Mitral Stenosis:

Medical, Transcatheter, Surgical Therapy

Pantila V. Bateman, MD, FACC

Indiana University
 Disclosures
• Nothing to disclose
 Case
36 year-old female from Thailand with a history of
rheumatic fever during childhood presents with
progressive shortness of breath over the past months.
 Echocardiogram
• Severe rheumatic mitral stenosis with MVA 1.4
cm2. Mean MV gradient 10mmHg at HR 80bpm.
Mild MR.
• Normal bi-ventricular function.
• Mild TR.
• LA dilatation
• Small pericardial effusion
Echocardiogram
Otto CM et al. J Am Coll Cardiol 2020:doi: 10.1016
 Medical management
• Symptom control
• Prevention of thromboembolism
• Prevention of endocarditis and rheumatic
fever
 Symptom control
• Decrease heart rate to reduce mitral valve
gradient
• Allowing more diastolic time to fill left
ventricle
Prevention of thromboembolism
• Anticoagulation when
– Atrial fibrillation
– Prior embolic event (even in sinus rhythm)
– LA thrombus
• Vitamin K antagonist indicated with
targeted INR 2.5
 Prevention of endocarditis
• Prophylaxis of endocarditis: high-risk group
prior to dental procedures only
• High risk: prosthetic valves, prosthetic materials
(i.e. post repair), and h/o infective endocarditis.
• Rheumatic MS alone – not an indication!

Otto CM et al. J Am Coll Cardiol 2020:doi: 10.1016

 Prevention of rheumatic fever
• Primary prevention

Benzathine penicillin treatment in patients

with streptococcal pharyngitis

Otto CM et al. J Am Coll Cardiol 2020:doi: 10.1016

 Secondary prevention of rheumatic fever

Nishimura RA, Otto CM, Bonow RO, et al.; AJ Am Coll Cardiol 2014;63:e57- 185
 When to intervene?
Rheumatic MS

Otto CM et al. J Am Coll Cardiol 2020:doi: 10.1016

 Surgical vs. Percutaneous?

Wunderlich NC, Beigel R, Ho SY, et al. JACC Cardiovasc Imaging 2018;11:872-901.

ACCSAP
Back to our patient
Echocardiogram
Wilkins score: 6
PMBC
All of a sudden, BP dropped
Post PMBC
What happened here?

Asymmetric calcification

ACCSAP
 Surgery
• Open or closed commissurotomy
• Mitral valve replacement - usually with
mechanical valve
• Beware pulmonary hypertension and RV
dysfunction
 Calcific mitral stenosis
• No role for PMBC
• Usually significant co-morbidities
• Surgery technically difficult due to annular
calcification
• TMVR (Transcatheter Mitral Valve
Replacement) – promising alternative!
Thank you!