Management of mitral stenosis: a systematic review of clinical practice guidelines and recommendations

Abstract

A number of guidelines exist with recommendations for diagnosis and management of mitral stenosis (MS). We systematically reviewed existing guidelines for diagnosis and management of MS, highlighting their similarities and differences, in order to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (5/4/2011 - 5/9/2021), the Guidelines International Network International, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and Web sites of relevant organizations. Two independent reviewers screened titles and abstracts, and full-text of potentially relevant articles where needed. Selected guidelines were assessed for rigor of development; only guidelines with Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument score >50% were included in the final analysis. Four guidelines were retained for analysis. There was consensus for percutaneous mitral balloon commissurotomy (PMBC) as first-line treatment of symptomatic severe rheumatic MS with suitable anatomy. In patients with unfavourable anatomy, surgical intervention should be considered. Exercise testing is indicated if discrepancy exists between symptoms and echocardiographic measurements. There was no clear divide between rheumatic MS and degenerative MS for their respective diagnoses and management. Pregnancy in severe MS is discouraged and the stenosis should be treated before conception. Long-term antibiotic prophylaxis is recommended for patients with rheumatic MS. Recommendations for the management of patients with mixed valvular diseases are lacking.

Mitral valve stenosis in the current era: a changing landscape

“…6 In all the other cases, surgical approaches (including closed commissurotomy, open commissurotomy and mitral valve replacement) performed by experienced surgical teams may represent a valid alternative to PMBV in the absence of futility. 6,44 When discrepancy exists between clinical assessment and mitral stenosis severity, exercise testing and exercise stress echocardiography Mitral valve stenosis in the current era Giannini et al 707 2D-echocardiographic evaluation of mitral valve to assess the amount of calcification in each of the medial and lateral commissures through the detection of high-intensity bright echoes.…”

“…In all the other cases, surgical approaches (including closed commissurotomy, open commissurotomy and mitral valve replacement) performed by experienced surgical teams may represent a valid alternative to PMBV in the absence of futility 6,44 . When discrepancy exists between clinical assessment and mitral stenosis severity, exercise testing and exercise stress echocardiography may be useful to guide treatment by observing exercise-induced symptoms and/or pathological increase in pulmonary arterial pressure 6,44,51 …”

“…The main scoring systems are presented in Table 2. Nevertheless, PMBV should also be considered in symptomatic patients with suboptimal anatomy but clinically suitable for the procedure 6,44,50 . In the presence of significant mitral stenosis, also asymptomatic patients without unfavourable characteristics as well a high thromboembolic risk (history of systemic embolism, dense spontaneous contrast in the left atrium, new-onset or paroxysmal atrial fibrillation), and/or high risk of haemodynamic decompensation (systolic pulmonary pressure >50 mmHg at rest, need for major noncardiac surgery, desire for pregnancy) may be eligible for PMBV 6 .…”

“…In the presence of significant mitral stenosis, also asymptomatic patients without unfavourable characteristics as well a high thromboembolic risk (history of systemic embolism, dense spontaneous contrast in the left atrium, new-onset or paroxysmal atrial fibrillation), and/or high risk of haemodynamic decompensation (systolic pulmonary pressure >50 mmHg at rest, need for major noncardiac surgery, desire for pregnancy) may be eligible for PMBV 6 . In all the other cases, surgical approaches (including closed commissurotomy, open commissurotomy and mitral valve replacement) performed by experienced surgical teams may represent a valid alternative to PMBV in the absence of futility 6,44 . When discrepancy exists between clinical assessment and mitral stenosis severity, exercise testing and exercise stress echocardiography may be useful to guide treatment by observing exercise-induced symptoms and/or pathological increase in pulmonary arterial pressure 6,44,51 …”

“…may be useful to guide treatment by observing exerciseinduced symptoms and/or pathological increase in pulmonary arterial pressure. 6,44,51 Data from randomized clinical trials regarding the best treatment approaches for DMS because of MAC are lacking. In the vast majority of these patients, surgery is technically challenging and at high risk, and PMBV is not feasible because of the absence of commissural fusion.…”