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 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:
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Horstkotte D, Niehues R, Strauer BE. Pathomorphological aspects, aetiology and natural history of acquired mitral valve stenosis. Eur Heart J 1991; 12 Suppl B:55.
- Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S.
- Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
- Karthikeyan G, Ananthakrishnan R, Devasenapathy N, et al. Transient, subclinical atrial fibrillation and risk of systemic embolism in patients with rheumatic mitral stenosis in sinus rhythm. Am J Cardiol 2014; 114:869.
- Chiang CW, Lo SK, Ko YS, et al. Predictors of systemic embolism in patients with mitral stenosis. A prospective study. Ann Intern Med 1998; 128:885.
- Pérez-Gómez F, Salvador A, Zumalde J, et al. Effect of antithrombotic therapy in patients with mitral stenosis and atrial fibrillation: a sub-analysis of NASPEAF randomized trial. Eur Heart J 2006; 27:960.
- Boonyasirinant T, Phankinthongkum R, Komoltri C. Clinical and echocardiographic parameters and score for the left atrial thrombus formation prediction in the patients with mitral stenosis. J Med Assoc Thai 2007; 90 Suppl 2:9.
- Acartürk E, Usal A, Demir M, et al. Thromboembolism risk in patients with mitral stenosis. Jpn Heart J 1997; 38:669.
- Rittoo D, Sutherland GR, Currie P, et al. A prospective study of left atrial spontaneous echo contrast and thrombus in 100 consecutive patients referred for balloon dilation of the mitral valve. J Am Soc Echocardiogr 1994; 7:516.
- Goswami KC, Yadav R, Bahl VK. Predictors of left atrial appendage clot: a transesophageal echocardiographic study of left atrial appendage function in patients with severe mitral stenosis. Indian Heart J 2004; 56:628.
- Manjunath CN, Srinivasa KH, Panneerselvam A, et al. Incidence and predictors of left atrial thrombus in patients with rheumatic mitral stenosis and sinus rhythm: a transesophageal echocardiographic study. Echocardiography 2011; 28:457.
- Bruce CJ, Nishimura RA. Newer advances in the diagnosis and treatment of mitral stenosis. Curr Probl Cardiol 1998; 23:125.
- Austin SM, Schreiner BF, Kramer DH, et al. The acute hemodynamic effects of ethacrynic acid and furosemide in patients with chronic postcapillary pulmonary hypertension. Circulation 1976; 53:364.
- Meister SG, Engel TR, Feitosa GS, et al. Propranolol in mitral stenosis during sinus rhythm. Am Heart J 1977; 94:685.
- Stoll BC, Ashcom TL, Johns JP, et al. Effects of atenolol on rest and exercise hemodynamics in patients with mitral stenosis. Am J Cardiol 1995; 75:482.
- Klein HO, Sareli P, Schamroth CL, et al. Effects of atenolol on exercise capacity in patients with mitral stenosis with sinus rhythm. Am J Cardiol 1985; 56:598.
- Toutouzas P. Left ventricular function in mitral valve disease. Herz 1984; 9:297.
- Gaasch WH, Folland ED. Left ventricular function in rheumatic mitral stenosis. Eur Heart J 1991; 12 Suppl B:66.
- Nair M, Shah P, Batra R, et al. Chronic atrial fibrillation in patients with rheumatic heart disease: mapping and radiofrequency ablation of flutter circuits seen at initiation after cardioversion. Circulation 2001; 104:802.
- Stapleton JF. Natural history of chronic valvular disease. In: Cardiovascular Clinics. Valvular heart disease: comprehensive evaluation and management, Frankl WS, Brest AN (Eds), FA Davis, Philadelphia 1986. p.128.
- Edwards WD, Peterson K, Edwards JE. Active valvulitis associated with chronic rheumatic valvular disease and active myocarditis. Circulation 1978; 57:181.
- Clawson, BJ. Rheumatic heart disease. An analysis of 796 cases. Am Heart J 1940; 20:454.
- Dickinson GM, Bisno AL. Antimicrobial prophylaxis of infection. Infect Dis Clin North Am 1995; 9:783.
- Wilson W, Taubert KA, Gewitz M, et al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 115 published online April 19, 2007. www.circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1 (Accessed on May 04, 2007).
- Antonini-Canterin F, Moura LM, Enache R, et al. Effect of hydroxymethylglutaryl coenzyme-a reductase inhibitors on the long-term progression of rheumatic mitral valve disease. Circulation 2010; 121:2130.
- Ellis LB, Singh JB, Morales DD, Harken DE. Fifteen-to twenty-year study of one thousand patients undergoing closed mitral valvuloplasty. Circulation 1973; 48:357.
- Orrange SE, Kawanishi DT, Lopez BM, et al. Actuarial outcome after catheter balloon commissurotomy in patients with mitral stenosis. Circulation 1997; 95:382.
- Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
- Mitchell JH, Haskell W, Snell P, Van Camp SP. Task Force 8: classification of sports. J Am Coll Cardiol 2005; 45:1364.
- Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol 2005; 45:1334.
- 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