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Mitral stenosis

Background

Overview

Definition
MS is a form of structural heart disease characterized by obstruction to diastolic flow of blood across the mitral valve, from the left atrium to the left ventricle.
1
Pathophysiology
The etiology of MS is rheumatic disease in over 99% of patients. Other rare causes of MS include congenital malformed valves, active infective endocarditis, massive annular calcium, and metabolic or enzymatic abnormalities.
2
Epidemiology
The prevalence of MS in the US is estimated at 100 patients per 100,000 population.
1
Disease course
Clinical manifestations of MS often occur when there is an increased demand for cardiac output, and thus more transmitral flow, which causes elevation of the resting transmitral gradient. This may occur with pregnancy, fever, arrhythmias, infection, thyrotoxicosis, or during exercise. MS is associated with a significantly increased risk of AF.
3
Prognosis and risk of recurrence
In patients with degenerative MS, 1- and 5-year survival rates are estimated at 78% and 47%, respectively. Mortality is correlated with echocardiographic severity grades.
4

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of mitral stenosis are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ACC 2021), the European Society of Cardiology (ESC/EACTS 2021), the Canadian Cardiovascular Society (CCS 2018), and the Cardiac Society of Australia and New Zealand (CSANZ/NHFA 2018). ...
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Diagnostic investigations

TTE
As per ACC/AHA 2021 guidelines:
Obtain TTE in patients with signs or symptoms of rheumatic MS to establish the diagnosis, quantify hemodynamic severity, assess concomitant valvular lesions, and demonstrate valve morphology (to determine suitability for mitral commissurotomy).
B
Obtain TTE to assess the presence or absence of LA thrombus and to evaluate the severity of MR in patients considered for percutaneous mitral balloon commissurotomy.
B
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  • Exercise testing

Diagnostic procedures

Left heart catheterization: as per ACC/AHA 2021 guidelines, obtain invasive hemodynamic assessment or exercise testing with Doppler in patients with rheumatic MS and a discrepancy between resting echocardiographic findings and clinical symptoms, to evaluate symptomatic response, exercise capacity, and the response of the mean mitral gradient and pulmonary artery pressure.
B

Medical management

HR control
As per ACC/AHA 2021 guidelines:
Consider initiating HR control in patients with rheumatic MS and AF with a rapid ventricular response.
C
Consider initiating HR control to manage symptoms in patients with rheumatic MS in normal sinus rhythm with symptomatic resting or exertional sinus tachycardia.
B

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  • Anticoagulant therapy

Therapeutic procedures

Percutaneous mitral balloon commissurotomy, asymptomatic patients
As per ACC/AHA 2021 guidelines:
Consider performing percutaneous mitral balloon commissurotomy at a comprehensive valve center in asymptomatic patients with severe rheumatic MS (mitral valve area ≤ 1.5 cm², stage C) and favorable valve morphology with < 2+ MR in the absence of LA thrombus and with elevated pulmonary pressures (pulmonary artery systolic pressure > 50 mmHg).
C
Consider performing percutaneous mitral balloon commissurotomy at a comprehensive valve center in asymptomatic patients with severe rheumatic MS (mitral valve area ≤ 1.5 cm², stage C) and favorable valve morphology with < 2+ MR in the absence of LA thrombus and with new-onset AF.
C

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  • Percutaneous mitral balloon commissurotomy (symptomatic patients)

Surgical interventions

Mitral valve surgery: as per ACC/AHA 2021 guidelines, perform mitral valve surgery (repair, commissurotomy, or valve replacement) in severely symptomatic patients (NYHA class III-IV) with severe rheumatic MS (mitral valve area ≤ 1.5 cm², stage D) not suitable for percutaneous mitral balloon commissurotomy, failed a previous percutaneous mitral balloon commissurotomy, requiring other cardiac procedures, or not having access to percutaneous mitral balloon commissurotomy.
B

Specific circumstances

Pregnant patients, evaluation: as per ACC/AHA 2021 guidelines, obtain clinical evaluation and TTE before pregnancy in female patients with suspected valve disease considering pregnancy.
B
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  • Pregnant patients (medical therapy)

  • Pregnant patients (interventions)

  • Patients with AF (anticoagulation)

  • Patients with AF (surgical management)

  • Patients with prosthetic valve stenosis

  • Patients with mixed valve disease

  • Patients with coronary artery disease

  • Patients undergoing non-cardiac surgery

Preventative measures

Secondary prevention of rheumatic fever: as per ACC/AHA 2021 guidelines, initiate secondary prevention of rheumatic fever in patients with rheumatic heart disease.
B