Mitral Stenosis Management

Clinical Presentation

Exertional dyspnea is the most common symptom, often developing gradually as patients unconsciously reduce their activity levels 1
Fatigue and palpitations are frequently reported, especially with development of atrial fibrillation 3
Hemoptysis may occur due to pulmonary hypertension and rupture of bronchial veins 4
The European Society of Cardiology recommends that symptoms may be absent or subtle even in severe mitral stenosis due to enhanced left atrial compliance 5
Family members may report diminished activity levels that patients themselves are unaware of 3
Diastolic rumbling murmur best heard at the apex with the patient in left lateral position 3
Opening snap followed by a low-pitched diastolic murmur 1
Loud S1 in early disease (becomes softer as valve calcifies) 4
Signs of pulmonary hypertension and right heart failure in advanced disease 4
Atrial fibrillation is common, especially as disease progresses 1

Mild: mitral valve area >1.5 cm², mean gradient <5 mmHg, pulmonary artery systolic pressure <30 mmHg 4
Moderate: mitral valve area 1-1.5 cm², mean gradient 5-10 mmHg, pulmonary artery systolic pressure 30-50 mmHg 4
Severe: mitral valve area <1 cm², mean gradient >10 mmHg, pulmonary artery systolic pressure >50 mmHg 4

Diuretics can improve symptoms by reducing pulmonary congestion and peripheral edema 1
Beta-blockers, calcium channel blockers (verapamil, diltiazem), or digoxin help control heart rate in patients with atrial fibrillation 1
The European Heart Society recommends heart rate control is particularly important as tachycardia shortens diastolic filling time, worsening symptoms 1
Anticoagulation with vitamin K antagonists (target INR 2-3) is indicated for patients with atrial fibrillation (paroxysmal or permanent) 1
Anticoagulation with vitamin K antagonists (target INR 2-3) is indicated for patients with history of systemic embolism 1
Anticoagulation with vitamin K antagonists (target INR 2-3) is indicated for patients with left atrial thrombus 6
Anticoagulation with vitamin K antagonists (target INR 2-3) is indicated for patients with dense spontaneous echo contrast in the left atrium 6
Anticoagulation with vitamin K antagonists (target INR 2-3) is indicated for patients with enlarged left atrium (M-mode diameter >50 mm or volume >60 mL/m²) 6

The American College of Cardiology recommends percutaneous mitral commissurotomy (PMC) as first-line intervention for symptomatic patients with favorable valve anatomy 1
PMC is indicated for symptomatic patients (NYHA class II-IV) with moderate to severe mitral stenosis 1
PMC is indicated for asymptomatic patients with high risk of thromboembolism or hemodynamic decompensation 6
Contraindications for PMC include left atrial thrombus 1
Contraindications for PMC include more than mild mitral regurgitation 1
Contraindications for PMC include severe or bicommissural calcification 1
Contraindications for PMC include absence of commissural fusion (degenerative mitral stenosis) 1
Contraindications for PMC include severe concomitant aortic valve disease or severe tricuspid stenosis/regurgitation 1
Mitral valve repair (commissurotomy) or replacement is indicated when PMC is contraindicated or unsuccessful 1
Mitral valve repair (commissurotomy) or replacement is indicated when valve morphology is unfavorable for PMC 1
Mitral valve repair (commissurotomy) or replacement is indicated when concomitant cardiac surgery is required 1

Asymptomatic patients with significant mitral stenosis should have yearly clinical and echocardiographic examinations 1
Patients with moderate stenosis can be followed at longer intervals (2-3 years) 1
Exercise testing may be useful to unmask symptoms or assess exercise capacity in apparently asymptomatic patients 5

In elderly patients with rheumatic mitral stenosis and high surgical risk, PMC may be a useful palliative option 1
Transcatheter mitral valve implantation may be an emerging option for inoperable patients with degenerative mitral stenosis 1