Symptoms in mild to moderate mitral stenosis can be improved with medical therapy. Beta-blockers and calcium channel blockers help to control heart rate and increase diastolic filling time. Diuretics can help with heart failure symptoms.
Severe symptomatic mitral stenosis should be treated with percutaneous mitral balloon valvuloplasty (PMBV) or surgically.
Surgical commissurotomy has been compared with percutaneous valvuloplasty in several randomized trials and outcomes are consistently better with percutaneous valvuloplasty in patients who are good candidates. Surgical commissurotomy should, however, be considered in patients with severe subvalvular or calcific mitral valve disease.
Valvuloplasty is performed in certain situations in order to open a heart valve that has become stiff. Not all conditions in which a heart valve becomes stiff are treatable with valvuloplasty. There may be other reasons for your doctor to recommend a valvuloplasty.
PMBV is indicated for patients with:
severe mitral stenosis (MVA < 1.5 cm2), favorable valve morphology and absence of contraindications such as left atrial thrombus or significant mitral regurgitation.
asymptomatic patients with severe mitral stenosis, pulmonary hypertension (systolic pulmonary pressure >50 mm Hg at rest or >60 mm Hg with exercise) and favorable valve morphology should also be considered for PMBV.
patients with calcific mitral stenosis who are at high risk for surgical commissurotomy should be considered for PMBV when advanced heart failure and severe mitral stenosis are present. Similar patients who are at lower risk for surgical commissurotomy may also be considered for PMBV.
symptomatic patients with milder stenosis and pulmonary hypertension may be considered for PMBV.
asymptomatic patients with severe mitral stenosis with new atrial fibrillation may also be considered for PMBV.
palliative treatment may be considered in patients who are not suitable candidates for surgery even when valve morphology is not ideal.
Though limited, experience with balloon valvuloplasty for congenital mitral stenosis suggests little benefit from a potentially dangerous procedure. Surgery is usually preferable in these patients who often have associated complex anatomy. These patients should, therefore, be evaluated by a multidisciplinary team at an experienced center.
Contraindication
The presence of left atrial thrombus is an absolute contraindication to PMBV because of the high risk for systemic embolism. If left atrial thrombus is found, the patient should be treated with systemic anticoagulation for 3-6 months and undergo repeat TEE to confirm resolution of thrombus prior to PMBV. Patients with left atrial thrombus requiring more urgent therapy should be considered for surgical mitral valve replacement with ligation of the left atrial appendage.
Moderate to severe mitral regurgitation is also a contraindication to PMBV because of the risk of worsening regurgitation as a result of the procedure.
Severe concomitant aortic valve disease, severe organic tricuspid stenosis, and severe functional tricuspid regurgitation with an enlarged annulus are also contraindications to PMBV.
Severe concomitant coronary artery disease requiring bypass surgery is a contraindication to PMBV. These patients should be considered for a combined coronary artery bypass and surgical mitral valve procedure.
Unfavorable valve morphology is a relative contraindication to PMBV, although in selected patients, especially in those who are high surgical risk or in cases of palliation, PMBV can be considered.