Medical management and indications for intervention for mitral stenosis
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
Mitral stenosis (MS) is a condition characterized by obstruction of blood flow across the mitral valve from the left atrium to the left ventricle. The mechanical obstruction leads to increases in pressure within the left atrium, pulmonary vasculature, and right side of the heart. Most cases of MS are caused by rheumatic heart disease with mitral commissural adhesion; thickened, immobile mitral valve leaflets; and fibrosis, thickening, shortening, fusion, and calcification of the chordae tendineae. Infrequent causes of MS include mitral annular calcification and congenital mitral stenosis (including parachute mitral valve). (See "Clinical manifestations and diagnosis of mitral stenosis" and "Pathophysiology and natural history of mitral stenosis".)
The medical management and indications for intervention for MS will be reviewed here. Outcomes and management of patients undergoing percutaneous mitral balloon valvotomy and mitral valve surgery for MS are discussed separately. (See "Percutaneous mitral balloon valvotomy for mitral stenosis" and "Surgical and investigational approaches to management of mitral stenosis".)
MONITORING AND EVALUATION
Periodic monitoring is recommended in asymptomatic patients with mitral stenosis (MS) to assess for disease progression and development of indications for intervention. For all patients, the follow-up should include yearly history and physical examination. Follow-up transthoracic echocardiography should be performed with frequency based upon the severity of disease. We agree with the 2014 American Heart Association/American College of Cardiology (AHA/ACC) valve guideline recommendation for echocardiography every three to five years if the mitral valve area (MVA) is >1.5 cm2, every one to two years if the MVA is 1.0 to 1.5 cm2, and once per year if the MVA is <1.0 cm2 . The long interval between testing in asymptomatic, stable, mild disease is based in part upon the natural history of MS, as mitral valve area declines at a mean of about 0.1 cm2 per year. (See "Pathophysiology and natural history of mitral stenosis", section on 'Rate of progression'.) More frequent monitoring may be required in patients with concurrent mitral regurgitation and/or disease affecting other valves. All patients should undergo re-evaluation whenever there is a change in clinical status.
Monitoring and evaluation prior to and during pregnancy are discussed separately. (See "Pregnancy in women with mitral stenosis".)
The rationale for monitoring is to optimize timing of mitral valve intervention. The timing of surgical or percutaneous intervention for MS is crucial for the following reasons:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- MONITORING AND EVALUATION
- MEDICAL MANAGEMENT
- Prevention of thromboembolism
- - Antithrombotic recommendations
- - Evidence
- Other medical therapy
- Management of atrial fibrillation
- Rate versus rhythm control
- Secondary prevention of rheumatic fever
- Prevention of infective endocarditis
- Statin therapy
- INDICATIONS FOR INTERVENTION
- Our approach
- NONCARDIAC SURGERY
- Pre-operative evaluation
- Perioperative management
- PHYSICAL ACTIVITY AND EXERCISE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS