1. The Place of Closed Mitral Valvotomy Procedure in Facility Deprived Countries in the Modern PTMC/PMBV Era: 20 Years Experience at SMS Hospital, Jaipur, Rajasthan. Prof. Anil Sharma, Assit. Prof. Sunil Dixit, Ram Chandra Sherawat, CTVS Department, SMS Medical College, Jaipur, Rajasthan

2. INTRODUCTION Rheumatic heart disease remains a major health problem in developing countries. Mitral valve stenosis(MS) is the most common complication of it. It’s consequences are pulmonary hypertension, atrial fibrillation, thromboembolism (TE), heart failure, and if untreated death ensues. The management of MS varies depending on availability of expertise and resource; however in a facility deprived country with low economic status closed mitral valvotomy (CMV) remain the standard palliative treatment.

3. OBJECTIVE The aim of this study was to evaluate the clinical status of patients with mitral stenosis following closed mitral valvotomy(CMV).

4. Materials and Methods: Data obtained over a 20-year period from 4,341 patients who underwent CMV were analyzed. The analysis was carried out retrospectively from hospital records, with follow up examinations being conducted mainly at the outpatient clinic. All patients presenting with severe mitral stenosis without thrombus, significant calcification and regurgitation were enrolled for the study from August 1994 to August 2014.

5. Inclusion Criteria: The suitable valves were selected according to echocardiographic criteria: (1) pliable anterior mitral leaflet, (2) absence of significant mitral subvalvular disease, (3) absence of significant calcification, and (4) the mitral valve orifice area (<1.1 cm 2 ) on echocardiography. The indications also include asymptomatic women of child bearing age with mitral valve areas of < 1.2 cm2.

6. Exclusion Criteria: Patients with -  Severe mitral valve regurgitation,  leaflet calcification >2,  Severe subvalvular fibrosis,  LA thrombus and those who does not give consents.

7. OBSERVATION In-hospital mortality (≤30 days after surgery) was 0.5% (n = 22). Cardiac failure with significant MR was the main cause of early death, and no postoperative peripheral embolism occurred in cases which were operated after TEE and occurred in 0.5% cases which were operated without TEE. Freedom from thromboembolism was 99.0 ± 0.5% at 20 years. Operative results were satisfactory in most patients, and severe mitral incompetence was seen only in hundred cases in which 15 cases converted to open heart and remaining treated with medical management in whom we lost 12 patients.

8. RESULTS

9. PathologyNo. of Patient (%)  No Calcification  Calcication  +1  +2  +3 2951 (68) 1390 (32) 1123 (25) 267 (7) Nil No Sub-valvular Fibrosis Sub-valvular Fibrosis  Mild  Mod  Severe 3518 (81) 823 (19) 667 (15) 156 (4) Nil LA Clot (in TEE)Nil Table 1- Preoperative echocardiographic findings.

10. S noFeaturePre-opPost-op After 5 Yrs 1NYHA Class3.4 +/- 0.41.4 +/- 0.21.7 +/- 0.3 2 Mean Pressure Gradient 30.9 +/- 10.613.7 +/- 7.7 14.8 +/- 7.6 3 Mean Mitral Valve Area (cm2) 0.6 +/- 0.22.3 +/- 0.62.2 +/- 0.5 4 Mean Left Atrial Area (cm2) 5.8 +/- 0.74.0 +/- 0.54.1 +/- 0.5 5 Mean Ejection Fraction 50.9 +/- 7.160.2 +/- 5.5 60.0 +/- 6Mean Pulmonary Hypertension 54.2 +/- 23.514 +/- 13.515 +/- 11.3 Table 2- Comparison between pre-operative and post-operative findings

11. NYHA classPreoperative (%)Postoperative (%) I0 (0)3876 (91.6) II1471 (33.8)256 (5.8) III284 (65.5)52 (1.2) IV13 (.3)0 (0) Table 3- Functional capacity of patients based on NYHA functional class before and after closed mitral valvotomy (CMV).

12. ComplicationNo. of patient (%) Mitral Regurgitation  Mild  Moderate  Severe 682 (16) 412 (9) 170 (5) 100 (2) Intraoperative hypotention442 (10) Intraoperative VT/VF78 (1.8) Systemic Emolisation22 (0.5) Failure to dilate valve8 (0.2) Bleeding22 (0.5) Death22 (0.5) Table 4- Operative complications after closed mitral valvotomy (CMV).

13. CauseNo. of Patient Low cardiac output with severe MR 12 VT/VF08 Post op bleeding01 Septicemia01 Total22 Table 5 – Causes of death after CMV

14. Conversion of casesNo. of Patients Converted to MVR ( with bioprosthesis ) after CMV 04 Converted to MVR ( with mechanical valve ) after CMV 19 Total23 Table 6 Conversion of cases Conversion cases were 23 {Severe MR (15) + Failure to dilate (8)}

15. Surgical InterventionNo. of Patients MVR ( with bioprosthesis )224 MVR ( with mechanical heart valve ) 711 DVR54 AVR01 Total990 Table 7- Surgical reinterventions following closed mitral valvotomy (CMV).

16. Figure 1. Age and Sex Distribution.

17. Figure 2- No. of Post Operative Follow-up cases.

18. Figure 3 – Freedom from reoperation following CMV. Freedom from reoperation after CMV was 81.4 ± 1.3% at 10 years, 74.42 ± 2.1% at 20 years.

19. Figure 4- Total no of restenosis cases.

20. Discussion A number of previous studies of CMV and BMV have been reported. Ravkilde and Hansen analyzed 35 years of follow-up of 240 patients and found that CMV offered good long-term palliation of the symptoms of isolated mitral stenosis in patients without signs of irreversible organ damage and with pliable valves. John and Bashi, in a study of CMV in 367 patients over 40 years of age, reported that this procedure was the most effective palliative operation.

21. Contd In spite of the initial optimistic pronouncement that BMV would significantly improve care for rheumatic valve disease in developing countries, the low cost and equally good results of CMV make it the procedure of choice in many parts of the world where valvular heart disease is prevalent, and ours is no exception.

22. Conclusion There was an overall highly significant improvement in clinical stage of the disease, reduction in mean pressure gradient across the mitral valve, reduction in pulmonary hypertension and mean left atrial size. Similarly there was improvement in ventricular function in terms of ejection fraction and increase in mean mitral valve area.

23. CONTD The lower cost of CMV is an important factor for its consideration in developing countries; in fact, the cost of a CMV was shown to be 25-fold less than that for an open procedure. In the present authors’ experience, the cost of CMV is approximately 10-fold less than that of PMBV.

24. Thanks Ram Chandra Sherawat SMS Medical College, Jaipur, Rajasthan