Q. Surgical Treatment of mitral stenosis?

Available surgical treatment modalities include closed mitral valvotomy, open mitral valvotomy, and mitral valve replacement. With the advent of balloon valvuloplasty, closed mitral valvotomy is fast becoming extinct. Selection of patients is like that of balloon valvuloplasty. However, surgical morbidity is more. It may be considered in a rare situation, when balloon valvuloplasty cannot be done expeditiously in a very sick patient but surgical therapy is immediately available. Barring such a situation, there is hardly any scope for closed mitral valvotomy in modern day cardiology practice. Open mitral valvotomy is an attractive procedure for the surgeon but neither to the patient nor to the cardiologist. It has been proved in a randomized trial that open mitral valvotomy is not superior to balloon valvuloplasty both in immediate and long term results. It is much more costly procedure with higher risk of morbidity and mortality compared to balloon valvuloplasty. It may be considered in a rare patient who has tight mitral stenosis, sinus rhythm and a large left atrial clot with a pliable valve or along with other open cardiac surgical procedures like aortic valve replacement and coronary artery by pass surgery.

Mitral valve replacement is the procedure of choice in a symptomatic patient with tight mitral stenosis and a non pliable valve. Any valve replacement is like buying a new disease and patient should be economically and logistically prepared for it. Patient will be committed for life long anticoagulation and possibility of infective endocarditis. Mechanical prosthetic valves are prone for valve thrombosis, and embolic complications. Inadequately monitored anticoagulant treatment could lead to valve thrombosis or hemorrhagic complications. Presence of atrial fibrillation by itself is not an indication for vale replacement in a patient with pliable valve and tight mitral stenosis, as the long term complications are more with prosthetic valve. Surgery should not be denied to a patient with significant symptoms as the delay in surgery will expose the patient to the complications of mitral stenosis and will adversely affect the long term outcome of the surgery.

These include severe pulmonary hypertension, which some times may not come down following mitral valve replacement. A patient with advanced right heart failure and severe cardiac cachexia and hepatic and renal failure also is a poor candidate for surgery and patient should not be allowed to reach that stage before performing mitral valve replacement.