SURGICAL APPROACH

MITRAL VALVE

TRICUSPID VALVE

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MITRAL VALVE STENOSIS

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AETIOLOGY:
Almost exclusively Rheumatic disease.
FEATURES:

• Fibrous thickening of the Mitral valve.
• Followed later by heavy calcification.
• Commisures are typically fused.
• Thickened chordae and sometime shortened up to a degree where the leaflets are directly attached to the papillary muscles.
• Pathognomonic fish mouth narrowing  of the mitral valve orifice.

HAEMODYNAMICS:

• Resultant increase in the transvalvular gradient.
• Elevated left atrial pressure leading to left atrial enlargement.
• Gradually increasing pulmonary hypertension.
• Late onset of atrial fibirillation
• Thrombus formation in the dilated fibrillating left atrium.
• LV function remain preserved except with concomitant heavy rheumatic pericarditis.
• Congestive heart failure with low cardiac output features causing worseing dysponea and fatigue.

INDICATION FOR SURGERY 
Surgery is indicated in symptomatic patients who do not meet the echocardiographic criteria for percutaneous transluminal balloon valvoplasty:

• Excessive calcification
• Commissural calcification
• Concomitant mitral regurgitation
• Left atrial thrombi 

Surgery is offered for:

• Severely symptomatic NYHA III-IV with MVA < 1.5cm2 (<0.8 cm2/m2) with diastolic gradient > 8mmHg.
  
• Less symptomatic NYHA II with 

              - MVA < 1cm2, or
              - Systolic PAP > 50mmHg at rest or 60mmHg during exercise

• Onset of AF and / or left atrial thrombi

            

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