How should a middle‑aged adult with rheumatic mitral stenosis be initially managed medically, and when are percutaneous balloon mitral valvotomy and surgical repair indicated?

Management of Rheumatic Mitral Stenosis

For middle-aged adults with rheumatic mitral stenosis, initial medical management consists of diuretics for congestion, beta-blockers or rate-limiting calcium channel blockers for heart rate control, and anticoagulation with warfarin (not DOACs) when atrial fibrillation develops, while percutaneous balloon mitral valvotomy is indicated for symptomatic patients with valve area <1.5 cm² and favorable anatomy, and surgery is reserved for those with unfavorable anatomy or contraindications to percutaneous intervention. 1

Initial Medical Management

Medical therapy is purely palliative and does not prevent disease progression, but provides symptomatic relief while determining the need for intervention 2, 3:

Symptom Control

• Diuretics are the cornerstone for relieving pulmonary congestion and peripheral edema 3
• Beta-blockers are first-line for heart rate control, particularly critical in atrial fibrillation to prevent severe pulmonary congestion 1, 3
• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) serve as effective alternatives for rate control 1, 3
• Digoxin is specifically recommended for heart rate control in patients with atrial fibrillation and mitral stenosis 1, 3

Anticoagulation Strategy

• Warfarin (vitamin K antagonist) with target INR 2.0-3.0 is mandatory for new-onset or paroxysmal atrial fibrillation 1
• Warfarin is also indicated (Class I) for history of systemic embolism or left atrial thrombus 1
• Consider warfarin (Class IIa) when transesophageal echo shows dense spontaneous contrast or enlarged left atrium (diameter >50 mm or volume >60 mL/m²) 1
• Never use DOACs in mitral stenosis patients with atrial fibrillation—only warfarin is guideline-recommended 1, 3

Indications for Percutaneous Balloon Mitral Valvotomy (PMC)

PMC is the treatment of choice for most patients with severe mitral stenosis and favorable valve anatomy 1, 2:

Class I Indications (Strongest Recommendation)

• Symptomatic patients (NYHA class II-IV) with valve area <1.5 cm² and favorable anatomy 1, 2
• Symptoms include dyspnea, fatigue, or pulmonary congestion 2, 3

Additional High-Priority Indications

• Pulmonary artery systolic pressure >50 mmHg at rest, even if asymptomatic 1, 2
• New-onset atrial fibrillation or paroxysmal atrial fibrillation 2, 3
• History of systemic embolism or presence of left atrial thrombus 2
• Dense spontaneous contrast in the left atrium on echocardiography 2
• Need for major non-cardiac surgery in a patient with severe mitral stenosis 1, 2
• Desire for pregnancy in women with severe mitral stenosis 1, 2

Special Consideration

• PMC may be considered in symptomatic patients with valve area >1.5 cm² if symptoms cannot be explained by another cause and anatomy is favorable 1

Indications for Surgical Intervention

Surgery is indicated when PMC is not feasible or contraindicated 1:

Class I Surgical Indications

• Symptomatic patients not suitable for PMC due to unfavorable anatomy 1, 2
• Unfavorable anatomy includes severe valve calcification, moderate or greater mitral regurgitation, or left atrial thrombus 1, 4
• Concomitant severe aortic valve disease requiring surgery 1

Surgical Options

• Open commissurotomy may be preferred by experienced surgeons in young patients with mild to moderate mitral regurgitation 1
• Valve replacement is required when commissural fusion is absent (non-rheumatic degenerative stenosis) or when restenosis occurs after previous intervention 1

Critical Pre-Intervention Requirements

• Transesophageal echocardiography must be performed to exclude left atrial thrombus before PMC or after an embolic episode 1, 3
• Cardioversion is not indicated before intervention in patients with severe mitral stenosis, as it does not durably restore sinus rhythm 1
• If atrial fibrillation is of recent onset and left atrium is only moderately enlarged, cardioversion should be performed soon after successful intervention 1

Common Pitfalls to Avoid

• Treating symptomatic severe mitral stenosis with medical therapy alone for extended periods leads to irreversible pulmonary hypertension, right heart failure, and increased mortality 2, 3
• Using DOACs instead of warfarin in mitral stenosis with atrial fibrillation is not guideline-recommended 3
• Failure to exclude left atrial thrombus before PMC is a serious oversight 3
• Delaying intervention in symptomatic patients can lead to irreversible pulmonary hypertension and death 2
• Attempting PMC in degenerative mitral stenosis with severe annular calcification fails because there is no commissural fusion to dilate 1, 4

Monitoring Strategy

For Asymptomatic Patients Not Undergoing Intervention

• Yearly clinical and echocardiographic examinations for clinically significant mitral stenosis 1
• Every 2-3 years for moderate stenosis 1

After Successful PMC

• Management is similar to asymptomatic patients 1
• More frequent follow-up if asymptomatic restenosis occurs 1

When PMC is Unsuccessful

• Surgery should be considered early unless there are definite contraindications 1