ESC/EACTS 595
Guidelines
Management of clinically significant rheumatic mitral stenosis (MVA ≤
1.5 cm2)
Sympto
ms
N Y
High risk of
Contraindicatio
on 14 April 2025
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embolism or n to PMC
haemodynamic
N
N Y
Contraindicatio
Exercise n or high Y Y
testing risk for
surgery
Sympto N
ms
Y
Contraindication Favourable
N to or anatomical Y
unfavourable
characteristic
Favourable
N Y Y
clinical
characteristic
Follow PM Surger Surger PMC Surger
up C yd y b
y
Figure 7 Management of clinically significant rheumatic mitral stenosis (MVA <_1.5 cm2). AF = atrial fibrillation; LA = left
atrium/left atrial; MVA = mitral valve area; NCS = non-cardiac surgery; PMC = percutaneous mitral commissurotomy. aHigh
thromboembolic risk: history of systemic embolism, dense spontaneous contrast in the LA, new-onset AF. High-risk of
haemodynamic decompensation: systolic pulmonary pressure >50 mmHg at rest, need for major NCS, desire for pregnancy.
b
Surgical commissurotomy may be considered by experienced surgical teams in patients with contraindications to PMC. cSee
recommendations on indications for PMC and mitral valve surgery in clinically significant mitral stenosis in section 7.2. dSurgery if
symptoms occur for a low level of exercise and operative risk is low.
.
7.1.3 Medical therapy isolation are indicated before intervention in patients with
Diuretics, beta-blockers, digoxin, non-dihydropyridine significant
calcium chan- nel blockers and ivabradine can improve .. mitral stenosis, as they do not durably restore sinus
symptoms. Anticoagulation with vitamin K antagonist rhythm. If AF is
.
(VKA) with a target international normal- ized ratio (INR) of recent onset and the LA is only moderately enlarged,
between 2 and 3 is indicated in patients with AF.
.
cardiover-
Patients with moderate-to-severe mitral stenosis and AF . sion should be performed soon after successful
should be kept on VKA and not receive NOACs. intervention, it
.
Currently there is no solid evidence to support the should also be considered in patients with less than
.
use of NOACs in this setting370 and a randomized severe mitral
clinical trial is underway (INVICTUS VKA NCT . stenosis. Amiodarone is most effective in maintaining
02832544). Neither cardioversion nor catheter .
the sinus
pulmonary vein
ESC/EACTS 595
Guidelines
. rhythm after cardioversion. In patients in sinus rhythm,
OAC is rec-
. ommended when there has been a history of systemic
.
embolism or a
. thrombus is present in the LA and should also be
considered when
. TOE shows dense spontaneous echocardiographic
.
contrast or an
enlarged LA (M-mode diameter >50 mm or LA volume .
>60 mL/m2).
