This document discusses diagnostic and surgical treatment options for mitral valve stenosis. It presents the case of a 46-year-old female patient with severe mitral stenosis who has not responded well to pharmacological treatment. Two main surgical interventions are considered: balloon mitral valvuloplasty and mitral valve annuloplasty. Studies are presented showing that valvuloplasty can improve left ventricular function and strain, while annuloplasty may be associated with higher gradients and worse quality of life. Based on the patient's history and characteristics, the document recommends valvuloplasty as it allows for variable improvement in health compared to mitral surgery, which carries a higher risk of compromising health. Close monitoring is still advised

1. UNIVERSIDAD AUTÓNOMA DEL ESTADO DE
MÉXICO
FACULTAD DE MEDICINA
Por: Ramos Jiménez Christian.
«DIAGNÓSTICO Y TRATAMIENTO
QUIRÚRGICO DE LA ESTENOSIS DE LA
VÁLVULA MITRAL»
OBJETIVO: Se pretende conocer cuál es la mejor
intervención quirúrgica para el paciente referido.

2. ESTENOSIS DE VÁLVULA MITRAL
 El estrechamiento del pasaje a
través de la válvula mitral debido
a la fibrosis, y calcinosis en los
folletos y las zonas de acordes.
Esto eleva la presión de la
aurícula izquierda, que, a su vez,
plantea la vena pulmonar y la
presión capilar que conduce a
episodios de disnea y taquicardia
durante el ejercicio físico.
FIEBRE REUMÁTICA es su
causa principal.
Universidad Autónoma del Estado de México
Facultad de Medicina

3. HISTORIA CLÍNICA DEL PACIENTE
 Paciente femenino de 46 años de edad, con Estenosis
en la Válvula Mitral “Severa”, presenta una falta de
actividad física preestablecida. Se sospecha que sea de
tipo congénito, aun sin confirmar.
 En ocasiones, el paciente refiere dolor en el tórax del
lado izquierdo, pudiéndose tratar de posible infarto
agudo cardíaco; además de levantarse con dificultad
respiratoria por las mañanas, fatiga, palpitaciones e
hinchazón de pies. Los estudios pertinentes como,
estudios de sangre y el Holttler, revelaron un alto índice
de Ca+ en la válvula del lado izquierdo del corazón
(válvula Mitral). Para tratamiento, se suministran
diferentes fármacos, a saber: Captopril, ... Sin ver
resultados favorables, se propuso un cambio
farmacológico sin posteriores resultados.
Universidad Autónoma del Estado de México
Facultad de Medicina

4. INVESTIGACIÓN
PREGUNTA CLÍNICA ESPECÍFCA.
Tratamiento
 Ante pacientes femeninos de entre 40-60 años de edad con
Estenosis en la Válvula Mitral “Severa” y tratamiento
farmacológico no controlado ¿Qué intervención quirúrgica será
la más apropiada para la mejoría del paciente ante un
tratamiento farmacológico no favorable con repercusiones en
su salud?
Universidad Autónoma del Estado de México
Facultad de Medicina

6. VALVULOPLASTÍA (BALLOON MITRAL VALVULOPLASTY)
ARTÍCULO:
EFFECTS OF PERCUTANEOUS BALLOON MITRAL VALVULOPLASTY ON LEFT VENTRICULAR DEFORMATION IN
PATIENTS WITH ISOLATED SEVERE MITRAL STENOSIS: A SPECKLE-TRACKING STRAIN ECHOCARDIOGRAPHIC STUDY.
PUBMED. HTTP://WWW.NCBI.NLM.NIH.GOV/PUBMED/24637055
Abstract
 BACKGROUND:
 Previous studies have reported abnormal left ventricular (LV) contraction in patients with mitral stenosis
(MS). The aim of this study was to explore the serial changes in LV mechanics in patients with severe
MS undergoing balloon mitral valvuloplasty (BMV) to understand the reversibility and determinants of
abnormal LV contractile function.
 METHODS:
 Fifty-seven patients with severe MS and 19 healthy controls underwent echocardiographic
examinations, including two-dimensional speckle-tracking-based LV global longitudinal strain (GLS) and
global circumferential strain measurements. In patients with MS, the same measurements were
repeated 72 hours after BMV.
 RESULTS:
 In comparison with controls, patients with MS had faster heart rates and lower LV end-diastolic volumes
and LV ejection fractions (P = .008). The magnitudes of both GLS and global circumferential strain were
reduced in patients with MS (P < .001 for both), with 48 patients (84.2%) having GLS below the 25th
percentile of controls. BMV resulted in significant improvements in GLS and global circumferential strain
(-14.6 ± 3.3% vs -17.8 ± 3.5% and -20.0 ± 5.0% vs -22.5 ± 4.6%, respectively, P < .005 for both). On
multivariate analysis, left atrial volume, mean transmitral gradient, and LV end-diastolic volume were
independently correlated with baseline GLS, whereas increment in LV end-diastolic volume was the only
determinant of increased GLS after BMV.
 CONCLUSIONS:
 LV deformation is reduced in patients with severe MS and is related to the hemodynamic severity of
MS. BMV results in rapid improvement of LV deformation, which is correlated with serial
improvement in LV diastolic loading. These findings suggest that reduced LV diastolic filling rather than
an irreversible myocardial structural abnormality contributes predominantly to reduced LV mechanical
performance in patients with MS.

7. CIRUGÍA MITRAL: ANULOPLASTÍA (ANNULOPLASTY)
CLINICAL EVALUATION OF FUNCTIONAL MITRAL STENOSIS AFTER MITRAL VALVE REPAIR FOR
DEGENERATIVE DISEASE: POTENTIAL AFFECT ON SURGICAL STRATEGY. PUBMED.
HTTP://WWW.NCBI.NLM.NIH.GOV/PUBMED/24075470
Abstract
 BACKGROUND:
 Mitral annuloplasty with either a partial band or complete ring is an integral part of mitral valve repair for
degenerative disease. The affect of annuloplasty type on outcomes has not been well described.
The objective of our study was to compare echocardiographic and functional characteristics of patients
who underwent mitral repair with either a complete ring or a partial band.
 METHODS:
 We evaluated 107 patients who underwent mitral repair of myxomatous degeneration at our institution
by stress echocardiography, 6-minute walk testing, and short form-36 questionnaire. These
assessments were performed 4.3 ± 2.2 years following mitral repair by a single surgeon. A band was
used in 65 patients (61%) and a ring in 42 patients (39%). Parametric and nonparametric tests were
used in the analyses.
 RESULTS:
 The labeled band and ring size used for repair were 30.7 ± 2.8 mm and 30.4 ± 2.1 mm, respectively
(P = .6). The resting mean mitral gradient and valve area were 3.7 ± 1.9 mm Hg and 2.3 ± 0.6 cm(2) for
patients who received a band and 5.8 ± 2.6 mm Hg and 1.8 ± 0.5 cm(2) for patients who received a ring
(both P < .001). Distance traversed on 6-minute walk testing was 471 ± 77 m in the band group and 443
± 107 m in the ring group (P = .1). At peak exercise, the mean mitral gradient (15.3 ± 8.2 mm Hg vs 10.6
± 4.8 mm Hg; P < .001) and right ventricular systolic pressure (52.6 ± 14.2 mm Hg vs 45.8 ± 9.5 mm Hg;
P = .004) were higher for patients who received a ring versus a band. Ring patients reported lower
levels of energy (P = .02) and general health (P = .007) on short form-36 assessment.
 CONCLUSIONS:
 Annuloplasty using a complete ring may be associated with a higher mitral valve gradient at rest and
at peak exercise in certain patients. These patients may also have worse quality of life. In view of
these findings, we recommend careful consideration of annuloplasty type and size at the time of
mitral repair of organic disease.

8. EMERGENCY MITRAL VALVE REPLACEMENT FOR ACUTE SEVERE MITRAL REGURGITATION FOLLOWING
BALLOON MITRAL VALVOTOMY: PATHOPHYSIOLOGY OF HEMODYNAMIC COLLAPSE AND PERI-OPERATIVE
MANAGEMENT ISSUES. PUBMED. HTTP://WWW.NCBI.NLM.NIH.GOV/PUBMED/24401304
Abstract
 Severe mitral regurgitation (MR) following balloon mitral valvotomy (BMV) needing
emergent mitral valve replacement is a rare complication. The unrelieved mitral
stenosis is compounded by severe MR leading to acute rise in pulmonary hypertension
and right ventricular afterload, decreased coronary perfusion, ischemia and right
ventricular failure. Associated septal shift and falling left ventricular preload leads to a
vicious cycle of myocardial ischemia and hemodynamic collapse and needs to be
addressed emergently before the onset of end organ damage. In this report, we describe
the pathophysiology of hemodynamic collapse and peri-operative management
issues in a case of mitral valve replacement for acute severe MR following BMV.
 Regurgitación mitral severa (MR) siguiendo globo mitral valvotomía (BMV) que necesitan
reemplazo de la válvula mitral emergente es una complicación poco frecuente. La
estenosis mitral sin alivio se ve agravado por la MR grave que lleva a aumento agudo de
la hipertensión pulmonar y la poscarga del ventrículo derecho, disminución de la
perfusión coronaria, isquemia e insuficiencia ventricular derecha. Desplazamiento septal
asociado y la caída de la precarga ventricular izquierda conduce a un círculo vicioso de
la isquemia miocárdica y colapso hemodinámico y deben abordarse de forma urgente
antes de la aparición de daño orgánico. En este reporte se describe la fisiopatología de
colapso hemodinámico y cuestiones de gestión perioperatorias en un caso de sustitución
de la válvula mitral para MR aguda grave tras BMV.

9. CONCLUSIONES
 En base a las características de la historia clínica
del paciente, se recomienda que sea intervenido
ante una Valvuloplastía; está permite mejorar en
porcentajes variables la salud del paciente ante
una Cirujía Mitral que puede comprometer en un
mayor porcentaje la salud del paciente.
 Al usarse la Valvuloplastía, se aconseja un
tratamiento de vigilancia ya que de igual forma
compromete a la salud del paciente al existir una
derivación de una complicación.
 La Anatomía favorable es indispensable para la
elección de la cirugía y más aun para la
recuperación posoperatorio.