Mitral stenosis treatment overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Treatment Algorithm

Shown below is an algorithm depicting the indications for mitral stenosis intervention according to the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.

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

Determine the severity of rheumatic 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 atrial clot AND ❑ No or mild MR

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

Is there a new onset of AF?

Order an exercise treadmill 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 atrial clot AND ❑ No or mild MR

No

Yes

Yes

No

Yes

No

Periodic monitoring

PMBC (Class IIa)

PMBC (Class I)

Mitral valve surgery (Class I)

PMBC (Class IIb)

Periodic monitoring

PMBC (Class IIb)

Periodic monitoring