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Surgical and investigational approaches to management of mitral stenosis

Mackram F Eleid, MD
Bongani Mayosi, MBChB, PhD, FCP(SA)
Section Editors
Gabriel S Aldea, MD
Jeroen J Bax, MD, PhD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Mitral stenosis (MS) is a condition caused most commonly by rheumatic heart disease and characterized by obstruction of blood flow across the mitral valve (MV) 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. If untreated, symptomatic MS leads to progressive symptoms (eg, dyspnea and fatigue) and serious complications (eg, pulmonary edema, systemic arterial embolism, pulmonary hypertension, and death). Medical therapy can alleviate symptoms, but surgical or percutaneous intervention is required to relieve the obstruction to flow. (See "Clinical manifestations and diagnosis of mitral stenosis" and "Medical management and indications for intervention for mitral stenosis".)

Surgical and investigational approaches to management of MS are reviewed here. Issues directly related to the indications for intervention and choice of percutaneous mitral balloon valvotomy versus surgery and the medical management of MS are discussed separately. (See "Percutaneous mitral balloon valvotomy for mitral stenosis" and "Medical management and indications for intervention for mitral stenosis".)


Assessment of valve pathology — Preprocedural imaging of the mitral valve (MV) includes echocardiography as well as multidetector computed tomography (MDCT), when available. Echocardiography (initial transthoracic, complemented by transesophageal if needed) is used primarily for the hemodynamic (functional) assessment of valve pathology while MDCT is essential for precise preoperative anatomical delineation of MV apparatus anatomy and pathology including delineation of whether calcium is limited to the leaflet, involves the subvalvular apparatus, or even extends into the left ventricle beyond the mitral annulus.

Transthoracic echocardiography is the initial test of choice for assessment of MV pathology and hemodynamic (functional) severity of disease. In selected cases in which transthoracic echocardiographic assessment is incomplete, transesophageal echocardiography is useful for further characterization of pathology including the presence/extent of calcification and assessment of mitral regurgitation. When available, MDCT is used for precise anatomical delineation of abnormalities/pathology of the MV apparatus.

The feasibility of percutaneous or surgical commissurotomy is assessed based upon the type and severity of pathologic change involving the valve and subvalvular apparatus. For percutaneous commissurotomy, this is most commonly assessed using the Wilkins score, as discussed separately. Assessment for open MV surgery includes more extensive evaluation of all rheumatic pathology including the leaflets (to determine need for surgical delamination and augmentation with pericardium ), commissures, and subchordal/chordal (elongation, splitting, chordal transfer or insertion) and papillary muscle pathologies. (See "Percutaneous mitral balloon valvotomy for mitral stenosis" and "Percutaneous mitral balloon valvotomy for mitral stenosis", section on 'Echocardiography'.)

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Literature review current through: Oct 2017. | This topic last updated: Sep 20, 2017.
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