Sandbox Rim

Mitral Stenosis

Abbreviations: AF: atrial fibrillation; MS: mitral stenosis; MR: mitral regurgitation; MVA: mitral valve area ; MVR: mitral valve replacement/repair ; PCWP: pulmonary capillary wedge pressure; PMBC: percutaneous mitral balloon commissurotomy; T_1/2: pressure half-time

Determine the severity of mitral stenosis (MS)

Very severe MS ❑ MVA ≤1 cm2 ❑ T1/2 ≥220 ms

Severe MS ❑ MVA ≤1.5 cm2 ❑ T1/2 ≥150 ms

Progressive MS MVA >1.5 cm2 T1/2 <150 ms

Is the patient symptomatic?

Is the patient symptomatic?

Is the patient symptomatic?

No ( Stage C)

Yes (Stage D)

No (Stage C)

Yes With no other cause for the symptoms

Does the patient have: ❑ Favorable valve morphology AND ❑ No left appendage clot AND ❑ No or mild MR

Does the patient have: ❑ Favorable valve morphology AND ❑ No left appendage clot AND ❑ No or mild MR

Is there a new onset of AF?

Order an exercise stress test

No

Yes

Yes

No

Yes

No

Is PCWP> 25 mm Hg?

Does the patient have: ❑ NYHA class III-IV symptoms AND ❑ High surgical risk

Does the patient have: ❑ Favorable valve morphology AND ❑ No left appendage clot AND ❑ No or mild MR

No

Yes

Yes

No

Yes

No

Periodic monitoring

PMBC (Class IIa)

PMBC (Class I)

MVR (Class I)

PMBC (Class IIb)

Periodic monitoring

PMBC (Class IIb)

Periodic monitoring