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| [[Image:250px-Diagram_of_the_human_heart_(cropped).svg.png|right|frame|Anterior (frontal) view of the opened heart. White arrows indicate normal blood flow. (Mitral valve labeled at center right.)]]
| | __NOTOC__ |
| {{Mitral valve stenosis surgery}} | | {{Mitral stenosis surgery}} |
| '''For the WikiPatient page for this topic, click [[Mitral valve surgery (patient information)|here]]''' | | '''For patient information, click [[Mitral valve surgery (patient information)|here]]''' |
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| {{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]][mailto:msbeih@perfuse.org];
| | '''To go back to the main page on mitral stenosis, click [[Mitral stenosis|here]]''' |
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| ==Overview==
| | {{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org] |
| [[Mitral valve]] surgery can be either a repair for the mitral valve or totally replace it in the heart. | |
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| Beside Percutaneous mitral balloon valvotomy (PMBV), surgical treatments for mitral stenosis include:
| | ==[[Mitral stenosis surgery overview|Overview]]== |
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| *Closed commissurotomy.
| | ==[[Mitral stenosis surgery indications|Indications]]== |
| *Open commissurotomy (valve repair).
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| *Mitral valve replacement.
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| In '''open surgery''', the surgeon makes a large cut in the sternum to reach the heart.
| | ==[[Mitral stenosis surgery preoperative evaluation|Preoperative Evaluation]]== |
| '''Minimally invasive''' mitral valve surgery is done through much smaller surgical cuts than the large cuts needed for open surgery.
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| | ==[[Mitral stenosis surgery procedure|Procedure]]== |
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| '''Symptoms of Mitral stenosis'''
| | ==[[Mitral stenosis surgery recovery|Recovery]]== |
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| In adults there may be no symptoms. Symptoms may, however, appear or get worse with exercise or any activity that raises the heart rate. In adults, symptoms usually develop between ages 20 - 50.
| | ==[[Mitral stenosis surgery outcomes and prognosis|Outcomes and Prognosis]]== |
| Symptoms may begin with an episode of [[atrial fibrillation]], or may be triggered by pregnancy or other stress on the body, such as infection in the heart or lungs, or other heart disorders.
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| Symptoms may include:
| | ==[[Mitral stenosis surgery complications|Complications]]== |
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| * Chest discomfort.
| | ==[[Mitral stenosis surgery videos|Videos]]== |
| *[[Heart failure]] symptoms, such as dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea.
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| *[[Palpitations]].
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| *Chest pain.
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| *[[Hemoptysis]].
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| *[[Thromboembolism]]
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| *Frequent respiratory infections such as bronchitis.
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| *[[Ascites]] and [[edema]] (if right-sided [[heart failure]] develops).
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| *Fatigue, becoming tired easily.
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| Symptoms increase with exercise and pregnancy
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| In infants and children, symptoms may be present from birth (congenital), and almost always develop within the first 2 years of life. Symptoms include:
| | ==External Links== |
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| *Bluish discoloration of the skin or mucus membranes ([[cyanosis]])
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| *Poor growth
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| *Shortness of breath
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| '''Causes of Mitral stenosis''' include:
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| *Almost all cases of mitral stenosis are due to disease in the heart secondary to [[rheumatic fever]] and the consequent [[rheumatic heart disease]].
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| *Calcification of the mitral valve leaflets.
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| *There are primary causes of mitral stenosis that emanate from a cleft [[mitral valve]].
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| *Bacterial endocarditis where the vegetations may favor increase risk of stenosis.
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| *Radiation treatment to the chest.
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| *Some medications may cause mitral stenosis.
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| Children may be born with mitral stenosis (congenital) or other birth defects involving the heart that cause mitral stenosis. Often, there are other heart defects present, along with the mitral stenosis.
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| Mitral stenosis may run in families.
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| Mitral stenosis is the most common valvular heart disease in pregnancy<ref>{{cite doi|10.1136/bmj.39365.655833.AE}}</ref>.
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| ==Treatments for Mitral valve stenosis==
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| ==Indications for Mitral valve stenosis surgery==
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| There is improvement in the mortality rates for mitral stenosis by intervention by percutaneous mitral balloon valvotomy or surgery.
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| The 2006 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the management of valvular heart disease recommended intervention in symptomatic patients with moderate to severe mitral stenosis <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref>.
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| In asymptomatic patients, intervention is recommended in moderate to severe MS and pulmonary hypertension (pulmonary artery systolic pressure >50 mmHg at rest or >60 mmHg with exercise).
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| When intervention is indicated in patients with rheumatic MS, the 2006 ACC/AHA guidelines recommend that Percutaneous mitral balloon valvotomy (PMBV) is preferred to surgery if the valve morphology is favorable and the patient does not have left atrial thrombus or moderate to severe (3+ to 4+) mitral regurgitation. Valve repair is performed if possible and preferred over valve replacement which has higher perioperative mortality and morbidity. Valve repair includes both open commissurotomy and placement of an annuloplasty ring after direct visualization of the valve <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref>.
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| The ACC/AHA guidelines indicates surgery when one of the following is presents <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref>:
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| *The mitral valve is severely calcified.
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| *Moderate to severe mitral regurgitation coexists with MS.
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| *PMBV is not available or the patient has unfavorable valve morphology.
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| *There is left atrial thrombus that persists despite anticoagulation.
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| Valve replacement improves long-term survival along with symptomatic improvement if the patient could not be treated by either PMBV or valve repair.
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| The decision of whether valvuloplasty is superior to surgery depends on age (<60 favors valvuloplasty), and Cath/ECHO findings (e.g. LVEDP, degree of mobility, thickening and calcification). The average end result with both strategies is about 2 cm2. Moderate or greater MR (mitral regurgitation) and LA thrombus are contraindications to valvuloplasty.
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| ==Preoperative preparation==
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| The patient may need to have some tests before the procedure. The Cardiologist usually conducts a physical examination and diagnose the condition within few days, he or she will assess the general health of the patient and will recommend the most appropriate treatment for the patient and if he or she needs surgery. Some of the '''tests that can be done before the procedure''' include:
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| *[[Cardiac catheterization]].
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| *Chest X-ray.
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| *Computed tomography (CT) scan.
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| *[[Echocardiogram]] (Doppler echocardiogram).
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| *[[Electrocardiogram]] (ECG).
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| *[[Electrophysiology]] tests.
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| *Exercise tests.
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| *[[Holter monitor]].
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| *[[Magnetic resonance imaging]] (MRI).
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| Many patients with mitral stenosis requiring surgery also have [[coronary artery disease]]<ref name="pmid11326232">{{cite journal| author=Lin SS, Lauer MS, Asher CR, Cosgrove DM, Blackstone E, Thomas JD et al.| title=Prediction of coronary artery disease in patients undergoing operations for mitral valve degeneration. | journal=J Thorac Cardiovasc Surg | year= 2001 | volume= 121 | issue= 5 | pages= 894-901 | pmid=11326232 | doi=10.1067/mtc.2001.112463 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11326232 }} </ref>. Usually coronary disease treated at the same operation if CABG (Coronary artery bypass grafting) is indicated. Studies showed that '''concurrent bypass surgery''' adds little morbidity to the valvular procedure and does not increase the mortality <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref>. The 2006 [[ACC]]/[[AHA]] guidelines on the treatment of valvular heart disease included recommendations for coronary angiography prior to valve surgery in those who are suspected to have coronary artery disease and in those at risk for coronary disease <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref>. A noninvasive angiography using computed tomography (CT) or magnetic resonance imaging may be an alternative.
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| '''Before the surgery''':
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| *The surgeon needs to know if the patient is taking any drugs, supplements, or herbs before the procedure.
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| *The patient may be able to store blood in the blood bank for transfusions during and after the surgery. The family members can also donate blood (autologous donation).
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| *For the 2-week period before surgery, the patient should be asked to stop taking drugs that make it harder for the blood to clot. These might cause increased bleeding during the surgery. Some of these drugs are [[aspirin]], [[ibuprofen]] (Advil, Motrin), and [[naproxen]] (Aleve, Naprosyn).
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| *The day before the surgery, the patient should shower and shampoo well and wash the whole body below the neck with a special soap.
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| *The patient may also be asked to take an [[antibiotic]] to guard against infection.
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| *The patient should be informed which drugs he or she should still take on the day of the surgery.
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| *The patient should stop smoking.
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| '''On the day of the surgery''':
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| *An intravenous (IV) line will be placed into a blood vessel in the patient's arm or chest to give fluids and medicines.
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| *The patient should be asked not to drink or eat anything after midnight the night before surgery. This includes chewing gum and using breath mints. The patient can rinse mouth with water if it feels dry without swallowing.
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| *Make sure that the patient is taking the drugs that he or she needs to take with a small sip of water.
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| *Hair near the incision site may be shaved immediately before the surgery.
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| *The patient should be informed when to arrive to hospital on the day of the surgery.
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| ==The procedure==
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| The Procedure can be done either by the traditional open heart surgery or by the [[Minimally invasive surgery]].
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| Before the surgery, the patient will receive '''[[general anesthesia]]'''. This will make the patient asleep and pain-free during the entire procedure.
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| Beside Percutaneous mitral balloon valvotomy (PMBV); there are three approaches for Mitral stenosis surgical treatment:
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| *'''Closed commissurotomy'''
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| It is the earliest surgical procedure. It is performed on a beating heart. In this procedure; the surgeon makes a left thoracotomy incision and introduce a dilator to the mitral valve via either a transatrial or transventricular approach. Closed commissurotomy is usually indicated for the patients with minimal mitral valve calcifications and in those who lack significant subvalvular involvement. This approach is contraindicated in the following conditions:
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| :*Mitral regurgitation (moderate or severe); as regurgitation may be worsened by the procedure.
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| :*Atrial thrombosis.
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| The limitation of closed commissurotomy is the difficulty for the surgeon to fully expose and visualize the Mitral valve during the procedure.
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| Some studies showed that Percutaneous mitral balloon valvotomy (PMBV) is associated with better long-term outcomes than closed commissurotomy <ref name="pmid9462525">{{cite journal| author=Ben Farhat M, Ayari M, Maatouk F, Betbout F, Gamra H, Jarra M et al.| title=Percutaneous balloon versus surgical closed and open mitral commissurotomy: seven-year follow-up results of a randomized trial. | journal=Circulation | year= 1998 | volume= 97 | issue= 3 | pages= 245-50 | pmid=9462525 | doi= | pmc= | url= }} </ref>, recently, closed commissurotomy becomes less performed than before in the developed countries.
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| Also in pregnancy; the PMBV is preferred over closed commissurotomy for mitral valve stenosis treatment <ref name="pmid3387943">{{cite journal| author=Pavankumar P, Venugopal P, Kaul U, Iyer KS, Das B, Sampathkumar A et al.| title=Closed mitral valvotomy during pregnancy. A 20-year experience. | journal=Scand J Thorac Cardiovasc Surg | year= 1988 | volume= 22 | issue= 1 | pages= 11-5 | pmid=3387943 | doi= | pmc= | url= }} </ref>.
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| *'''Open commissurotomy (valve repair)'''
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| The surgeon performs the procedure via median sternotomy. Via this surgical approach; it is better for the surgeon to fully expose and visualize the mitral valve during the procedure as compared to closed commissurotomy approach. Other advantages for this approach includes:
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| :*The surgeon can repair the valve by the dipridation of calcium deposits.
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| :*The surgeon can split fused chordae tendineae or papillary muscles.
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| :*The surgeon can insert annuloplasty ring to correct the valvular stenosis. This is needed in case of severe mitral regurgitation (grade 3 or 4) as the valve repair alone is in adequate.
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| :*The surgeon can remove a left atrial thrombus if presents.
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| Some studies showed that Percutaneous mitral balloon valvotomy (PMBV) is associated with better long-term outcomes than Open commissurotomy <ref name="pmid8084354">{{cite journal| author=Reyes VP, Raju BS, Wynne J, Stephenson LW, Raju R, Fromm BS et al.| title=Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. | journal=N Engl J Med | year= 1994 | volume= 331 | issue= 15 | pages= 961-7 | pmid=8084354 | doi=10.1056/NEJM199410133311501 | pmc= | url= }} </ref>, along with shorter hospital stay and less morbidity from thoracotomy (in Open commissurotomy) <ref name="pmid9462525">{{cite journal| author=Ben Farhat M, Ayari M, Maatouk F, Betbout F, Gamra H, Jarra M et al.| title=Percutaneous balloon versus surgical closed and open mitral commissurotomy: seven-year follow-up results of a randomized trial. | journal=Circulation | year= 1998 | volume= 97 | issue= 3 | pages= 245-50 | pmid=9462525 | doi= | pmc= | url= }} </ref><ref name="pmid9034637">{{cite journal| author=Lau KW, Ding ZP, Hung JS| title=Percutaneous transvenous mitral commissurotomy versus surgical commissurotomy in the treatment of mitral stenosis. | journal=Clin Cardiol | year= 1997 | volume= 20 | issue= 2 | pages= 99-106 | pmid=9034637 | doi= | pmc= | url= }} </ref>.
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| *'''Mitral valve replacement'''
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| This procedure is indicated if the mitral stenosis could not be corrected by other surgical approaches previously mentioned and the patient has one of the following:
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| :*Moderate to severe mitral stenosis (≤1.5 cm2).
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| :*[[NYHA]] class III or IV symptoms.
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| :*Mild symptoms (NYHA class I or II) that associated with severe mitral stenosis (mitral valve area ≤1.0 cm2) or severe [[pulmonary hypertension]] (pulmonary artery systolic pressure >60 to 80 mmHg).
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| :*Severe mitral stenosis (mitral valve area ≤1.0 cm2) or severe pulmonary hypertension (pulmonary artery systolic pressure >60 to 80 mmHg) even if the patient is asymptomatic.
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| Mitral valve replacement significantly improves symptoms and has a favorable survival rate at five years <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref><ref name="pmid14324511">{{cite journal| author=BRAUNWALD E, BRAUNWALD NS, ROSS J, MORROW AG| title=EFFECTS OF MITRAL-VALVE REPLACEMENT ON THE PULMONARY VASCULAR DYNAMICS OF PATIENTS WITH PULMONARY HYPERTENSION. | journal=N Engl J Med | year= 1965 | volume= 273 | issue= | pages= 509-14 | pmid=14324511 | doi=10.1056/NEJM196509022731001 | pmc= | url= }} </ref>.
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| The 2006 ACC/AHA guidelines recommended amputation or ligation the left atrial appendage during mitral valve replacement or open commissurotomy, as this may decrease the risk of potential embolism <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref>, but it is not proofed if this may reduce the risk of stroke <ref name="pmid14522491">{{cite journal| author=García-Fernández MA, Pérez-David E, Quiles J, Peralta J, García-Rojas I, Bermejo J et al.| title=Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 7 | pages= 1253-8 | pmid=14522491 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14522491 }} </ref>.
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| In the '''traditional open heart surgery''':
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| :*The surgeon will make a 10-inch-long cut in the middle of the chest (sternum).
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| :*Next, the surgeon will separate the breastbone (sternum) to be able to see the heart.
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| :*Most people are connected to a [[heart-lung bypass machine]] or bypass pump. The heart is stopped while the patient is connected to this machine. This machine does the work of the heart while the heart is stopped.
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| :*A small cut is made in the left side of the heart so the surgeon can repair or replace the mitral valve.
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| In '''minimally invasive mitral valve surgery'''; there are several different ways to perform the procedure:
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| :*The heart surgeon may make a 2-inch to 3-inch-long cut in the right part of your chest near the [[sternum]]. Muscles in the area will be divided so the surgeon can reach the heart. A small cut is made in the left side of the heart so the surgeon can replace the [[mitral valve]].
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| :*In '''[[Endoscopic surgery]]''', the surgeon makes one to four small holes in the chest, then he or she uses special instruments and a camera to do the surgery.
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| :*For '''Robotically-assisted valve surgery''', the surgeon makes two to four tiny cuts (about a ½ to a ¾ inch) in the chest. The surgeon uses a special computer to control [[robotic]] arms during the surgery. The surgeon sees a three-dimensional view of the heart and mitral valve on the computer. This method is very precise.
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| The patient may or may not need to be on a [[heart-lung machine]] for these types of surgery, but if not, the heart rate will be slowed by medicine or a mechanical device.
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| There are two '''types of valves''':
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| 1. Mechanical which is made of man-made (synthetic) materials, such as a metal like titanium. These valves last the longest, but the patient will need to take blood-thinning medicine, such as [[warfarin]] (Coumadin) or [[aspirin]], for the rest of his or her life.
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| 2. [[Biological]] which made of human or animal tissue. These valves last 10 to 12 years, but the patient may not need to take blood thinners for life.
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| Once the new or repaired valve is working, the surgeon will:
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| :*Close the heart and take you off the [[heart-lung machine]].
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| :*Place [[catheters]] (tubes) around the heart to drain fluids that build up.
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| :*Close the sternum with stainless steel wires. It will take about 6 weeks for the bone to heal. The wires will stay inside the body.
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| The patient may have a temporary [[pacemaker]] connected to the heart until his or her natural heart [[rhythm]] returns.
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| The surgeon may also perform [[coronary artery bypass surgery]] at the same time, if needed.
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| *'''Percutaneous mitral balloon valvotomy (PMBV)'''
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| The development of this approach was done by Inoue in 1984 and Lock in 1985 for the treatment of mitral stenosis <ref name="pmid8411505">{{cite journal| author=Carroll JD, Feldman T| title=Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis. | journal=JAMA | year= 1993 | volume= 270 | issue= 14 | pages= 1731-6 | pmid=8411505 | doi= | pmc= | url= }} </ref><ref name="pmid6700245">{{cite journal| author=Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N| title=Clinical application of transvenous mitral commissurotomy by a new balloon catheter. | journal=J Thorac Cardiovasc Surg | year= 1984 | volume= 87 | issue= 3 | pages= 394-402 | pmid=6700245 | doi= | pmc= | url= }} </ref>. For a long time, surgical commissurotomy and open valve replacement were the only methods by which mitral stenosis could be corrected <ref name="pmid4069160">{{cite journal| author=Lock JE, Khalilullah M, Shrivastava S, Bahl V, Keane JF| title=Percutaneous catheter commissurotomy in rheumatic mitral stenosis. | journal=N Engl J Med | year= 1985 | volume= 313 | issue= 24 | pages= 1515-8 | pmid=4069160 | doi=10.1056/NEJM198512123132405 | pmc= | url= }} </ref>.
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| PMBV can be performed in chronically symptomatic patients, patients who present emergently with cardiac arrest or [[pulmonary edema]] and in asymptomatic patients who plan on childbearing or major noncardiac surgery <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref><ref name="pmid9669264">{{cite journal| author=Lokhandwala YY, Banker D, Vora AM, Kerkar PG, Deshpande JR, Kulkarni HL et al.| title=Emergent balloon mitral valvotomy in patients presenting with cardiac arrest, cardiogenic shock or refractory pulmonary edema. | journal=J Am Coll Cardiol | year= 1998 | volume= 32 | issue= 1 | pages= 154-8 | pmid=9669264 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9669264 }} </ref>.
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| When intervention is indicated in patients with mitral stenosis, the 2006 [[ACC]]/[[AHA]] guidelines recommend that Percutaneous mitral balloon valvotomy (PMBV) is preferred to surgery if the valve morphology is favorable and the patient does not have left atrial thrombus or moderate to severe (3+ to 4+) mitral regurgitation <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref>.
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| '''The technique of Percutaneous mitral balloon valvotomy (PMBV)'''
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| The interventional cardiologist gains access to the mitral valve by making a puncture in the interatrial septum during cardiac catheterization. Inflation and rapid deflation of a single balloon or a double-balloon opens the stenotic valve. This mechanism is similar to that of surgical commissurotomy <ref name="pmid8448794">{{cite journal| author=Inoue K, Feldman T| title=Percutaneous transvenous mitral commissurotomy using the Inoue balloon catheter. | journal=Cathet Cardiovasc Diagn | year= 1993 | volume= 28 | issue= 2 | pages= 119-25 | pmid=8448794 | doi= | pmc= | url= }} </ref>.
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| :* Transvenous transeptal technique is most commonly used with the Inoue balloon system.
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| :* [[Fossa ovalis]] lies usually at 1-7 o’clock but this orientation can be distorted in the presence of mitral stenosis where the interatrial septum becomes more flat, horizontal and lower.
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| :* For the femoral vein approach a 70 cm Brockenbrough needle should be used or an 8 Fr Mullins sheath and advanced under fluoroscopic guidance with pressure monitoring.
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| :* The latter is necessary to monitor for puncture into adjacent structures such as aorta.
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| :* Further catheter manipulation may be necessary to direct the catheter into the left ventricle through the mitral valve rather than towards one of the pulmonary veins.
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| :* The Mullins sheath is exchanged for a solid-core coiled 0.025 inch guidewire over which a 14 Fr dilator is placed.
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| :* This is exchanged for the Inoue balloon (24-30 mm) which inflates in three stages allowing for balloon self-positioning with the last inflation resulting in commissural splitting.
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| Mitral stenosis is amenable to percutaneous mitral valvuloplasty if the echocardiography demonstrates :
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| :* Thickening confined to valve tips.
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| :* Good mobility of Anterior mitral valve leaflet.
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| :* Little chordal involvement.
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| :* No more than trivial [[mitral regurgitation]].
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| :* No left atrial thrombus.
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| :* No commissural calcification.
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| A transthoracic echocardiography should be done to measure the mitral valve area and assess the severity of regurgitation as a complication of the procedure. PMBV should be stopped if adequate valve area has been achieved or if the severity of mitral regurgitation has been increased.
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| ==Recovery==
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| '''Recovery at hospital'''
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| The patient may spend 4 to 7 days in the hospital after surgery (much less in Minimally invasive mitral valve surgery-3 to 5 days). Then patient will wake up in the [[intensive care unit]] (ICU) and recover there for 1 or 2 days. Two to three tubes will be in the patient's chest to [[drain]] fluid from around the heart. They are usually removed 1 to 3 days after surgery.
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| The patient may have a [[catheter]] in the bladder to drain urine, and may also have intravenous lines to get fluids. Nurses will closely watch monitors that show information about the [[vital signs]] (pulse, temperature, and breathing).
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| The patient will be moved to a regular hospital room from the ICU. The nurses and doctors will continue to monitor the heart and vital signs until the patient is stable enough to go home. The patient will receive pain medicine to control pain around your surgical cut.
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| A nurse should help the patient to slowly resume some activity, and the patient should begin a physical therapy program to make the heart and body stronger.
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| A temporary [[pacemaker]] may be placed in the patient's heart if the heart rate becomes too slow after surgery.
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| '''Recovery at home'''
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| The patient should be informed about the following:
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| *Taking care for his or her healing incisions.
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| *Recognizing signs of infection or other complications.
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| *Coping with after-effects of surgery.
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| *Followup appointments, medicines, and situations when he or she should call the doctor right away.
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| *When he or she can go back to daily routine, such as working, driving, and physical activity.
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| After-effects of heart surgery are normal. They may include muscle pain, chest pain, or swelling.
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| Other after-effects may include loss of appetite, problems sleeping, constipation, and mood swings and [[depression]]. After-effects usually go away over time.
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| Less recovery time is needed for off-pump heart surgery and [[minimally invasive]] heart surgery.
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| '''Ongoing care'''
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| Ongoing care after valve surgery may include periodic checkups with the doctor. During these visits, the patient may have blood tests, an [[EKG]] (electrocardiogram), [[echocardiography]], or a [[stress test]]. These tests will show how the patient's heart is working after the surgery.
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| Routine tests should be done to make sure the patient is getting the right amount of the blood-thinning medicine in case of mechanical valve placement.
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| The patient may be advised to change his or her lifestyle, this includes: quitting smoking, making changes to diet, being physically active, and reducing and managing stress.
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| ==Surgical outcome==
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| * Results of the commissurotomy should be assessed with hemodynamics and echocardiography.
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| * If second inflation is needed mitral regurgitation should be assessed.
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| * In general increasing valve area to greater than 1 cm2/m2 is an acceptable result.
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| * Usually the valve area doubles and the pulmonary pressures degrease immediately.
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| * 5 year survival is in the 90% range.
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| *'''PMBV versus open and closed surgical commissurotomy'''
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| Some trials showed that the outcome after PMBV is better than the surgical commissurotomy approach <ref name="pmid1918709">{{cite journal| author=Patel JJ, Shama D, Mitha AS, Blyth D, Hassen F, Le Roux BT et al.| title=Balloon valvuloplasty versus closed commissurotomy for pliable mitral stenosis: a prospective hemodynamic study. | journal=J Am Coll Cardiol | year= 1991 | volume= 18 | issue= 5 | pages= 1318-22 | pmid=1918709 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1918709 }} </ref>. Long term outcome studies showed that the mitral valve area was less in closed commissurotomy compared to other approaches, also the rate of restenosis was higher for closed commissurotomy approach <ref name="pmid2013139">{{cite journal| author=Turi ZG, Reyes VP, Raju BS, Raju AR, Kumar DN, Rajagopal P et al.| title=Percutaneous balloon versus surgical closed commissurotomy for mitral stenosis. A prospective, randomized trial. | journal=Circulation | year= 1991 | volume= 83 | issue= 4 | pages= 1179-85 | pmid=2013139 | doi= | pmc= | url= }} </ref>.
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| *'''PMBV versus mitral valve replacement combined with tricuspid valve repair'''
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| Some trials showed that the outcome after mitral valve replacement combined with tricuspid valve repair (if the patient has tricuspid regurgitation) is better than PMBV in patients with severe mitral stenosis and severe tricuspid regurgitation <ref name="pmid17846312">{{cite journal| author=Song H, Kang DH, Kim JH, Park KM, Song JM, Choi KJ et al.| title=Percutaneous mitral valvuloplasty versus surgical treatment in mitral stenosis with severe tricuspid regurgitation. | journal=Circulation | year= 2007 | volume= 116 | issue= 11 Suppl | pages= I246-50 | pmid=17846312 | doi=10.1161/CIRCULATIONAHA.107.678151 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17846312 }} </ref>.
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| The results of mitral valve stenosis surgery are excellent in centers that regularly perform this surgery.
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| Techniques for minimally invasive heart valve surgery have improved greatly over the past 10 years. These techniques are safe for most patients, and they reduce recovery time and pain.
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| *'''Mechanical versus Biological valves'''
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| Mechanical heart valves do not fail often. They last from 12 to 20 years. However, blood clots develop on them. If a blood clot forms, the patient may have a stroke. Bleeding can occur, but this is rare.
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| [[Biological]] valves tend to fail over time <ref name="pmid8469251">{{cite journal| author=Hammermeister KE, Sethi GK, Henderson WG, Oprian C, Kim T, Rahimtoola S| title=A comparison of outcomes in men 11 years after heart-valve replacement with a mechanical valve or bioprosthesis. Veterans Affairs Cooperative Study on Valvular Heart Disease. | journal=N Engl J Med | year= 1993 | volume= 328 | issue= 18 | pages= 1289-96 | pmid=8469251 | doi=10.1056/NEJM199305063281801 | pmc= | url= }} </ref><ref name="pmid11028464">{{cite journal| author=Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH| title=Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. | journal=J Am Coll Cardiol | year= 2000 | volume= 36 | issue= 4 | pages= 1152-8 | pmid=11028464 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11028464 }} </ref>, but they have a lower risk of blood clots.
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| ==Possible complications==
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| '''Risks of any surgery'''
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| *Blood clots in the legs that may travel to the lungs.
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| *Blood loss.
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| *Breathing problems.
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| *Infection, including in the lungs, kidneys, bladder, chest, or heart valves.
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| *Reactions to medicines.
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| '''Possible risks from having open-heart surgery'''
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| *[[Heart attack]] or stroke.
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| *Heart [[rhythm]] problems.
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| *Infection in the cut, which is more likely to happen in people who are obese, have [[diabetes]], or have already had this surgery.
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| *Memory loss and loss of mental clarity, or "fuzzy thinking."
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| *[[Post-pericardiotomy syndrome]], which is a low-grade fever and chest pain. This could last for up to 6 months.
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| '''Prosthetic heart valves are associated with a variety of complications'''
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| *Structural deterioration, particularly with bioprosthetic valves.
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| *Valve obstruction due to [[thrombosis]] or pannus formation.
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| *Systemic [[embolization]].
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| *Bleeding.
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| *[[Endocarditis]] and other infections.
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| *Left ventricular systolic dysfunction, which may be preexisting.
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| *[[Hemolytic anemia]].
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| ==Videos==
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| *'''Mitral valve replacement surgery animation'''
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| <youtube v=QBSKEAb7f2w/>
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| *'''Robotic mitral valve repair surgery animation'''
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| <youtube v=GYAmSH2zwic/>
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| ==External links== | |
| http://en.wikipedia.org/wiki/Mitral_valve#cite_note-0
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| http://en.wikipedia.org/wiki/Mitral_valve_stenosis
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| http://www.nlm.nih.gov/medlineplus/ency/article/000175.htm
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| http://www.nhlbi.nih.gov/health/health-topics/topics/hs/before.html
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| http://www.mayoclinic.org/mitral-valve-disease/
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|
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|
| http://www.nlm.nih.gov/medlineplus/ency/article/007411.htm | | http://www.nlm.nih.gov/medlineplus/ency/article/007411.htm |
|
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| http://www.nhlbi.nih.gov/health/health-topics/topics/hs/during.html
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|
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| http://www.nhlbi.nih.gov/health/health-topics/topics/hs/after.html
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|
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| ==References==
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| {{Reflist|2}}
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|
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
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| [[Category:Cardiac surgery]] | | [[Category:Cardiac surgery]] |
| [[Category:Surgical procedures]] | | [[Category:Surgical procedures]] |
| [[Category:Overview complete]]
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| [[Category:Template complete]]
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| [[Category:For review]] | | [[Category:For review]] |
| [[Category:Valvular heart disease]] | | [[Category:Valvular heart disease]] |
| | | [[Category:Up-To-Date cardiology]] |
| | [[Category:Up-To-Date]] |
| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |