve replacement (PMVR).[4] This chapter will describe in detail the mitral valve, pathology of mitral stenosis, possible options for catheter management for mitral stenosis, indications, contraindications, Wilkins scoring system, techniques, complications, and the clinical significance of catheter management of mitral stenosis.