From the Guidelines
Percutaneous mitral commissurotomy (PMC) is the recommended treatment for symptomatic patients with severe mitral stenosis and favorable anatomy, as stated in the most recent guidelines 1.
Treatment Overview
The management of mitral stenosis depends on the severity of symptoms and the anatomy of the valve.
- For symptomatic patients with severe mitral stenosis, PMC is the preferred treatment if the valve anatomy is favorable.
- Mitral valve surgery, which is mostly valve replacement, is indicated in patients with unfavorable anatomy or those who are not suitable for PMC.
Medical Management
Before considering procedural interventions, medical management is crucial to control symptoms and prevent complications.
- Diuretics, such as furosemide, can be used to reduce fluid overload.
- Beta-blockers, like metoprolol, are recommended to control heart rate, as suggested by both American and European guidelines 1.
- Anticoagulation with warfarin or direct oral anticoagulants may be necessary to prevent thromboembolic complications, especially in patients with atrial fibrillation.
Procedural Interventions
Procedural interventions are necessary for moderate to severe stenosis causing significant symptoms.
- Percutaneous balloon mitral valvuloplasty is the preferred treatment for suitable valve anatomy, as it has a high success rate and low risk of complications, according to the 2023 ACC/AHA and ESC/EACTS guidelines comparison 1.
- Mitral valve replacement (mechanical or bioprosthetic) is indicated for severely calcified or deformed valves.
- Surgical repair may be an option in select cases, especially in young patients with mild to moderate mitral regurgitation, as mentioned in the 2017 ESC/EACTS guidelines 1.
Asymptomatic Patients
In asymptomatic patients with mitral stenosis, the decision to intervene is based on the risk of cardiac complications and the presence of contraindications for PMC.
- PMC may be considered in asymptomatic patients with favorable anatomy and elevated pulmonary pressures (systolic pulmonary artery pressure >50 mm Hg at rest), as suggested by the 2023 guidelines comparison 1.
- Surgery is limited to those rare patients at high risk of cardiac complications who have contraindications for PMC and are at low risk for surgery.
From the Research
Treatment Options for Mitral Stenosis
The treatment for mitral stenosis depends on the severity of symptoms and clinical findings. The following are some of the treatment options:
- Mitral valve replacement: indicated when marked dyspnoea on mild exertion, dyspnoea at rest or pulmonary oedema, haemoptysis, atrial fibrillation, recurrent systemic emboli or right ventricular failure occur in a patient with a mitral valve area of less than 1.5 cm2, as measured by Doppler echocardiography 2
- Closed commissurotomy: no longer considered a valid therapeutic alternative due to its limited success rate 2
- Open commissurotomy: may be performed in patients with no significant calcification of valve cusps and no major concomitant mitral regurgitation 2
- Balloon valvotomy: may be performed in patients with no significant calcification of valve cusps and no major concomitant mitral regurgitation 2
- Anticoagulation therapy: mandatory when atrial fibrillation complicates mitral stenosis, regardless of its severity and CHA2DS2-VASc score 3
- Percutaneous mitral commissurotomy: does not appear to prevent the occurrence of atrial fibrillation in mitral stenosis, but should be considered as the first-line therapy when atrial fibrillation is associated with severe symptomatic mitral stenosis 3
Anticoagulation Therapy
Anticoagulation therapy is an essential part of the treatment for mitral stenosis, especially when associated with atrial fibrillation. The following are some of the anticoagulation options:
- Low intensity oral anticoagulant treatment: effective and safe in high-risk patients with mitral stenosis and atrial fibrillation, with a target INR of 2 4
- Vitamin K antagonist: mandatory for patients with atrial fibrillation and mitral stenosis, but used by less than 80% of those eligible, and less than 30% have the international normalized ratio in the therapeutic range 5
- Direct factor Xa inhibitor anticoagulant: safety and efficacy demonstrated in the RIVER trial, but further studies are needed to determine its applicability in patients with atrial fibrillation and mitral stenosis 5
- Dabigatran and warfarin therapy: being compared in a randomized, open-label study (DAVID-MS) for stroke prevention in patients with atrial fibrillation and moderate or severe mitral stenosis 5