- percutaneous mitral balloon valvulotomy (PMBV)
- mitral commissurotomy
- mitral valve replacement
Percutaneous Mitral Balloon ValvulotomyIn MS, the flexible flaps that open and close as the heart contracts (mitral valve leaflets) often become fused together, preventing the valve from opening completely. PMBV attempts to separate the leaflets from one another to relieve the obstruction.
In PMBV, a long, thin, flexible tube (catheter) with a deflated balloon attached to it is passed across the mitral valve. The balloon is then expanded. The aim is to break the adhesions that have fused the mitral valve leaftlets to each other.
Because PMBV is not an open surgery, it is much less of an ordeal for patients than the other forms of mitral valve surgery. Complications tend to be relatively minimal, and recovery from the procedure is usually quite easy. PMBV is also very effective when performed on the right patients.
In general, PMBV is the surgical procedure your doctor will recommend to address your mitral stenosis, unless you have:
- a left atrial thrombus (blood clot)
- severe calcium deposits on or near your mitral valve
- moderate to severe mitral regurgiation -- when the mitral valve doesn't close properly, allowing blood to leak through the valve
In addition, PMBV is usually not an option when your MS is part of a congenital heart condition, since that means that you also likely have complicated heart anatomy.
MS can gradually worsen again following PMBV. For this reason, even after having this procedure, it is important to have routine cardiac evaluations. Up to 21% of patients who have PMBV will eventually need a second treatment.
The goal of a mitral commissurotomy is the same as PMBV -- to separate the fused leaflets from one another. What's different with mitral commissurotomy, however, is that it is an open-heart procedure that achieves this goal with the use of a sharp surgical blade.
Commissurotomy very often leads to good results. Still, you're exposed to the risks of a major surgery and much longer recovery time, which is what stops doctors from recommending it as a first choice.
Commissurotomy is often a good option for people who would be candidates for PMBV except for the presence of a left atrial thrombus, calcification, or mitral regurgitation.
Similar to PMBV, MS can gradually recur following commissurotomy, so patients who have this procedure require continued routine cardiac evaluations.
Mitral Valve Replacement
Mitral valve replacement is the last choice, because it carries a higher risk of complications than either PMBV or commissurotomy. Valve replacement is necessary when the MS has caused the mitral valve to become very severely damaged or calcified, making the other two procedures impossible.
In mitral valve replacement, the valve is replaced with an artificial (prosthetic) valve. Prosthetic valves can either consist entirely of man-made materials (mechanical valves), or they can be made from the heart valve of an animal, generally a pig (bioprosthetic valve). Deciding which type of artificial valve to use depends on your age and whether you can take the blood thinner Coumadin.
All artificial heart valves have an increased propensity to form blood clots. However, blood clotting is less of a problem with bioprosthetic than mechanical valves, so people with the former generally do not have to take chronic Coumadin therapy; those with mechanical valves do.
Mechanical valves generally seem to last longer than bioprosthetic valves. If you need a mitral valve replacement, are under age 65, and you can take Coumadin, your doctor will likely recommend this option to you. If you are older than 65, or you are younger but can't take Coumadin, a bioprosthetic valve is generally recommended.
Your Mitral Stenosis Surgery DecisionIf you have MS, you will need to work closely with your cardiologist to decide whether and when surgery becomes necessary, and then choose the surgical approach that best suits your individual needs. With early diagnosis and conscientious cardiac care, most individuals with MS today can plan to live nearly normal lives.
Bonow, RO, Carabello, BA, Chatterjee, K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.