Timing of Intervention in Mitral Stenosis Ted Feldman

Timing of Intervention in Mitral Stenosis Ted Feldman, M. D. , FSCAI FACC FESC Evanston Hospital CRT Cardiovacular Research Technologies Washington, D. C. February 23 – 26, 2013

Ted E. Feldman, MD Consulting: Abbott Laboratories Boston Scientific Corporation Edwards Lifesciences, LLC

Indications for Percutaneous Mitral Balloon Valvotomy CLASS I Indication A Symptomatic, MVA ≤ 1. 5 cm 2, MR≤ 2, no LA clot C Asymptomatic, PASP>50 mm Rest/60 mm exercise IIa C Calcified valve, NYHA III–IV, and are either not candidates or high risk for surgery IIb C Asymptomatic with new onset of atrial fibrillation C Symptomatic, MVA>1. 5 , PASP>60 mm. Hg, PCW≥ 25 mm, mn MV gradient >15 mm Hg exercise C Alternative to surgery with mod-severe MS, calcified valve, NYHA III–IV III C Mild MS, moderate to severe MR or left atrial clot JACC 52, 2008: e 1– 142

Indications for Percutaneous Mitral Balloon Valvotomy CLASS I Indication A Symptomatic, MVA ≤ 1. 5 cm 2, MR≤ 2, no LA clot C Asymptomatic, PASP>50 mm Rest/60 mm exercise IIa C Calcified valve, NYHA III–IV, and are either not candidates or high risk for surgery IIb C Asymptomatic with new onset of atrial fibrillation C Symptomatic, MVA>1. 5 , PASP>60 mm. Hg, PCW≥ 25 mm, mn MV gradient >15 mm Hg exercise C Alternative to surgery with mod-severe MS, calcified valve, NYHA III–IV III C Mild MS, moderate to severe MR or left atrial clot JACC 52, 2008: e 1– 142

ECHO Score Mobility Subvalvular Thickening Calcium 1 tips restricted minimal thickening nl (4 -5 mm) single area 2 mid & base nl 1/3 chordal length leaflet margins 5 scattered -8 mm 3 valve moves forward thick to distal chords entire leaflet 58 mm 4 barely mobile extensive to paps >8 -10 mm thick mid leaflets extensive Br Heart J 60: 299, 1988

Spectrum of Valve Deformity LV LA Mild LV LA Moderate LA Severe LV

Left Atrial Smoke

Left Atrial Thrombus Resolution After Warfarin Therapy PRE Post 4 months warfarin 80% of thrombi resolve after 2 months of anticoagulation AHJ 140: 150, 2000

Organized Left Atrial Thrombus 65 F, CABG 6 months prior, Stroke 2 months prior Coumadin 8 for weeks, Successful PTMC

Leaflet Lesion Recent TIA

Mitral Stenosis & Mitral Annular Calcification

Calcific Mitral Stenosis Dialysis

Bioprosthetic Mitral Stenosis 88 YO female with atrial fibrillation & bioprosthetic aortic and mitral valve replacement, TV repair in 2009

Bioprosthetic Stenosis 24 mm PTMC