Acquired Mitral Stenosis Treatment & Management

Updated: Apr 29, 2014
  • Author: M Silvana Horenstein, MD; Chief Editor: Stuart Berger, MD  more...
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Treatment

Medical Care

Asymptomatic patients with mild mitral stenosis (MS) require yearly follow-up care to monitor for disease progression. Yearly evaluation should include physical examination, chest radiography, and echocardiography.

Critically ill inpatients or those unable to receive oral medications may be treated intravenously.

For the patient with signs or symptoms of CHF, diuretics may provide benefit.

Tachyarrhythmias, such as atrial flutter and atrial fibrillation, usually require medical treatment aimed at restoration and maintenance of sinus rhythm. If this is not possible, therapy may be aimed at decreasing ventricular response and maintaining an acceptable heart rate. Pharmacotherapy may include the following:

  • Digoxin, beta-blockers, and calcium channel blockers have all been used to slow atrioventricular (AV) node conduction and decrease ventricular rate response.

  • Antiarrhythmics from class I (eg, procainamide, flecainide, propafenone) and class III (eg, sotalol, amiodarone) have been used with variable success in converting to and maintaining sinus rhythm.

  • Thromboembolic complication from chronic atrial arrhythmia can be reduced with anticoagulation using warfarin.

Electrophysiologic ablation of atrial fibrillation or flutter circuits may be performed in the catheterization laboratory.

Surgical ablation via a Cox-Maze procedure during mitral valve repair or replacement has been shown to be an effective treatment for atrial fibrillation with freedom from atrial fibrillation recurrence of nearly 80% after 10 years. [14]

Percutaneous mitral balloon valvuloplasty for acquired MS was first described in 1984 and approved by the US Food and Drug Administration in 1994. Indications for this procedure are similar to those for surgery, including CHF unresponsive to medical management and in asymptomatic patients with a pulmonary artery (PA) systolic pressure of 50 mm Hg or greater at rest or greater than 60 mm Hg with exercise in the absence of a left atrial thrombus or moderate to severe MR. [15] In some centers, the procedure is successful in 80-90% of selected cases. The procedural mortality rate is 1-2%.

Hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) have reportedly slowed the progression of rheumatic MS. [16, 17]

Consultations

Consult a cardiologist and a cardiothoracic surgeon.

Transfer

Transfer patients to an ICU when general status is unstable because of CHF with pulmonary edema or serious cardiac dysrhythmia.

Once medically stabilized, surgical or transcatheter intervention should be considered.

Diet and activity

Salt intake should be restricted and excessive fluid intake minimized to avoid exacerbating signs and symptoms of CHF.

Patients with more severe than mild MS should avoid strenuous exertion. Increased heart rate may result in decreased diastolic filling, thereby decreasing cardiac output. Coexistent atrial arrhythmias result in loss of atrial augmentation of LV filling and may further impair cardiac output.

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Surgical Care

Surgical intervention is indicated in symptomatic (NYHA functional class III-IV) moderate or severe MS when percutaneous MV balloon valvuloplasty is unavailable or contraindicated because of left atrial thrombus despite anticoagulation or concomitant moderate to severe MR, or when valve morphology is unfavorable for valvotomy. [10, 18]

Mitral valvotomy

Commissurotomy consists of an incision of fused mitral valve commissures and shaving of thickened mitral valve leaflets. Fused chordae tendineae and papillary muscles can be divided to relieve subvalvular stenosis.

Supravalvular tissue contributing to the MS should be resected.

Combined valvuloplasty with prosthetic ring annuloplasty is also used with reportedly good results. [19]

Mitral valve replacement with mechanical valve or bioprosthesis

This procedure is reserved for patients in whom mitral valvotomy is considered unlikely to achieve a satisfactory result, such as in those with moderate to severe MR.

Mechanical mitral valve replacement is performed frequently in adolescents and adults in whom anticoagulation with warfarin (Coumadin) is not contraindicated. In older patients in whom warfarin therapy may be relatively contraindicated or in patients who have other contraindications to warfarin therapy, mitral valve replacement can be performed using a bioprosthesis, although these are less durable than mechanical prostheses.

Weigh the risk of warfarin therapy against that of bioprosthetic valve deterioration resulting in the need for reoperation. Warfarin is contraindicated during pregnancy.

Complications after mitral valve replacement include anticoagulation-related complications, valve thrombosis, valve dehiscence, infective endocarditis, valve malfunction, and embolic events.

Hemolytic anemia when mild-to-moderate paravalvular leakage is present predicts poor clinical outcome in patients who have undergone mitral valve replacement. [20]

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