Mitral stenosis stages

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sogand Goudarzi, MD [2]

Overview

According to the 2014 AHA/ACC guidelines for management of valvular heart diseases and valve morphology, the valve hemodynamics characteristics, the consequences of MS on the left atrium and the pulmonary arterial system, and base on the presence or absence of symptoms, there are 4 stages of mitral stenosis. Staging of mitral stenosis (MS) is of utmost importance because it dictates the appropriate management plan for the affected patients.

Stages of Mitral Stenosis

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^[1]

Table 16. Stages of MS

Stage	Definition	Valve anatomy	Valve hemodynamics	Hemodynamic consequences	Symptoms
A	At risk of MS	❑ Mild diastolic doming of mitral valve leaflets	❑ Normal transmitral velocity	None	None
B	Progressive MS	❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets Planimetered mitral valve area >1.5 cm2	❑ Increased transmitral flow velocities ❑Mitral valve area >1.5 cm² ❑ Diastolic pressure half-time <150 ms	❑ Mild to moderate left atrial enlargement ❑ Normal pulmonary pressure at rest	None
C	Asymptomatic severe MS	❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of mitral valve ❑ Planimetered mitral valve area ≤1.5 cm²	❑ Mitral valve area ≤1.5 cm² ❑ Diastolic pressure half-time ≥150 ms	❑ Severe left atrial enlargement ❑ Elevated PASP >50 mm Hg	None
D	Symptomatic severe MS	❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of mitral valve ❑ Planimetered mitral valve area ≤1.5 cm²	❑ Mitral valve area ≤1.5 cm² ❑ Diastolic pressure half-time ≥150 ms	❑ Severe left atrial enlargement ❑ PASP > 50 mm Hg	❑Decreased exercise tolerance ❑ Exertional dyspnea

The transmitral mean pressure gradient should be obtained to further determine the hemodynamic effect of the MS and is usually >5 mm Hg to 10 mm Hg in severe MS; however, because of the variability of the mean pressure gradient with heart rate and forward flow, it has not been included in the criteria for severity.LA indicates left atrial; MS, mitral stenosis; and PASP, pulmonary artery systolic pressure.

According to the 2014 AHA/ACC guidelines for management of valvular heart diseases and valve morphology, the valve hemodynamics characteristics, the consequences of MS on the left atrium and the pulmonary arterial system, and base on the presence or absence of symptoms, there are 4 stages of mitral stenosis.^[2]

Shown below is a table depicting the 4 stages of mitral stenosis, adapted from 2014 AHA/ACC guidelines for management of valvular heart diseases.^[3]

Abbreviations: MS: mitral stenosis; MVA: mitral valve area; PASP: pulmonary artery systolic pressure

Stage	Definition	Valve anatomy	Valve hemodynamics	Hemodynamic consequences	Symptoms
A	At risk of MS	❑ Mild diastolic doming of mitral valve leaflets	❑ Normal transmitral velocity	Absent	Absent
B	Progressive MS	❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of mitral valve ❑ MVA > 1.5 cm² (planimetered)	❑ Increased transmitral flow velocities ❑ MVA > 1.5 cm² ❑ Pressure half time during diastole < 150 ms	❑ Mild to moderate left atrial enlargement ❑ Normal pulmonary pressure at rest	Absent
C	Asymptomatic severe MS	❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of mitral valve ❑ MVA ≤ 1.5 cm² ❑ MVA ≤ 1 cm² in very severe MS	❑ MVA ≤ 1.5 cm² (planimetered) ❑ MVA ≤ 1 cm² (planimetered) in very severe MS ❑ Diastolic pressure half time ≥ 150 ms ❑ Diastolic pressure half time ≥ 220 ms with very severe MS	❑ Severe left atrial enlargement ❑ PASP > 30 mm Hg	Absent
D	Symptomatic severe MS	❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of mitral valve ❑ MVA ≤ 1.5 cm² (planimetered)	❑ MVA ≤ 1.5 cm² ❑ MVA ≤ 1 cm² in very severe MS ❑ Diastolic pressure half time ≥ 150 ms ❑ Diastolic pressure half time ≥ 220 ms with very severe MS	❑ Severe left atrial enlargement ❑ PASP > 30 mm Hg	❑ Dyspnea on exertion ❑ Decreased exercise tolerance

References

↑ 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).
↑ Nishimura, Rick A.; Otto, Catherine M.; Bonow, Robert O.; Carabello, Blase A.; Erwin, John P.; Guyton, Robert A.; O’Gara, Patrick T.; Ruiz, Carlos E.; Skubas, Nikolaos J.; Sorajja, Paul; Sundt, Thoralf M.; Thomas, James D. (2014). “2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary”. Circulation. 129 (23): 2440–2492. doi:10.1161/CIR.0000000000000029. ISSN 0009-7322.
↑ 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.

[pmid33332150-1] 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).

[NishimuraOtto2014-2] Nishimura, Rick A.; Otto, Catherine M.; Bonow, Robert O.; Carabello, Blase A.; Erwin, John P.; Guyton, Robert A.; O’Gara, Patrick T.; Ruiz, Carlos E.; Skubas, Nikolaos J.; Sorajja, Paul; Sundt, Thoralf M.; Thomas, James D. (2014). “2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary”. Circulation. 129 (23): 2440–2492. doi:10.1161/CIR.0000000000000029. ISSN 0009-7322.

[pmid24589852-3] 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.

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