Dear Jose,

as far as I know the Wilkins score is an echocardiographic score used to assess the success chance of BVP. A score of greater than 8 predicts worse outcome of BVP.

Undoubtedly, you are treating younger people with MS than the ones we see in central Europe. If you do not have access to a surgeon who has good reconstruction rates by means of commissurotomy, resection of thickened secondary chordae and by fenestrating fused marginal chordae if necessary every endeavour to postpone valve replacement is justified from my point of view. In addition a ring annuloplasty might be necessary if the mitral orifice is dilated and the left atrium severely enlarged. Frankly, I have no idea if your surgeons have access to mitral rings all the time.

Kind regards,

Ivan Aleksic

Dear Aleksic. What is the percentage of sucsses obtained by yours surgeons avoiding the mitral replacement in MS with 12 to 14 score? What is the mean follow-up from the conservative surgery to the valve replacement in these patients? There is no more than moderate regurgitation after surgery? Access to mitral rings is not warranty of good results.

This is an interesting discussion. My experience with percutaneous balloon mitral valvotomy in Nairobi Kenya is that w can successfully use the procedure as abridge to surgery in patients who have high Wilkins score but are very ill with ascites, cachexia and severe PHTN thus poor surgical risks due. They usually improve and then undergo elective valve replacement.

Dear Dr. Sarano. I agree with you. In our country mitral valve calcified with important subvalvar thickness is frequent in young adult people, and the balloon valvoplasty allows to pospone the surgery for many years, in general. The valve replacement is the end point of all significant stenotic mitral valve, even if the inicial valvoplasty score is 8.

Thanks Drs Sarano and Jacob for your excellent insights. In Kenya, rheumatic mitral stenosis still affects many children. I have done balloon valvulotomy on up to 9yrs old. I have published part of this series early on. The children and young adults with good Wilkins scores do very well and we have event free survival at 10yrs for more than 85%. Rheumatic fever prophylaxis is key to these results. We also see the older patients with rheumatic and some degenerative mitral stenosis, and these still benefit but do not seem to have as good long-term results especially when they have AF or degenerative disease and end up with valve replacement earlier. The quality of life with a native valve is an important consideration for young patients especially female patients contemplating pregnancies.

For SYMPTOMATIC patients with Mitral Stenosis and high scores, the best possible treatment is cardiac surgery, ideally with mitral valve repair - There are few reports of these procedures in recent literature, but there are safe and effective forms of mitral valve repair in mitral stenosis, such as mitral comissurotomy and papilarotomy. If done with adequate expertise, we have noted excellent long-term results with surgical mitral valve repair in these patients - sometimes with up to 20 years of follow-up with no need for reintervention.

My oppinion is that that symptomatic patients with high scores are unsutable for percutaneous baloon valvoplasty.

Dear Spina. I agre with you. The successful surgical treatment with only valve repair is the best. However there are many young people with mitral prosthesis in which was promised mitral valve preservation. The problem is if the surgeon will be able to preserve a calcified valve. Best regards

We recently published a study in which the Wilkins score was compared with a newly designed coding of the MS morphologie: "A differentiated morphological parameter-coding system to describe the suitability of mitral valve stenoses intended for percutaneous valvotomy", Heart and Vessels, DOI 10.1007/s00380-014-0536-1, 2014

In this study we included also few cases with a high Wilkins score >8. Those patients astonishingly mostly had a successful initial outcome of a catheter-interventionally performed  valvoplasty. We think, that not the Wilkins score alone is a predictor for good or bad outcome but the whole morphological configuration of a valve. This configuration is not completely covered by the Wilkins score. The same is with several other scores in echo. Especially the location of the valve opening compared to the calcification distribution seems to be a main factor for success or poor result, but unfortunately this is not included in most of the echo scores like the Wilkins score.