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Media Gallery

Mitral Stenosis. M-mode across the mitral valve showing a flat E-F slope resulting from elevated left atrial pressure throughout diastole due to a significant gradient across the mitral valve. Increased thickness and calcification of anterior leaflet of the mitral valve and decreased opening of the anterior and posterior leaflets in diastole are also shown.
Mitral Stenosis. Parasternal long-axis view demonstrating calcification and doming in diastole of the anterior valve leaflet and mild restriction in the opening of posterior mitral valve leaflet.
Mitral Stenosis. Apical 4-chamber view demonstrating restricted opening of the anterior and posterior mitral valve leaflet with diastolic doming of anterior leaflet with left atrial enlargement.
Mitral Stenosis. Transesophageal echocardiogram with continuous wave Doppler interrogation across the mitral valve demonstrating an increased mean gradient of 16 mm Hg consistent with severe mitral stenosis.
Mitral Stenosis. Apical 4-chamber view with color Doppler demonstrating aliasing in the atrial side of the mitral valve consistent with increased gradient across the valve. This figure also shows mitral regurgitation and left atrial enlargement.
Mitral Stenosis. Magnified view of the mitral valve in apical 4-chamber view revealing restricted opening of both leaflets.
Mitral Stenosis. Transesophageal echocardiogram in an apical 3-chamber view showing calcification and doming of the anterior mitral leaflet and restricted opening of both leaflets.
Mitral Stenosis. Transesophageal echocardiogram in an apical 3-chamber view with color Doppler interrogation of the mitral valve revealing aliasing, which is consistent with increased gradient across the mitral valve secondary to stenosis. Also shown in this image, a posteriorly directed jet of severe mitral regurgitation.

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Table 1. Duration of Secondary Rheumatic Fever Prophylaxis

Category	Duration After Last Attack	Rating*
Rheumatic fever with carditis and residual heart disease (persistent valvular disease† )	10 y or until age 40 y (whichever is longer); sometimes lifelong prophylaxis	IC
Rheumatic fever with carditis but no residual heart disease (no valvular disease† )	10 y or until age 21 y (whichever is longer)	IC
Rheumatic fever without carditis	5 y or until age 21 y (whichever is longer)	IC
*Rating indicates classification of recommendation and level of evidence (eg, IC indicates Class I, level of Evidence C). †Clinical or echocardiographic evidence.

Table 2. Secondary Prevention of Rheumatic Fever (Prevention of Recurrent Attacks)

Agent	Dose	Mode	Rating*
Benzathine penicillin G	Children 27 kg (60 lb): 600,000 U Patients >27 kg: 1,200,000 every 4 wk†	Intramuscular	IA
Penicillin V	250 mg bid	Oral	IB
Sulfadiazine	Children 27 kg: 0.5 g qd Patients >27 kg: 1 g qd	Oral	IB
Macrolide or azalide (for individuals allergic to penicillin and sulfadiazine)	Variable	Oral	IC
*Rating indicates classification of recommendation and level of evidence (eg, IA indicates Class I, level of Evidence A). †In high-risk situations, administration every 3 weeks is justified and recommended.

Table 3. Primary Prevention of Rheumatic Fever (Treatment of Streptococcal Tonsillopharyngitis*)

Agent	Dose	Mode	Duration	Rating †
Penicillins
Penicillin V (phenoxymethyl penicillin)	Children 27 kg (60 lb): 250 mg bid or tid Patients >27 kg: 500 mg bid or tid	Oral	10 d	IB
Amoxicillin	50 mg/kg qd (maximum 1 g)	Oral	10 d	IB
Benzathine penicillin G	Children 27 kg (60 lb): 600,000 U Patients >27 kg: 1,200,000 U	Intramuscular	Once	IB
For individuals allergic to penicillin
Narrow-spectrum cephalosporin (cephalexin, cefadroxil)	Variable	Oral	10 d	IB
Clindamycin	20 mg/kg/d divided in 3 doses (maximum 1.8 g/d)	Oral	10 d	IIaB
Azithromycin	12 mg/kg qd (maximum 500 mg)	Oral	5 d	IIaB
Clarithromycin	15 mg/kg/d divided bid (maximum 250 mg bid)	Oral	10 d	IIaB
*Sulfonamides, trimethoprim, tetracyclines, and fluoroquinolones are not acceptable. †Rating indicates classification of recommendation and level of evidence (eg, IB indicates Class I, level of Evidence B)

Table 4. Recommendations for Mitral Stenosis (MS) Intervention

Recommendation	AHA/ACC (2014)^[12]	ESC/EACTS (2012)^{[5, 28]}
Concomitant mitral valve surgery for patients with severe MS (stage C or D) undergoing other cardiac surgery	Class I
Percutaneous mitral balloon commissurotomy (PMBC) for asymptomatic patients with very severe MS (stage C) and favorable valve morphology in the absence of left atrial (LA) thrombus or moderate-to-severe mitral regurgitation (MR)	Class IIa: Reasonable
PMBC for asymptomatic patients without unfavorable clinical characteristics when the risk of thromboembolism or hemodynamic decompensation is high		Class IIa: Reasonable
Mitral valve surgery for severely symptomatic patients (NYHA class III/IV) with severe MS (stage D), provided there are other operative indications	Class IIa: Reasonable
PMBC for asymptomatic patients with severe MS (stage C) and favorable valve morphology who have new onset of atrial fibrillation (AF) in the absence of an LA thrombus or moderate-to-severe MR	Class IIb: Consider
PMBC for symptomatic patients with a mitral valve area (MVA) above1.5 cm² if there is evidence of hemodynamically significant MS during exercise	Class IIb: Consider
PMBC for severely symptomatic patients (NYHA class III/IV) with severe MS (stage D) who have suboptimal valve anatomy and are not candidates or are at high risk for surgery	Class IIb: Consider	Class IIa: Reasonable
Concomitant mitral valve surgery for patients with moderate MS undergoing cardiac surgery for other causes	Class IIb: Consider
Mitral valve surgery and excision of the LA appendage for patients with severe MS (stages C and D) who have had recurrent embolic events while receiving anticoagulation	Class IIb: Consider

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