From the Guidelines
Surgery is indicated in mitral stenosis patients with clinically significant (moderate to severe) mitral stenosis (valve area <1.5 cm2) who are symptomatic, or in asymptomatic patients with high risk of cardiac complications and contraindications for percutaneous mitral commissurotomy (PMC). The management of mitral stenosis involves a multidisciplinary approach, considering the patient's clinical characteristics, valve anatomy, and local expertise 1.
Indications for Surgery
The following are indications for surgery in mitral stenosis patients:
- Symptomatic patients with moderate to severe mitral stenosis (valve area <1.5 cm2)
- Asymptomatic patients with high risk of cardiac complications, such as those with increased risk of systemic embolism or haemodynamic decompensation, and contraindications for PMC
- Patients with unfavourable anatomy, such as severe calcification or impaired subvalvular apparatus, who are not candidates for PMC
- Patients with left atrial thrombus, especially if the thrombus persists despite anticoagulation therapy
Surgical Options
The two main surgical options for mitral stenosis are:
- Mitral valve repair (commissurotomy) for suitable valve anatomy
- Mitral valve replacement when the valve is heavily calcified or has significant subvalvular apparatus involvement Percutaneous mitral balloon valvuloplasty may be preferred in younger patients with pliable valves and minimal calcification 1.
Timing of Surgery
The timing of surgery is critical, as waiting too long can lead to irreversible right ventricular dysfunction and pulmonary hypertension, while intervening too early exposes patients to unnecessary surgical risks 1. Patients should be evaluated by an experienced heart team to determine the optimal timing and type of intervention based on their specific valve morphology, comorbidities, and surgical risk profile.
From the Research
Indications for Surgery in Mitral Stenosis Patients
The indications for surgery in mitral stenosis patients include:
- Severe mitral stenosis, particularly in patients who are in functional classes III or IV and do not respond to medical management 2
- Symptomatic mitral stenosis, where patients should be treated with mitral commissurotomy whenever possible 2
- Mitral insufficiency, which may require mitral valve replacement in certain settings, such as rheumatic disease, rupture of mitral chordae tendineae, or postinfarction rupture of a papillary muscle 2
- Congestive heart failure, where corrective mitral valve intervention should be considered as the main and definitive treatment 3
- Severe pulmonary hypertension, where surgery may be a higher risk, but the potential benefits justify the risks in the majority of cases 3
Patient Selection for Surgery
Patients selected for commissurotomy should have:
- A pliable valve
- No other major valve dysfunction
- Sinus rhythm
- No systemic embolism
- Good left ventricular function 2
Surgical Options
Surgical options for mitral stenosis patients include:
- Mitral valve replacement, which is considered for patients with severe mitral stenosis or insufficiency 2
- Mitral commissurotomy, which is preferred for patients with symptomatic mitral stenosis and a pliable valve 2
- Minimally invasive surgical replacement of the mitral valve, which may be considered for patients with severe mitral stenosis or insufficiency 4