Mitral Stenosis

Classify severe mitral stenosis when mitral valve area (MVA) is 1.5 cm2 or less. Obtain MVA by direct planimetry when feasible and calculate pressure half-time from the continuous-wave Doppler mitral inflow signal; both are commonly used approaches. AHA Journals+2AHA JournalsCardiovascular Magnetic Resonance Imaging for Valvular Heart ...AHA JournalsLow‐Gradient Severe Mitral Stenosis: Hemodynamic Profiles ...AHA JournalsGradient Severe Mitral Stenosis - American Heart Association Journals

Do not use mean transmitral gradient as a stand-alone severity measure. At an MVA of 1.5 cm2 or less, mean gradient can vary considerably with hemodynamic profile; document rhythm and heart rate when interpreting a low or high gradient against the anatomic valve area. AHA JournalsAHA JournalsGradient Severe Mitral Stenosis - American Heart Association Journals

The etiologic distinction changes the procedural pathway. Rheumatic disease is the anatomy for which percutaneous mitral balloon commissurotomy (PMBC) is used; favorable features include pliable leaflets and subvalvular apparatus. Calcific mitral stenosis is typically associated with extensive mitral annular calcification, in which planimetry may be inaccurate and abnormal left atrial and left ventricular compliance can produce a high gradient without severe anatomic obstruction. jacc+1jacc2020 ACC/AHA Guideline for the Management of Patients ... - JACCcdn clinicaltrials[PDF] Tendyne Holdings, Inc. CONFIDENTIAL CS0005-P MAC Feasibility ...

For symptomatic severe rheumatic mitral stenosis, select PMBC when valve morphology is favorable. The cited criteria emphasize pliability of the leaflets and subchordal apparatus and absence of grade 3 or 4 mitral regurgitation; this approach achieves results similar to surgical valvotomy with less trauma and scarring in the randomized-trial evidence summarized by NICE. cdn clinicaltrials+1cdn clinicaltrials[PDF] Tendyne Holdings, Inc. CONFIDENTIAL CS0005-P MAC Feasibility ...nice org ukRationale and impact | Heart valve disease presenting in adults: investigation and management | Guidance | NICE

When the rheumatic valve is unsuitable for PMBC because morphology is unfavorable or regurgitation is grade 3 or 4, pursue surgical evaluation rather than forcing balloon intervention. Surgical treatment is advised for severe mitral stenosis when morphology is not favorable for PMBC. cdn clinicaltrialscdn clinicaltrials[PDF] Tendyne Holdings, Inc. CONFIDENTIAL CS0005-P MAC Feasibility ...

Send every patient with severe mitral stenosis being considered for intervention to a multidisciplinary team or Primary/Comprehensive Valve Center. This is particularly important when concomitant valve disease, advanced age, extensive calcification, or major comorbidity makes the procedural risk-benefit assessment nonstandard. jaccjacc2020 ACC/AHA Guideline for the Management of Patients ... - JACC

In atrial fibrillation with rheumatic mitral stenosis, prescribe oral anticoagulation with a vitamin K antagonist rather than a non-vitamin K oral anticoagulant. ACC/AHA guidance identifies rheumatic mitral stenosis, along with mechanical prostheses, as the exception to CHA2DS2-VASc-based selection of either agent class for other native valve disease. jacc+2jacc2020 ACC/AHA Guideline for the Management of Patients ... - JACCACCNew in Clinical Documents | Implementing the New ACC/AHA Guideline on Valvular Heart Disease - American College of Cardiologyjtcvs2020 ACC/AHA guideline for the management of patients with ...

Warfarin is the primary oral anticoagulant option because direct oral anticoagulant trials consistently excluded patients with mitral stenosis. The cited rheumatic mitral stenosis review recommends indefinite therapeutic warfarin with a target INR of 2.5 in the setting of concomitant rheumatic mitral stenosis and embolic risk. The LancetThe LancetManagement of rheumatic mitral stenosis

Do not substitute aspirin for therapeutic anticoagulation when rheumatic mitral stenosis coexists with an embolic indication. Historical cohorts before widespread anticoagulation experienced embolic events in more than 25% of patients during the disease course, supporting the high-risk framing in this population. The LancetThe LancetManagement of rheumatic mitral stenosis

Calcific mitral stenosis should not be managed as rheumatic commissural fusion. Extensive calcification can prevent accurate planimetered area measurement, while left atrial and left ventricular compliance abnormalities can generate a high gradient without severe fixed obstruction. Invasive treatment is therefore limited to patients who are highly symptomatic, with evaluation at an experienced valve center. jaccjacc2020 ACC/AHA Guideline for the Management of Patients ... - JACC

When severe aortic stenosis coexists with mitral stenosis, avoid assuming that mitral intervention should occur first. Treating mitral stenosis first can precipitate severe pulmonary edema by abruptly increasing preload to a small-cavity, low-flow left ventricle downstream from stenotic aortic valve. jaccjaccAortic Valve Disease, Transcatheter Aortic Valve Replacement, and the Heart Failure Patient: A State-of-the-Art Review

If intervention is pursued in extensive mitral annular calcification, recognize the elevated risk created by calcification, advanced age, and comorbidity. Surgical approaches may require complex annular reconstruction or replacement strategies, and transcatheter approaches are considered in patients who are not surgical candidates; neither pathway is a routine analog of rheumatic PMBC. jacc+2jacc2020 ACC/AHA Guideline for the Management of Patients ... - JACCcdn clinicaltrials[PDF] Tendyne Holdings, Inc. CONFIDENTIAL CS0005-P MAC Feasibility ...jaccAortic Valve Disease, Transcatheter Aortic Valve Replacement, and the Heart Failure Patient: A State-of-the-Art Review

New or worsening exertional limitation, pulmonary congestion, or atrial fibrillation should prompt repeat transthoracic echocardiography with MVA, mean gradient, rhythm, and assessment of left atrial and pulmonary circulatory consequences. ACC/AHA staging integrates valve anatomy, hemodynamics, left atrial and pulmonary effects, and symptoms rather than a single measurement. jaccjacc2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Escalate promptly to a Heart Valve Team when severe disease is symptomatic, when MVA and gradient are discordant, when there is substantial calcification, or when mixed aortic and mitral disease makes sequencing uncertain. A multidisciplinary valve-center review is recommended for severe valve disease under consideration for intervention. jaccjacc2020 ACC/AHA Guideline for the Management of Patients ... - JACC

After PMBC or surgical treatment, reassess the residual stenosis and mitral regurgitation using echocardiographic valve-area methods. In patients after mitral valve repair, pressure half-time may not correlate with mean gradient, so interpret the measurement in the postoperative anatomy rather than using preintervention assumptions. AHA JournalsAHA JournalsAssessment of Mitral Valve Area During Percutaneous Mitral Valve ...