Closed Mitral Valvotomy (CMV) was among the earliest successful operations performed on the heart before the advent of cardiopulmonary bypass. The first CMV procedure was carried out by Elliot Cutler [1] in 1923 at Boston’s Peter Bent Brigham Hospital. Subsequently, in 1925, Souttar [2] performed what is recognized as the first true mitral valve commissurotomy via the left atrial appendage. Over time, the procedure fell into relative obscurity. However, it was revisited in the late 1940s by Dwight Harken [3] and Charles Bailey[4]. it underwent various refinements on both the procedural approach and the surgical instruments used. The introduction of the Tubbs dilator standardized the procedure, making it the official tool for commissurotomy.

By the 2^nd half of 20^th century CMV became the commonest heart surgery for mitral valve stenosis and it continued to flourish for decades. The largest case series was published by Stanley [5] of more than 500 patients in South Africa and 5326 patients in India.

With advancements in open-heart surgery, particularly with the introduction of cardiopulmonary bypass (CPB), mitral valve repair and open mitral valvotomy became the preferred options for surgeons. These methods offered direct and clear visualization of the mitral valve anatomy, enabling procedural benefits such as access to the sub-valvular apparatus, decalcification of the valve, and removal of clots—features that were previously considered contraindications for CMV. The next significant development was the emergence of percutaneous balloon valvotomy. This minimally invasive technique gained popularity within the cardiology community because it was less invasive, involved less pain, and could be rapidly adopted. It was widely acclaimed for its minimal invasiveness compared to traditional open procedures.

Although advancements in cardiac interventions have shifted the management paradigm toward balloon mitral valvotomy (BMV) and open surgical commissurotomy, these procedures are often unavailable or unaffordable in resource-constrained settings. In this context, closed mitral valvotomy may offer a cost-effective and technically viable alternative and necessitates a re-evaluation of CMV’s relevance today.

This retrospective study was conducted on patients who underwent closed mitral valvotomy (CMV) between September 2019 and September 2023. A total of 632 patient records were reviewed.

The inclusion criteria were patients aged 15 to 50 years with moderate to severe mitral stenosis (mitral valve area ≥ 1.2 cm²) and no mitral regurgitation or only minimal/mild mitral regurgitation, with minimal or mild mitral valve calcification as confirmed by echocardiography. Only patients who had undergone complete preoperative evaluation and for whom detailed surgical notes and imaging data were available were included in the study.

Patients were excluded if they had a history of previous percutaneous mitral valvotomy, prior surgical commissurotomy, thrombus in the left atrial cavity, prior embolization events, or associated valvular or subvalvular disease requiring surgical intervention.

All eligible patient records included a comprehensive preoperative assessment, comprising physical examination, chest radiography, electrocardiography, transthoracic echocardiography, and transesophageal echocardiography (TEE). Transthoracic findings were confirmed with TEE, and preoperative re-evaluation of mitral regurgitation and left atrial/left atrial appendage (LA/LAA) thrombus status was documented. The feasibility of the procedure and the condition of the subvalvular apparatus were also assessed preoperatively.

The standard surgical approach described in the operative notes involved a left anterolateral thoracotomy through the 4th or 5th intercostal space, selected based on optimal access to the LAA. After pericardiotomy, the incision was extended to the upper level of the pulmonary artery and toward the cardiac apex. A purse-string suture of Prolene was typically placed around the LAA, and a triangulated suture was applied at the apex for ventriculotomy. Following this, serial dilatation was performed. Mitral valve assessment and finger fracture commissurotomy were done through the LAA. Valvotomy was performed using a Tubbs dilator with the instrument blades opened to a width of 2.5–3 cm. Ventriculotomy and LAA closure were documented using Prolene sutures.

FOLLOW-UP PROTOCOL

Postoperative records indicated that approximately 92% of patients were discharged by the third postoperative day with advice on wound care and suture removal. Follow-up protocols included clinical assessment, chest radiography, and 2D echocardiography at monthly intervals for the first three months, and every three months thereafter.

All patients were prescribed warfarin for anticoagulation. Rate-controlling and anti-arrhythmic medications such as digoxin and verapamil were initiated as clinically indicated. Weekly prophylaxis with azithromycin (500 mg once weekly) was administered to prevent recurrent infections. Patients were instructed to report symptoms such as fever, palpitations, or dyspnea immediately.

Despite resource limitations, 88% follow-up adherence was achieved. Both early and late complications were recorded. More than 80% of patients demonstrated favorable outcomes during follow-up, with avoidance of immediate mitral valve replacement (MVR) in this cohort.

Ethical approval for the study was obtained from the institutional human research ethics committee prior to data collection.

Demographic Profile

A total of 632 patients were included in the study. The mean age was 25 years (range: 15–50 years). The majority (65%) were aged 15–25 years; Females (60%) outnumbered males. Amongst all female patients, ten were pregnant at the time of surgery.

Clinical Profile

Rheumatic mitral stenosis and thrombus formation were the predominant indications for surgery.

TABLE 1: showing presenting Clinical features

NYHA Class: Approximately 10% of patients presented in NYHA functional class IV, while 28% were in class III and the remainder in class II

Chest radiography revealed pleural effusion in 5% of patients, cardiomegaly in the majority, and features of pulmonary arterial hypertension (PAH) in several cases.

Electrocardiography demonstrated right ventricular hypertrophy in 73% of patients, tall R waves in V1/V5, and S-wave predominance in V5/V6.

Transesophageal echocardiography (TEE) showed:

1. Left atrial size: 4.0-5.5 cm. 86%
2. Mitral stenosis: valve area 0.5–1 cm² (severe stenosis in 80–85% of cases)
3. Mitral regurgitation: no MR 65%, mild 20%,moderate-to-severe in ~15% of patients.
4. Aortic regurgitation: mild in ~12% of patients.
5. Tricuspid regurgitation: 10% mild, 45% moderate, 5% severe.
6. Pulmonary arterial hypertension (PAH): 25% mild, 35% moderate, 15% severe (those with severe PAH were medically optimized before closed mitral valvotomy [CMV]).
7. Left atrial appendage (LAA) clot: detected in ~30% of patients.
8. Patients with LAA clot who were not optimized were excluded from CMV.

Post procedure results

A satisfactory procedural result was defined as an increase in mitral valve area (MVA) to 2.0–2.8 cm² with a mean transvalvular gradient ≤5 mmHg. This was achieved in approximately 90% of patients. In about 8% of cases, the post-procedural MVA remained at 1.0–1.2 cm² with a mean gradient of 5–6 mmHg; these patients were considered for repeat dilatation in the same setting. During follow-up, 1.5% of patients with MVA between 1.2–2.0 cm² developed severe mitral regurgitation and underwent mitral valve replacement (MVR). Two patients required immediate MVR during the index procedure due to severe regurgitation. Of these, one survived with successful prosthetic valve implantation, whereas the other could not be revived despite intensive care efforts.

Ten pregnant women, in their second or third trimester, underwent CMV and tolerated the procedure well. The postoperative course was uneventful, and all were discharged in stable condition.

The most favourable outcomes were observed among patients aged 15–45 years, in whom the mitral valve was less calcified and the sub valvular apparatus relatively preserved. In contrast, patients older than 45 years often had heavily calcified valves, leading to a higher risk of procedural failure and severe regurgitation. In cases of severe mitral stenosis with atrial fibrillation and associated left atrial appendage thrombus, external ligation of the left atrial appendage was performed to prevent future clot formation and subsequent embolization.

With the advent of minimally invasive procedures such as percutaneous mitral commissurotomy (PMC) and the widespread availability of open mitral valve surgery, the practice of closed mitral valvotomy (CMV) has declined considerably, even in countries where it was once the mainstay of treatment. In fact, many centers in developed nations have largely abandoned CMV, and new generations of surgeons are often no longer trained in the technique.

In our institution, however, CMV continues to be performed with favourable outcomes. The operative mortality in this series ranged from 0.2% to 0.5%, which is lower than the 1.5–10% mortality reported in earlier studies of open procedures. Restenosis after CMV remains an important concern. While some studies, such as Houseman et al. [6], report an incidence of 16%, our experience demonstrated a lower rate, comparable to findings from other large case series. Similarly, a study from Vellore [7] suggested that CMV provides survival benefits and a reasonable quality of life over a decade of follow-up, particularly in younger patients. Our results corroborate these findings.

Atrial fibrillation was common in our patients, consistent with its high prevalence among patients with rheumatic mitral stenosis [8]. Despite this, the incidence of embolic complications was relatively low, likely due to routine anticoagulation. Reported embolism rates vary widely in the literature, with incidences as high as 5–8% in some series [9]. In contrast, our experience demonstrated fewer embolic events, highlighting the importance of strict adherence to anticoagulation protocols.

Overall, our findings suggest that CMV remains a safe and effective option for selected patients, particularly in resource-limited settings where advanced alternatives are not always feasible.

Previous studies have reported mortality rates as high as 1.8–7% [10], whereas the operative mortality in our institution was notably lower at 0.2–0.5%. Ellis et al. [11], in a review of 1,000 patients, documented a mortality of 1.9% in NYHA class IV patients. The incidence of severe post-operative mitral regurgitation (MR) was low in our series (0.3%), consistent with published data.

Restenosis rates following CMV were also favourable compared with larger reports, with our patient showing lower recurrence when compared to average figures of 3–10%. Stanley and John [5] have reported reintervention rates of 9.5% at 12 years, whereas Salerno et al.[12] described figures of 6–7%. Our study demonstrated a comparably low incidence, reinforcing the durability of CMV when patient selection is appropriate.

Several other authors have compared CMV with percutaneous balloon mitral valvotomy (PBMV). Studies by , Osmane Refare, M Kharry, Dayem A, Ramzy A[8], Pathak S and Yadav R[13] and Hernandaze et al. [14] , found no significant differences in terms of immediate or long-term outcomes. These reports, in line with our findings, suggest that CMV remains an effective and reliable technique.

Our institutional experience further supports CMV as a safe procedure, characterized by short operative time, minimal ICU and hospital stay, low mortality, and satisfactory long-term outcomes. Preservation of a functional native valve with adequate mitral valve area prolongs survival and quality of life, and remains an important advantage compared with valve replacement.

During a 4-year follow-up, 20 patients with a mitral valve area (MVA) of 1.2–2.0 cm² presented with dyspnoea and atrial fibrillation in emergency and responded on medical management. Five other patients responded to medical therapy initially but later developed severe mitral regurgitation and successfully underwent mitral valve replacement (MVR) after 2 years.

A total of 38 patients were lost to follow-up during the COVID-19 pandemic, the majority being between 17 and 21 years of age. Seven patients died outside the hospital, most of them older than 45 years; the exact cause of death could not be confirmed. Eight patients died in hospital—three due to congestive cardiac failure, four from embolic cerebrovascular accidents, and one following complications despite medical support. Two additional patients were brought in dead.

The remaining 552 patients are on regular follow-up and continue medical management, including heart rate–control drugs, antibiotic prophylaxis, diuretics, fluid restriction, and anticoagulation as indicated.

Considering the above outcomes, CMV (closed mitral valvotomy) should be regarded as a viable option for treating mitral stenosis, especially in settings with limited resources and overburdened healthcare centres where affordability is a significant concern for patients. For young surgeons, CMV offers benefits such as a short learning curve and quick procedure time, resulting in excellent outcomes. Rather than allowing this valuable technique to become obsolete, it is crucial to reintroduce and reinforce it. At our centre, we are committed to teaching and promoting CMV as a core component of our training curriculum, ensuring that new surgeons are thoroughly acquainted with the procedure.

1. Cutler EC , Levine SA. Cardiotomy and valvotomy for mitral stenosis: experimental observations and clinical notes concerning an operated cases with recovery. Boston med surg j 1923;188:1023-7.[cross ref]
2. Souttar HS. The surgical treatment of mitral stenosis. Br med j 1925;2:603-6. [cross ref][PubMed]
3. Harken DE, Ellis LB , ware PF et al. surgical treatment of mitral stenosis. i. valvuloplasty. N Engl j med 1948;239:801-9 [cross ref] [PubMed]
4. Bailey CP. The surgical treatment of mitral stenosis(mitral commissurotomy). Dis chest 1949;15:377-97. [cross ref] [PubMed]
5. John S, Shyam prasad KM , Ravikumar E, et al. closed commissurotomy for mitral stenosis: obsolete or relevant? Indian J Thorac Cardiovasc surg 1991;7:8-12. [cross ref]
6. Houseman LB, Bonchek L, Lambert L, Grunkemeier G, Starr A: prognosis of the patients after openmitral commissurotomy. Actuarial analysis of late results in 100 patients. J thorac cariovasc surg 73:743,1977. {cross ref]
7. John S, Bashi V, Jairaj PS, Muralidharan S . closed mitral valvotomy: Early results and long term follow-up of 3724 concecutive patients: American heart Association circulation 68 no. 5, 891-896, 1983. [cross ref]
8. Rifaie O, Abdel-Dayem MK, Ramzy A, et al.: percutaneous mitral valvotomy versus closed surgical commissurotomy. Upto 15 years of follow up of a prospective randomized study. J Cardiol.2009, 53:28-34.
9. Deverall PB, Olley PM, Smith DR, Watson DA , Whitaker W; incidence of systemic embolism before and after mitral valvotomy: BMJ Thorax 1968 sep: 23(5); 530-536 doi
10. Commerford PJ, Hastie T , Beck W: closed mitral valvotomy : actuarial analysis of result in 654 patients over 12 years and analysis of preoperative predictors of long-term survival. Ann Thorac surg, 1982, 33:473-9.
11. Ellis LB, Singh JB, Morales DD, Harken DE: Fifteen to twenty- year study of one thousand patients undergoing closed mitral valvuloplasty: circulations 1973 aha journals.org.
12. Salerno TA, Nelson IR, Edward JP, Charrette P, Lynn RB: a 25 year experience with closed method of treatment in 139 patients with mitral stenosis; the society of thoracic surgeon 1980:300-304.
13. Pathak S, Yadav R(July 28,2022):closed Mitral Valvotomy Reenvision; Cureus 14(7):e27401. DOI 10.7759/cureus.27401.
14. Hernandez R, Macaya C, Banuelos C, Alfonso F, Goicolea J, Iniguez A, et al. predictors, mechanism and the outcome of severe mitral regurgitation complicating percutaneous mitral valvotomy with Inoue balloon. Am J Cardiol1992:70:1169-74.