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10.3.1 Evaluation

Echocardiography is used for initial evaluation, but is frequently limited by acoustic shadowing due to severe calcification. Evaluation of MVA by planimetry is less reliable than in rheumatic MS, and TOE should therefore be used liberally. Degenerative MS can coexist with varying degrees of MR. Mean transmitral gradient has been shown to be associated with increased mortality irrespective of MR severity.674 Electrocardiogram-gated CCT is necessary to assess the degree and locations of calcifications, especially if an intervention is planned.647,674–676 Calcifications are usually more prominent at the posterior aspect of the annulus.

10.3.2 Indications for intervention

Intervention is recommended in symptomatic patients who are not responsive to medical therapy, weighing the potential benefits of the procedure against its associated risks. In elderly patients with degenerative MS and MAC, surgery is technically challenging and high risk. However,

Contraindication

or high risk

for surgery

Favourable

clinical characteristicsc

Favourable anatomical characteristicsc

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

Surgeryd Symptoms

Symptoms

Exercise testing

Surgery Surgery PMC Follow-up PMC

Contraindication

to PMCb High risk of embolism

or haemodynamic

decompensationa

Contraindication to

or unfavourable characteristics for PMC

Figure 14 Management of clinically severe rheumatic mitral stenosis (mitral valve area ≤1.5 cm2). AF, atrial fibrillation; LA, left atrium; MS, mitral stenosis; MV, mitral valve; MVA, mitral valve area; NCS, non-cardiac surgery; NYHA, New York Heart Association; PH, pulmonary hypertension; PMC, percutaneous mitral commissurotomy; SPAP, systolic pulmonary artery pressure; TR, tricuspid regurgitation. aHigh thromboembolic risk: history of systemic embolism, dense spontaneous contrast in the LA, new-onset AF. High-risk of haemodynamic decompensation: SPAP >50 mmHg at rest, need for major NCS, desire for pregnancy or pregnant. bSee Table 8. cFavourable = absence of unfavourable characteristics for PMC defined by unfavourable anatomical characteristics [echocardiographic score >8, Cormier score 3 (calcification of MV of any extent as assessed by fluoroscopy), severe TR] or unfavourable clinical characteristics (old age, history of commissurotomy, NYHA class IV, permanent AF, severe PH) (for the definition of scores see Supplementary data online, Table S3). dIf operative risk is low.

ESC Guidelines                                                                                                                                                                                          4681

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