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]

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. The interventional and surgical treatments for mitral stenosis include: percutaneous mitral balloon valvotomy (PMBV), closed commissurotomy, open commissurotomy (valve repair), and mitral valve replacement.

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.^[1]

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
❑ T_1/2 ≥220 ms

Severe MS
❑ MVA ≤1.5 cm2
❑ T_1/2 ≥150 ms

Progressive MS
MVA >1.5 cm2
T_1/2 <150 ms

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

Is there a new onset of AF?

Order an exercise treadmill test

No

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

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

References

↑ 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.

Template:WikiDoc Sources

[pmid24589852-1] 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.

[1]