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{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]][mailto:msbeih@perfuse.org]; {{CZ}}
__NOTOC__
{{Mitral stenosis}}
{{Mitral stenosis}}
{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]][mailto:msbeih@wikidoc.org]; {{CZ}}; {{Rim}}


==Medical treatment==
==Overview==
The choice of treatment depends on the symptoms present and the condition and function of the heart. Patients with high blood pressure or a weakened heart muscle may be given medications to reduce the strain on the heart and help improve the condition.
[[Medical]] therapy for mitral stenosis includes [[anticoagulation]] and rate control in [[patients]] with [[atrial fibrillation]]. [[Medical]] therapy can relieve [[Symptom|symptoms]], but the [[patient]] may need surgery to relieve the [[blood]] flow [[obstruction]] by mitral stenosis. Surgical treatment in the [[symptomatic]] [[patient]] reduces the [[mortality]] rate of mitral stenosis compared to [[medical]] treatment. The [[Interventional Cardiology|interventional]] and surgical treatments for mitral stenosis include: [[percutaneous mitral balloon valvotomy (PMBV)]], closed commissurotomy, open commissurotomy ([[valve]] repair), and [[mitral valve replacement]].


'''Pharmacotherapy''' may include:
==Medical Therapy==
===Treatment of Acute Decompensation===
==== Digoxin ====
[[Digitalis]] may be used among [[patients]] with [[AS]] and [[symptomatic]] [[right ventricular]] or [[left ventricular]] [[Dysfunctional|dysfunction]], and in those with [[atrial fibrillation]].  [[Digitalis]] increases [[myocardial]] contractility and slows the [[Ventricle (heart)|ventricular]] response in patients with [[atrial arrhythmias]]. Slowing the [[heart]] rate prolongs the diastolic filling time and allows better filling of the left [[ventricle]].<ref name="pmid14439687">{{cite journal| author=ROWE JC, BLAND EF, SPRAGUE HB, WHITE PD| title=The course of mitral stenosis without surgery: ten- and twenty-year perspectives. | journal=Ann Intern Med | year= 1960 | volume= 52 | issue=  | pages= 741-9 | pmid=14439687 | doi= | pmc= | url= }} </ref><ref name="pmid6015840">{{cite journal| author=Dahl JC, Winchell P, Borden CW| title=Mitral stenosis. A long term postoperative follow-up. | journal=Arch Intern Med | year= 1967 | volume= 119 | issue= 1 | pages= 92-7 | pmid=6015840 | doi= | pmc= | url= }} </ref><ref name="pmid4889600">{{cite journal| author=Roy SB, Gopinath N| title=Mitral stenosis. | journal=Circulation | year= 1968 | volume= 38 | issue= 1 Suppl | pages= 68-76 | pmid=4889600 | doi= | pmc= | url= }} </ref><ref name="pmid11907022">{{cite journal| author=Boon NA, Bloomfield P| title=The medical management of valvar heart disease. | journal=Heart | year= 2002 | volume= 87 | issue= 4 | pages= 395-400 | pmid=11907022 | doi= | pmc=PMC1767079 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11907022  }} </ref>


*[[Anticoagulant]] or [[antiplatelet]] medications (blood thinners) may be used to prevent clots from forming in patients with [[atrial fibrillation]]. The 2006 ACC/AHA guidelines on the management of valvular heart disease recommended long-term oral anticoagulation in patients with mitral stenosis who have a prior embolic event, left atrial thrombus, or atrial fibrillation <ref name="pmid18574274">{{cite journal| author=Salem DN, O'Gara PT, Madias C, Pauker SG, American College of Chest Physicians| title=Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 593S-629S | pmid=18574274 | doi=10.1378/chest.08-0724 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574274  }} </ref><ref name="pmid18574273">{{cite journal| author=Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL et al.| title=Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 546S-592S | pmid=18574273 | doi=10.1378/chest.08-0678 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574273  }} </ref>.
==== Diuretics ====
*[[Digitalis]] may be used to strengthen the heartbeat.
[[Diuretics]] may be used to remove excess fluid in the lungs in [[patients]] with [[pulmonary edema]].<ref name="El SabbaghReddy2019">{{cite journal|last1=El Sabbagh|first1=Abdallah|last2=Reddy|first2=Yogesh N. V.|last3=Barros‐Gomes|first3=Sergio|last4=Borlaug|first4=Barry A.|last5=Miranda|first5=William R.|last6=Pislaru|first6=Sorin V.|last7=Nishimura|first7=Rick A.|last8=Pellikka|first8=Patricia A.|title=Low‐Gradient Severe Mitral Stenosis: Hemodynamic Profiles, Clinical Characteristics, and Outcomes|journal=Journal of the American Heart Association|volume=8|issue=5|year=2019|issn=2047-9980|doi=10.1161/JAHA.118.010736}}</ref>
*[[Diuretics]] may be used to remove excess fluid in the lungs.


A low-sodium diet may be helpful. Most people have no symptoms; but if a person develops symptoms, activity may be restricted.
==== Low Sodium Diet ====
A low-[[sodium]] diet may be helpful.
==== Activity Restriction ====
Once a a [[patient]] develops [[Symptom|symptoms]], activity may be restricted.


Cases of mild mitral stenosis (mitral valve area >1.5 cm2) can be followed up yearly with history, physical examination, [[EKG]] and some imaging studies like echocardiography.
===Systemic Embolization Prevention===
Anticoagulation therapy is indicated for thromboembolic events prevention among AS [[patients]] in any of the following [[conditions]] ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence B]]):<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>
* Paroxysmal, persistent, or permanent [[atrial fibrillation]]
* Prior [[embolization]] event
* [[Left atrial]] [[thrombus]]


The 2006 American College of Cardiology/American Heart Association ([[ACC]]/[[AHA]]) guidelines for management of valvular heart disease recommended routine repeat echocardiography every year for patients with severe mitral stenosis, every one to two years for patients with moderate mitral stenosis and every three to five years for patients with mild mitral stenosis  <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref>. By echocardiography, the doctor can assess the pulmonary artery pressure to decide if the surgery is indicated for the patient with mitral stenosis or not.
===Rate Control===
Rate control with either [[beta blockers]] or [[calcium channel blocker]] is indicated in MS in the following conditions:<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>
* [[Atrial fibrillation]] associated with fast [[Ventricle (heart)|ventricular]] response ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa, Level of Evidence C]])
* Normal [[sinus rhythm]] plus symptoms associated with exercise ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb, Level of Evidence B]])


In asymptomatic patients, use endocarditis prophylaxis and chronic anticoagulation for intermittent or chronic atrial fibrillation, systemic embolism and marked LA enlargement (>55mm).
===Secondary Prevention of Rheumatic Fever===
====Indications====
Shown below is the table depicting the indication for secondary prophylaxis of [[rheumatic fever]].<ref name="pmid19246689">{{cite journal| author=Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST et al.| title=Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. | journal=Circulation | year= 2009 | volume= 119 | issue= 11 | pages= 1541-51 | pmid=19246689 | doi=10.1161/CIRCULATIONAHA.109.191959 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19246689  }} </ref>


The decision of whether to proceed with vavluloplasty or surgical commissurotomy depends on the severity of symptoms and/or severe (>50mm Hg) PHTN.
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
One of the complications of mitral stenosis is [[atrial fibrillation]], which may lead to systemic embolization.
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Duration of prophylaxis'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] and persistent [[valvular heart disease]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)''''' ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence C]])
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ▸ '''''[[Rheumatic fever]] with [[carditis]] but no [[valvular heart disease]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)''''' ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence C]])
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ▸ '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)''''' ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence C]])
|-
|}


==ACC/AHA Guidelines-Prevention of Systemic Embolization (DO NOT EDIT)==
====Antibiotic Regimens====
{{cquote|
Shown below is the table depicting the [[antibiotic]] regimens for secondary prophylaxis of [[rheumatic fever]].<ref name="pmid19246689">{{cite journal| author=Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST et al.| title=Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. | journal=Circulation | year= 2009 | volume= 119 | issue= 11 | pages= 1541-51 | pmid=19246689 | doi=10.1161/CIRCULATIONAHA.109.191959 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19246689  }} </ref>
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
'''1''' Anticoagulation is indicated in patients with MS and atrial fibrillation (paroxysmal, persistent, or permanent). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
'''2''' Anticoagulation is indicated in patients with MS and a prior embolic event, even in sinus rhythm. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
'''3''' Anticoagulation is indicated in patients with MS with left atrial thrombus. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
class iib


1 Anticoagulation may be considered for asymptomatic patients with severe MS and left atrial dimension greater than or equal to 55 mm by echocardiography.* ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])  
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
2 Anticoagulation may be considered for patients with severe MS, an enlarged left atrium, and spontaneous contrast on echocardiography. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])}}
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Antibiotics'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Dosage'''
|-
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''''[[Penicillin G benzathine]]''''' <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence A]])||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left| ▸ '''''Weight >27 Kg (60 lb): 1.2 million units IM every day for 4 weeks'''''<br>▸ '''''Weight ≤27 Kg (60 lb): 600,000 units IM every day for 4 weeks'''''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''''[[Penicillin V]]''''' <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence B]])|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |▸ '''''200 mg orally twice a day'''''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left|'''''[[Sulfadiazine]]''''' <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence B]])|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left|▸ '''''Weight >27 Kg (60 lb): 1 g orally once a day''''' <br> ▸ '''''Weight ≤27 Kg (60 lb): o.5 g orally once a day'''''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left|'''''[[Macrolide]] or [[azalide]] antibiotics (in patients allergic to [[penicillin]])''''' <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence C]])|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left|▸ '''''Varies'''''
|-
|}
 
===Prevention of Endocarditis===
[[Endocarditis]] [[prophylaxis]] is not indicated among [[patients]] with MS.<ref name="pmid17446442">{{cite journal| author=Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M et al.| title=Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. | journal=Circulation | year= 2007 | volume= 116 | issue= 15 | pages= 1736-54 | pmid=17446442 | doi=10.1161/CIRCULATIONAHA.106.183095 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17446442  }} </ref><ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>
 
== 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines<ref name="pmid33332150">{{cite journal| author=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F | display-authors=etal| title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2021 | volume= 143 | issue= 5 | pages= e72-e227 | pmid=33332150 | doi=10.1161/CIR.0000000000000923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332150  }}</ref> ==
 
=== Recommendations for Medical Therapy in Patients With Rheumatic MS Referenced studies that support the recommendations are summarized in Online Data Supplement ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1.   In patients with rheumatic MS and 1) AF, 2) a prior embolic event, or 3) an LA thrombus, anticoagulation with a VKA is indicated''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2.   In patients with rheumatic MS and AF with a rapid ventricular response, heart rate control can be beneficial''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
3.   In patients with rheumatic MS in normal sinus rhythm with symptomatic resting or exertional sinus tachycardia, heart rate control can be beneficial to manage symptoms''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|}
 
==2014_2017 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary (DO NOT EDIT)<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>==
 
===Medical Therapy (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Anticoagulation]] ([[vitamin K]] antagonist or [[heparin]]) is indicated in [[patients]] with:
 
*[[MS]] and [[AF]] (paroxysmal, persistent, or permanent), or
*[[MS]] and a prior [[embolic]] event, or
*[[MS]] and a [[Left atrium|left atrial]] [[thrombus]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Heart]] rate control can be beneficial in [[patients]] with [[MS]] and [[AF]] and fast [[Ventricle (heart)|ventricular]] response.  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Heart]] rate control may be considered for [[patients]] with [[MS]] in normal [[sinus rhythm]] and [[Symptom|symptoms]] associated with [[exercise]].  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
 
===Basic Principles of Medical Therapy (DO NOT EDIT)===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Secondary prevention of [[rheumatic fever]] is indicated in patients with [[rheumatic heart disease]], specifically mitral stenosis (MS). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
|}
 
==2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (DO NOT EDIT)<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==
 
===Systemic Embolization Prevention (DO NOT EDIT)<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref><ref name="NishimuraOtto2017">{{cite journal|last1=Nishimura|first1=Rick A.|last2=Otto|first2=Catherine M.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Fleisher|first6=Lee A.|last7=Jneid|first7=Hani|last8=Mack|first8=Michael J.|last9=McLeod|first9=Christopher J.|last10=O’Gara|first10=Patrick T.|last11=Rigolin|first11=Vera H.|last12=Sundt|first12=Thoralf M.|last13=Thompson|first13=Annemarie|title=2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines|journal=Circulation|volume=135|issue=25|year=2017|issn=0009-7322|doi=10.1161/CIR.0000000000000503}}</ref>===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Anticoagulation]] is indicated in [[patients]] with [[mitral stenosis]] and [[atrial fibrillation]] (paroxysmal, persistent, or permanent). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Anticoagulation]] is indicated in [[patients]] with [[mitral stenosis]] and a prior [[embolic]] event, even in [[sinus rhythm]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Anticoagulation]] is indicated in [[patients]] with [[mitral stenosis]] with left atrial [[thrombus]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Anticoagulation]] may be considered for [[asymptomatic]] [[patients]] with severe [[mitral stenosis]] and [[Left atrium|left atrial]] dimension greater than or equal to 55 mm by [[echocardiography]].* ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Anticoagulation]] may be considered for [[Patient|patients]] with severe [[mitral stenosis]], an enlarged [[left atrium]], and spontaneous contrast on [[echocardiography]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
 
 
 
'''2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease'''<ref name="NishimuraOtto20172">{{cite journal|last1=Nishimura|first1=Rick A.|last2=Otto|first2=Catherine M.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Fleisher|first6=Lee A.|last7=Jneid|first7=Hani|last8=Mack|first8=Michael J.|last9=McLeod|first9=Christopher J.|last10=O’Gara|first10=Patrick T.|last11=Rigolin|first11=Vera H.|last12=Sundt|first12=Thoralf M.|last13=Thompson|first13=Annemarie|title=2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines|journal=Circulation|volume=135|issue=25|year=2017|issn=0009-7322|doi=10.1161/CIR.0000000000000503}}</ref>
{| class="wikitable"
|+
! colspan="4" style="text-align:center; background:LightGreen" |'''Recommendations forAnticoagulation forAtrial Fibrillation (AF) in PatientsWith VHD'''
|-
| '''COR'''style="text-align:center; background:LightGreen" |
|'''LOE'''
|'''Recommendation'''
|'''Comment/Rationate'''
|-
|'''I'''
|'''B-NR'''
|"[[Anticoagulation]] with a [[vitamin K]] [[antagonist]] ([[VKA]]) is indicatedfor [[patients]] with [[rheumatic]] mitral stenosis (MS) and AF".<ref name="KangKim2009">{{cite journal|last1=Kang|first1=Duk-Hyun|last2=Kim|first2=Jeong Hoon|last3=Rim|first3=Ji Hye|last4=Kim|first4=Mi-Jeong|last5=Yun|first5=Sung-Cheol|last6=Song|first6=Jong-Min|last7=Song|first7=Hyun|last8=Choi|first8=Kee-Joon|last9=Song|first9=Jae-Kwan|last10=Lee|first10=Jae-Won|title=Comparison of Early Surgery Versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation|journal=Circulation|volume=119|issue=6|year=2009|pages=797–804|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.802314}}</ref><ref name="Enriquez-SaranoTajik1994">{{cite journal|last1=Enriquez-Sarano|first1=M|last2=Tajik|first2=A J|last3=Schaff|first3=H V|last4=Orszulak|first4=T A|last5=Bailey|first5=K R|last6=Frye|first6=R L|title=Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation.|journal=Circulation|volume=90|issue=2|year=1994|pages=830–837|issn=0009-7322|doi=10.1161/01.CIR.90.2.830}}</ref>
|'''MODIFIED:''' "[[Vitamin K antagonist|VKA]] as opposed to the direct oral [[anticoagulants]] (DOACs) are indicated in [[patients]] with [[Atrial fibrillation|AF]] and [[rheumatic]] MS to prevent [[thromboembolic]] events. The [[Randomized controlled trial|RCTs]] of DOACs versus [[Vitamin K antagonist|VKA]] have not included [[patients]] with MS. The specific recommendation for [[anticoagulation]] of [[patients]] with MS is contained in a subsection of the topic on [[anticoagulation]]".<ref name="Enriquez-SaranoTajik19943">{{cite journal|last1=Enriquez-Sarano|first1=M|last2=Tajik|first2=A J|last3=Schaff|first3=H V|last4=Orszulak|first4=T A|last5=Bailey|first5=K R|last6=Frye|first6=R L|title=Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation.|journal=Circulation|volume=90|issue=2|year=1994|pages=830–837|issn=0009-7322|doi=10.1161/01.CIR.90.2.830}}</ref>
|-
| colspan="4" style="text-align:center; background:LightGreen" |"A [[retrospective]] [[analysis]] of administrative claims [[databases]] (>20,000 [[DOAC]]-treated patients) showed no difference in the incidence of [[stroke]] or major [[bleeding]] in [[patients]] with [[rheumatic]] and nonrheumatic MS if treated with [[DOAC]] versus [[warfarin]]. However, the writing group continues to recommend the use of [[Vitamin K antagonist|VKA]] for [[patients]] with [[rheumatic]] MS until further evidence emerges on the efficacy of [[DOAC]] in this [[population]]".<ref name="Enriquez-SaranoTajik19942">{{cite journal|last1=Enriquez-Sarano|first1=M|last2=Tajik|first2=A J|last3=Schaff|first3=H V|last4=Orszulak|first4=T A|last5=Bailey|first5=K R|last6=Frye|first6=R L|title=Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation.|journal=Circulation|volume=90|issue=2|year=1994|pages=830–837|issn=0009-7322|doi=10.1161/01.CIR.90.2.830}}</ref>
|}


==References==
==References==
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Latest revision as of 03:28, 7 December 2022

Mitral Stenosis Microchapters

Home

Patient Information

Overview

Pathophysiology

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Differentiating Mitral Stenosis from other Diseases

Epidemiology and Demographics

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Diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D.[2]; Cafer Zorkun, M.D., Ph.D. [3]; Rim Halaby, M.D. [4]

Overview

Medical therapy for mitral stenosis includes anticoagulation and rate control in patients with atrial fibrillation. Medical therapy can relieve symptoms, but the patient may need surgery to relieve the blood flow obstruction by mitral stenosis. Surgical treatment in the symptomatic patient reduces the mortality rate of mitral stenosis compared to medical treatment. The interventional and surgical treatments for mitral stenosis include: percutaneous mitral balloon valvotomy (PMBV), closed commissurotomy, open commissurotomy (valve repair), and mitral valve replacement.

Medical Therapy

Treatment of Acute Decompensation

Digoxin

Digitalis may be used among patients with AS and symptomatic right ventricular or left ventricular dysfunction, and in those with atrial fibrillation. Digitalis increases myocardial contractility and slows the ventricular response in patients with atrial arrhythmias. Slowing the heart rate prolongs the diastolic filling time and allows better filling of the left ventricle.[1][2][3][4]

Diuretics

Diuretics may be used to remove excess fluid in the lungs in patients with pulmonary edema.[5]

Low Sodium Diet

A low-sodium diet may be helpful.

Activity Restriction

Once a a patient develops symptoms, activity may be restricted.

Systemic Embolization Prevention

Anticoagulation therapy is indicated for thromboembolic events prevention among AS patients in any of the following conditions (Class I, Level of Evidence B):[6]

Rate Control

Rate control with either beta blockers or calcium channel blocker is indicated in MS in the following conditions:[6]

Secondary Prevention of Rheumatic Fever

Indications

Shown below is the table depicting the indication for secondary prophylaxis of rheumatic fever.[7]

Indications Duration of prophylaxis
▸ Rheumatic fever with carditis and persistent valvular heart disease ▸ 10 years or until the patient is 40 years (whichever is longer) (Class I, Level of Evidence C)
▸ Rheumatic fever with carditis but no valvular heart disease ▸ 10 years or until the patient is 21 years (whichever is longer) (Class I, Level of Evidence C)
▸ Rheumatic fever without carditis ▸ 5 years or until the patient is 21 years (whichever is longer) (Class I, Level of Evidence C)

Antibiotic Regimens

Shown below is the table depicting the antibiotic regimens for secondary prophylaxis of rheumatic fever.[7]

Antibiotics Dosage
Penicillin G benzathine
(Class I, Level of Evidence A)		 ▸ Weight >27 Kg (60 lb): 1.2 million units IM every day for 4 weeks
▸ Weight ≤27 Kg (60 lb): 600,000 units IM every day for 4 weeks
Penicillin V
(Class I, Level of Evidence B)		 ▸ 200 mg orally twice a day
Sulfadiazine
(Class I, Level of Evidence B)		 ▸ Weight >27 Kg (60 lb): 1 g orally once a day
▸ Weight ≤27 Kg (60 lb): o.5 g orally once a day
Macrolide or azalide antibiotics (in patients allergic to penicillin)
(Class I, Level of Evidence C)		 ▸ Varies

Prevention of Endocarditis

Endocarditis prophylaxis is not indicated among patients with MS.[8][9]

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[10]

Recommendations for Medical Therapy in Patients With Rheumatic MS Referenced studies that support the recommendations are summarized in Online Data Supplement

Class I
1.   In patients with rheumatic MS and 1) AF, 2) a prior embolic event, or 3) an LA thrombus, anticoagulation with a VKA is indicated(Level of Evidence: C-LD)
Class IIa
2.   In patients with rheumatic MS and AF with a rapid ventricular response, heart rate control can be beneficial(Level of Evidence: C-LD)

3.   In patients with rheumatic MS in normal sinus rhythm with symptomatic resting or exertional sinus tachycardia, heart rate control can be beneficial to manage symptoms(Level of Evidence: A)

2014_2017 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary (DO NOT EDIT)[6]

Medical Therapy (DO NOT EDIT)

Class I
"1. Anticoagulation (vitamin K antagonist or heparin) is indicated in patients with:
Class IIa
"1. Heart rate control can be beneficial in patients with MS and AF and fast ventricular response. (Level of Evidence: C) "
Class IIb
"1. Heart rate control may be considered for patients with MS in normal sinus rhythm and symptoms associated with exercise. (Level of Evidence: B) "

Basic Principles of Medical Therapy (DO NOT EDIT)

Class I
"1. Secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically mitral stenosis (MS). (Level of Evidence: C) "

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (DO NOT EDIT)[11]

Systemic Embolization Prevention (DO NOT EDIT)[11][12]

Class I
"1. Anticoagulation is indicated in patients with mitral stenosis and atrial fibrillation (paroxysmal, persistent, or permanent). (Level of Evidence: B) "
"2. Anticoagulation is indicated in patients with mitral stenosis and a prior embolic event, even in sinus rhythm. (Level of Evidence: B) "
"3. Anticoagulation is indicated in patients with mitral stenosis with left atrial thrombus. (Level of Evidence: B) "
Class IIb
"1. Anticoagulation may be considered for asymptomatic patients with severe mitral stenosis and left atrial dimension greater than or equal to 55 mm by echocardiography.* (Level of Evidence: B) "
"2. Anticoagulation may be considered for patients with severe mitral stenosis, an enlarged left atrium, and spontaneous contrast on echocardiography. (Level of Evidence: C) "


2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease[13]

Recommendations forAnticoagulation forAtrial Fibrillation (AF) in PatientsWith VHD
LOE Recommendation Comment/Rationate
I B-NR "Anticoagulation with a vitamin K antagonist (VKA) is indicatedfor patients with rheumatic mitral stenosis (MS) and AF".[14][15] MODIFIED: "VKA as opposed to the direct oral anticoagulants (DOACs) are indicated in patients with AF and rheumatic MS to prevent thromboembolic events. The RCTs of DOACs versus VKA have not included patients with MS. The specific recommendation for anticoagulation of patients with MS is contained in a subsection of the topic on anticoagulation".[16]
"A retrospective analysis of administrative claims databases (>20,000 DOAC-treated patients) showed no difference in the incidence of stroke or major bleeding in patients with rheumatic and nonrheumatic MS if treated with DOAC versus warfarin. However, the writing group continues to recommend the use of VKA for patients with rheumatic MS until further evidence emerges on the efficacy of DOAC in this population".[17]

References

  1. ↑ ROWE JC, BLAND EF, SPRAGUE HB, WHITE PD (1960). "The course of mitral stenosis without surgery: ten- and twenty-year perspectives". Ann Intern Med. 52: 741–9. PMID 14439687.
  2. ↑ Dahl JC, Winchell P, Borden CW (1967). "Mitral stenosis. A long term postoperative follow-up". Arch Intern Med. 119 (1): 92–7. PMID 6015840.
  3. ↑ Roy SB, Gopinath N (1968). "Mitral stenosis". Circulation. 38 (1 Suppl): 68–76. PMID 4889600.
  4. ↑ Boon NA, Bloomfield P (2002). "The medical management of valvar heart disease". Heart. 87 (4): 395–400. PMC 1767079. PMID 11907022.
  5. ↑ El Sabbagh, Abdallah; Reddy, Yogesh N. V.; Barros‐Gomes, Sergio; Borlaug, Barry A.; Miranda, William R.; Pislaru, Sorin V.; Nishimura, Rick A.; Pellikka, Patricia A. (2019). "Low‐Gradient Severe Mitral Stenosis: Hemodynamic Profiles, Clinical Characteristics, and Outcomes". Journal of the American Heart Association. 8 (5). doi:10.1161/JAHA.118.010736. ISSN 2047-9980.
  6. ↑ 6.0 6.1 6.2 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
  7. ↑ 7.0 7.1 Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST; et al. (2009). "Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics". Circulation. 119 (11): 1541–51. doi:10.1161/CIRCULATIONAHA.109.191959. PMID 19246689.
  8. ↑ Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M; et al. (2007). "Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group". Circulation. 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442.
  9. ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
  10. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).
  11. ↑ 11.0 11.1 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)
  12. ↑ Nishimura, Rick A.; Otto, Catherine M.; Bonow, Robert O.; Carabello, Blase A.; Erwin, John P.; Fleisher, Lee A.; Jneid, Hani; Mack, Michael J.; McLeod, Christopher J.; O’Gara, Patrick T.; Rigolin, Vera H.; Sundt, Thoralf M.; Thompson, Annemarie (2017). "2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. 135 (25). doi:10.1161/CIR.0000000000000503. ISSN 0009-7322.
  13. ↑ Nishimura, Rick A.; Otto, Catherine M.; Bonow, Robert O.; Carabello, Blase A.; Erwin, John P.; Fleisher, Lee A.; Jneid, Hani; Mack, Michael J.; McLeod, Christopher J.; O’Gara, Patrick T.; Rigolin, Vera H.; Sundt, Thoralf M.; Thompson, Annemarie (2017). "2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. 135 (25). doi:10.1161/CIR.0000000000000503. ISSN 0009-7322.
  14. ↑ Kang, Duk-Hyun; Kim, Jeong Hoon; Rim, Ji Hye; Kim, Mi-Jeong; Yun, Sung-Cheol; Song, Jong-Min; Song, Hyun; Choi, Kee-Joon; Song, Jae-Kwan; Lee, Jae-Won (2009). "Comparison of Early Surgery Versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation". Circulation. 119 (6): 797–804. doi:10.1161/CIRCULATIONAHA.108.802314. ISSN 0009-7322.
  15. ↑ Enriquez-Sarano, M; Tajik, A J; Schaff, H V; Orszulak, T A; Bailey, K R; Frye, R L (1994). "Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation". Circulation. 90 (2): 830–837. doi:10.1161/01.CIR.90.2.830. ISSN 0009-7322.
  16. ↑ Enriquez-Sarano, M; Tajik, A J; Schaff, H V; Orszulak, T A; Bailey, K R; Frye, R L (1994). "Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation". Circulation. 90 (2): 830–837. doi:10.1161/01.CIR.90.2.830. ISSN 0009-7322.
  17. ↑ Enriquez-Sarano, M; Tajik, A J; Schaff, H V; Orszulak, T A; Bailey, K R; Frye, R L (1994). "Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation". Circulation. 90 (2): 830–837. doi:10.1161/01.CIR.90.2.830. ISSN 0009-7322.

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