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Medical management and indications for intervention for mitral stenosis

Author
William H Gaasch, MD
Section Editor
Catherine M Otto, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

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 [1]. 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:

                    

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Literature review current through: Nov 2016. | This topic last updated: Tue May 31 00:00:00 GMT+00:00 2016.
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