What are the treatment options for symptomatic mitral stenosis?

Treatment Options for Symptomatic Mitral Stenosis

Percutaneous mitral balloon commissurotomy (PMBC) is the first-line treatment for symptomatic patients with rheumatic mitral stenosis who have favorable valve anatomy, while mitral valve surgery is indicated for those not suitable for PMBC. 1, 2

Initial Assessment and Medical Therapy

Medical therapy can provide symptomatic relief but does not alter disease progression:

• Symptom management:

  • Diuretics for pulmonary congestion and edema
  • Heart rate control with beta-blockers (preferably beta-1 selective) in sinus rhythm
  • Calcium channel blockers (verapamil) or digoxin for rate control in atrial fibrillation 1, 2

• Anticoagulation:

  • Vitamin K antagonists (VKAs) with target INR 2-3 for patients with atrial fibrillation 1, 3
  • Oral anticoagulation indicated in sinus rhythm patients with:
    • History of systemic embolism
    • Left atrial thrombus
    • Dense spontaneous contrast on TEE
    • Enlarged left atrium (>50 mm or >60 mL/m²) 1, 2
  • NOACs are not recommended in mitral stenosis with atrial fibrillation 2

Interventional Treatment Algorithm

1. Rheumatic Mitral Stenosis

• For symptomatic patients with favorable valve anatomy:

  • PMBC is first-line therapy (Class I recommendation) 1, 2
  • Open commissurotomy may be preferred by experienced surgeons in young patients with mild to moderate mitral regurgitation 1

• For symptomatic patients with unfavorable valve anatomy:

  • PMBC should be considered as initial treatment for selected patients with mild to moderate calcification or impaired subvalvular apparatus who have otherwise favorable clinical characteristics (Class IIa recommendation) 1
  • Mitral valve surgery (mostly replacement) for other patients 1

• For asymptomatic patients with favorable valve anatomy:

  • PMBC should be considered (Class IIa recommendation) in those with:
    • High thromboembolic risk (history of systemic embolism, dense spontaneous contrast, new-onset or paroxysmal atrial fibrillation)
    • High risk of hemodynamic decompensation (systolic pulmonary pressure >50 mmHg at rest, need for major non-cardiac surgery, desire for pregnancy) 1, 2

2. Degenerative Mitral Stenosis

• Valve replacement is the only option for severe degenerative mitral stenosis where commissural fusion is absent 1, 4, 5
• In elderly inoperable patients with severely calcified mitral annulus, transcatheter valve implantation in the mitral position may be considered 1, 2

Special Considerations

• Left atrial thrombus: Most important contraindication to PMBC

  • If thrombus is located in LA appendage, PMBC may be considered after 1-3 months of oral anticoagulation if repeat TEE shows thrombus has disappeared
  • Surgery indicated if thrombus persists 1

• Concomitant valve disease:

  • With severe aortic valve disease: Surgery is preferable when not contraindicated
  • With moderate aortic valve disease: PMBC can be performed to postpone surgical treatment of both valves
  • With severe tricuspid regurgitation: PMBC may be considered in selected patients with sinus rhythm, moderate atrial enlargement, and functional tricuspid regurgitation secondary to pulmonary hypertension; otherwise, surgery on both valves is preferred 1, 2

• Restenosis after previous intervention:

  • When restenosis with symptoms occurs after surgical commissurotomy or PMBC, valve replacement is usually required
  • PMBC can be considered in selected candidates with favorable characteristics if the predominant mechanism is commissural refusion 1

Follow-up Recommendations

• Asymptomatic patients with clinically significant mitral stenosis: Annual clinical and echocardiographic examinations
• Moderate stenosis: Every 2-3 years
• After successful PMBC: Similar to asymptomatic patients
• More frequent follow-up if asymptomatic restenosis occurs
• When PMBC is unsuccessful: Consider surgery early unless contraindicated 1, 2