Mitral stenosis surgery indications

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]

Overview

Although mitral valvuloplasty is an effective less invasive treatment modality compared to surgery, mitral valve surgery is indicated if the mitral valve is severely calcified, if there is moderate to severe mitral regurgitation coexists with MS, if mitral valvuloplasty is not available or the patient has unfavorable valve morphology, and if there is left atrial thrombus that persists despite anticoagulation.

Indications

There is an improvement in the mortality rates for mitral stenosis by intervention of percutaneous mitral balloon valvotomy or surgery. The 2006 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the management of valvular heart disease recommended intervention in symptomatic patients with moderate to severe mitral stenosis.^[1]

In asymptomatic patients, intervention is recommended in moderate to severe MS and pulmonary hypertension pulmonary artery systolic pressure >50 mmHg at rest or >60 mmHg with exercise). The ACC/AHA guidelines indicates surgery when one of the following is presents:^[1]

The mitral valve is severely calcified.
Moderate to severe mitral regurgitation coexists with MS.
PMBV is not available or the patient has unfavorable valve morphology.
There is left atrial thrombus that persists despite anticoagulation.

Valve replacement improves long-term survival along with symptomatic improvement if the patient could not be treated by either PMBV or valve repair.

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary^[2]

Class I
“1. Mitral valve surgery (repair, commissurotomy, or valve replacement) is indicated in severely symptomatic patients (NYHA class III to IV) with severe MS (mitral valve area ≤1.5 cm2, stage D) who are not high risk for surgery and who are not candidates for or who have failed previous percutaneous mitral balloon commissurotomy. (Level of Evidence: B) ”
“2. Concomitant mitral valve surgery is indicated for patients with severe MS (mitral valve area ≤1.5 cm2, stage C or D) undergoing cardiac surgery for other indications. (Level of Evidence: C) ”

Class IIa
“1. Mitral valve surgery is reasonable for severely symptomatic patients (NYHA class III to IV) with severe MS (mitral valve area ≤1.5 cm2, stage D), provided there are other operative indications (e.g., aortic valve disease, coronary artery disease (CAD), tricuspid regurgitation (TR), aortic aneurysm). (Level of Evidence: C) ”

Class IIb
“1. Concomitant mitral valve surgery may be considered for patients with moderate MS (mitral valve area 1.6 cm2 to 2.0 cm2) undergoing cardiac surgery for other indications. (Level of Evidence: C) ”
“2. Mitral valve surgery and excision of the left atrial appendage may be considered for patients with severe MS (mitral valve area ≤1.5 cm2, stages C and D) who have had recurrent embolic events while receiving adequate anticoagulation. (Level of Evidence: C) ”

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)^[1]

Surgery Indications (DO NOT EDIT)^[1]

Class I
“1. Mitral valve surgery (repair if possible) is indicated in patients with symptomatic (NYHA functional class III-IV) moderate or severe mitral stenosis when 1) percutaneous mitral balloon valvotomy is unavailable, 2) percutaneous mitral balloon valvotomy is contraindicated because of left atrial thrombus despite anticoagulation or because concomitant moderate to severe mitral regurgitation is present, or 3) the valve morphology is not favorable for percutaneous mitral balloon valvotomy in a patient with acceptable operative risk.(Level of Evidence: B) ”
“2. Symptomatic patients with moderate to severe mitral stenosis who also have moderate to severe mitral regurgitation should receive mitral valve replacement, unless valve repair is possible at the time of surgery.(Level of Evidence: C) ”

Class III
“1. Mitral valve repair for mitral stenosis is not indicated for patients with mild mitral stenosis. (Level of Evidence: C) ”
“2. Closed commissurotomy should not be performed in patients undergoing mitral valve repair; open commissurotomy is the preferred approach.(Level of Evidence: C) ”

Class IIa
“1. Mitral valve replacement is reasonable for patients with severe mitral stenosis and severe pulmonary hypertension (pulmonary artery systolic pressure greater than 60 mm Hg) with NYHA functional class I–II symptoms who are not considered candidates for percutaneous mitral balloon valvotomy or surgical mitral valve repair.(Level of Evidence: C) ”

Class IIb
“1. Mitral valve repair may be considered for asymptomatic patients with moderate or severe mitral stenosis who have had recurrent embolic events while receiving adequate anticoagulation and who have valve morphology favorable for repair.(Level of Evidence: C) ”

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; 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.
↑ 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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[pmid18820172-1] 1.0 ^1.1 ^1.2 ^1.3 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; 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.

[pmid24589852-2] 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.

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