Percutaneoustransvenous mitral commissurotomy (PTMC) has become established as a procedureof choice for the treatment of mitral stenosis (MS) and it confers equivalent resultsto open and closed mitral valvotomy in patients whose valves are anatomicallysuitable. Appropriate patient selection, however, is of paramount importancefor a successfulPTMC. In the selection of patients for PTMC,the echocardiographic assessment of the mitral valve morphology plays a crucialrole and it is now performed routinely in most centers. The Wilkins score isone of the most widely used echocardiographic scoring systems in that itprovides a semi-quantitative assessment of mitral leaflets thickening,mobility, calcification,and the extent of the disease of  subvalvular apparatus. A favorable Wilkins score (<8 points) is highlypredictive of an optimal outcome after PTMC. The Wilkins scoring system, which ischaracterized by calcium and lipid deposition within the annular fibrosa of themitral valve might independently influence the outcome of  PTMC. We do not have much studies which have analyzed the precision ofcalcification in this scoring system as an independent  predictor of the outcome and thus suggestingthe need for more refined and comprehensive echocardiographic assessments withprecise calcium score.  Few study series have shown thefeasibility of PTMC in patients with calcified valves. Whether patients withcalcified valves should be candidates for PTMC or be referred for surgery asfirst-line treatment is still a debated issue. This is of particular importancein Indian population where valve calcification is frequently encountered inrheumatic MS. To our knowledge, there are not enough studies in Indianpopulation evaluating the impact of Mitral valve calcification on the immediateresults of  PTMC. The aim of this studyis, therefore, to analyze the results of PTMC according to the presence andextent of valve calcification, with a particular emphasis on immediate results.

Studypopulation-The study will be conducted on patients  with calcified mitral valves undergoing Percutaneous transmitralcommissurotomy.InclusionCriteria:●     Severe Rheumatic Mitral Stenosis withcalcification of Mitral Valve.Exclusioncriteria:●     Patients with Congenital mitral stenosis.●     Patients with Left Atrial thrombus.●     Patients with moderate to severe MitralRegurgitation.●     Patients with Aortic Valve disease requiringAortic Valve Replacement.●     Patients with Severe Coronary artery diseaserequiring CABG.●     Patients with associated congenital heartdiseases.Data collection methods-From January 2000 to December 2015, PTMC was attempted in 100  with calcified mitral valves. Pre-procedureconventional echocardiography conducted in all patients to investigate the MVmorphology in our echo lab equipped by Philips # iE33 echocardiographyapparatus (S5 Adult probe; 3.5- MHz transducer) as a routine protocol.A retrospective analysis conducted on the data of these 100 patients.The relation between the echocardiographic score of the valve morphologyand immediate result of PTMC was assessed by defining the optimal result asmitral valve area (MVA) ≥ 1.5 cm2 or more andincrease in the MVA of at least 25% without post-procedure MR grade > 2.This definition was employed on account of the fact that it is one of the mostcommonly employed criteria in the existing literature^12-25. Thestudy protocol was approved by the Ethics Committee Review Board of thehospital.

v  Themean increase in Mitral valve area (MVA) was 0.83±0.23 cm² .ie) from 1.01±0.14cm² to 1.84±0.2 cm².v  The average decrease in mean mitralgradient was 10.28 mmHg. ie) from 14.94±7.2 mmHg  to 4.68±4.5 mmHg.v  The average percentage decrease in meanmitral gradient was 71% .v  The average decrease in mean pulmonaryartery pressure was 6.42 mmHg. ie) from 33.63±12.31 mmHg  to 27.3±9.35 mmHg .v  These results suggest that PTMC is aeffective procedure in patients with calcified mitral valves.v  Only one patient had  Grade 3 mitral regurgitation. No  mortality occurred in our study. Theseresults suggest that PTMC can be performed safely in patients with calcifiedmitral valves.v Thus, we conclude that good immediate results can be achieved with PTMC,in patients having calcified mitral valve (Grade 1-3) with < 2% complicationrates.

In Indian population, calcification of rheumaticmitral valve  is a common feature. Thestepwise detailed echocardiographic technique in assessment of favorable mitralvalve morphology and careful selection of patients for PTMC may offer a saferand good results.   In our retrospective,non-randomized study, PTMC in patients with calcified mitral valves proved tobe safe and efficient procedure with a higher procedural success rate alongwith a optimal immediate result, regardless of the extent of calcium deposition.  Mitral valve calcification should not beconsidered as a contra-indication to PTMC. Our results further reinforce thecurrent guidelines on PTMC as a first-line therapy even in patients withcalcific mitral valves.