Rheumatic Mitral Stenosis with Mitral Valve Area ≤1.5 cm² When Medical Therapy Has Not Controlled Symptoms

Clinical Scenario

This protocol applies to patients with rheumatic mitral stenosis and a mitral valve area (MVA) of ≤1.5 cm². At this threshold, together with clinical factors such as persisting symptoms, elevated thromboembolic risk, or haemodynamic decompensation, the disease is classified as clinically severe.

When Initial Medical Management Is Insufficient

First-line management targets symptom relief through medical therapy — agents including diuretics, beta-blockers, digoxin, non-dihydropyridine calcium channel blockers, and ivabradine to control volume overload and heart rate, alongside anticoagulation where indicated. When this approach does not achieve adequate symptom control, a procedural intervention becomes the next step.

Next Step — Procedural Intervention

For symptomatic patients with severe rheumatic mitral stenosis, evidence-based management involves a specific valve procedure — either catheter-based or surgical — selected according to patient suitability. The full protocol details which approach is recommended first and under which conditions the alternative is indicated.

Instant Access to Structured Evidence-Based Regimens

References

Patient with rheumatic mitral stenosis and mitral valve area ≤1.5 cm²

An MVA of ≤1.5 cm² in conjunction with clinical factors (symptoms, high risk of thromboembolism, or haemodynamic decompensation) is indicative of clinically severe MS.

PMC is recommended in symptomatic patients in the absence of unfavourable characteristics for PMC.

MV surgery is recommended in symptomatic patients who are not suitable for PMC.

For patients in whom PMC is contraindicated, surgical MV repair or, more frequently, replacement are good alternatives.

DOI: 10.1093/eurheartj/ehaf194

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