Summary of recommendations for mitral stenosis intervention

Recommendations	Class of recommendation	Level of evidence
PMBC is recommended for symptomatic patients with severe MS (MVA ≤1.5 cm², stage D) and favorable valve morphology in the absence of contraindications	I	A
Mitral valve surgery is indicated in severely symptomatic patients (NYHA class III/IV) with severe MS (MVA ≤1.5 cm², stage D) who are not high risk for surgery and who are not candidates for or failed previous PMBC	I	B
Concomitant mitral valve surgery is indicated for patients with severe MS (MVA ≤1.5 cm², stage C or D) undergoing other cardiac surgery	I	C
PMBC is reasonable for asymptomatic patients with very severe MS (MVA ≤1.0 cm², stage C) and favorable valve morphology in the absence of contraindications	IIa	C
Mitral valve surgery is reasonable for severely symptomatic patients (NYHA class III/IV) with severe MS (MVA ≤1.5 cm², stage D), provided there are other operative indications	IIa	C
PMBC may be considered for asymptomatic patients with severe MS (MVA ≤1.5 cm², stage C) and favorable valve morphology who have new onset of AF in the absence of contraindications	IIb	C
PMBC may be considered for symptomatic patients with MVA >1.5 cm² if there is evidence of hemodynamically significant MS during exercise	IIb	C
PMBC may be considered for severely symptomatic patients (NYHA class III/IV) with severe MS (MVA ≤1.5 cm², stage D) who have suboptimal valve anatomy and are not candidates for surgery or at high risk for surgery	IIb	C
Concomitant mitral valve surgery may be considered for patients with moderate MS (MVA 1.6 to 2.0 cm²) undergoing other cardiac surgery	IIb	C
Mitral valve surgery and excision of the left atrial appendage may be considered for patients with severe MS (MVA ≤1.5 cm², stages C and D) who have had recurrent embolic events while receiving adequate anticoagulation	IIb	C

For the strength of recommendations: Class I means the procedure/treatment should be performed/administered. Class IIa means it is reasonable to perform the procedure/administer treatment. Class IIb means the procedure/treatment may be considered. Class III means that the procedure or treatment is not useful/effective and may be harmful.
For the level of evidence: Level A means multiple populations evaluated; data derived from multiple randomized clinical trials or meta-analyses. Level B means limited populations evaluated; data derived from a single randomized trial or nonrandomized studies. Level C means very limited populations evaluated; only consensus opinion of experts, case studies, or standard of care.

AF: atrial fibrillation; MS: mitral stenosis; MVA: mitral valve area; NYHA: New York Heart Association; PMBC: percutaneous mitral balloon commissurotomy.

Reproduced from: Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57. Table used with the permission of Elsevier Inc. All rights reserved.

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Summary of recommendations for mitral stenosis intervention