Favorable valve morphology consists of mobile and relatively thin valve leaflets, which are free of calcium, in the absence of significant subvalvular fusion.18,19,22,23 An anatomic mitral morphology score can be used to determine suitability for PMBC and to evaluate the appearance of the commissures and degree of calcification.1,24,25 Clinical factors, such as age, NYHA class, and presence or absence of AF, are also predictive of outcome. Older patients with lower gradients (<10 mmHg) will not have as good an outcome as patients with higher gra- dients, probably because of other concomitant problems that cause symptoms, such as LV dia- stolic dysfunction and LA noncompliance, mea- sured by net atrial ventricular compliance.26 30 PMBC should be performed only by experienced operators, with immediate availability of surgical backup for potential complications. Long-term follow-up has shown 70% to 80% of patients with an initial good result after PMBC to be free of recurrent symptoms at 10 years, and 30% to 40% are free of recurrent symptoms at 20 years.1 7 2. Mitral valve surgery is an established therapy for rheumatic MS, with the preferred approach being commissurotomy (either closed, where the valve is opened blindly through the LA or LV, or open, which allows more extensive surgery under direct visual- ization) when anatomy is favorable.31 36 However, in the presence of severe valvular thickening and subvalvular fibrosis with leaflet tethering, mitral valve replacement may be the best option. 