The AHA Guidelines and Scientific Statements Handbook

Chapter 18 Valvular Heart Disease

of MS when noninvasive tests are inconclusive or
when there is discrepancy between noninvasive tests
and clinical fi ndings regarding severity of MS. (Level
of Evidence: C)
2 Catheterization for hemodynamic evaluation
including left ventriculography (to evaluate severity
of MR) for patients with MS is indicated when there
is a discrepancy between the Doppler-derived mean
gradient and valve area. (Level of Evidence: C)

Class IIa
1 Cardiac catheterization is reasonable to assess the
hemodynamic response of pulmonary artery and
left atrial pressures to exercise when clinical symp-
toms and resting hemodynamics are discordant.
(Level of Evidence: C)
2 Cardiac catheterization is reasonable in patients
with MS to assess the cause of severe pulmonary
arterial hypertension when out of proportion to
severity of MS as determined by noninvasive testing.
(Level of Evidence: C)

Class III
Diagnostic cardiac catheterization is not recom-
mended to assess the MV hemodynamics when 2D

and Doppler echocardiographic data are concordant

with clinical fi ndings. (Level of Evidence: C)

Indications for percutaneous mitral balloon

valvotomy (Fig. 18.3)

Class I

1 Percutaneous mitral balloon valvotomy is effec-

tive for symptomatic patients (NYHA functional

class II, III, or IV), with moderate or severe MS* and

valve morphology favorable for percutaneous mitral

balloon valvotomy in the absence of left atrial

thrombus or moderate to severe MR. (Level of Evi-

dence: A) ESC recommendation, I (B)

2 Percutaneous mitral balloon valvotomy is effec-

tive for asymptomatic patients with moderate or

severe MS* and valve morphology which is favor-

able for percutaneous mitral balloon valvotomy who

have pulmonary hypertension (pulmonary artery

systolic pressure greater than 50 mm Hg at rest or

60 mm Hg with exercise) in the absence of left atrial

thrombus or moderate to severe MR. (Level of

Favorable

morphology

for PMBV?

Mitral stenosis

Yes

Yes

Yes

Yes

Yes Yes No

Yes No

No

No

No No No No

No

PAP rest >50 mmHg or

PA exercise >60 mmHg or

new onset AF

Favorable

morphology

for PMBV?

New onset

AF?

MVA ≥1.5 cm^2

Class IIa

Class IIb Class I

MVA <1.5 cm^2

High-risk

surgical

candidate?

Surgical MV repair

or replacement

Clinical follow-up

Percutaneous mitral annual echo

ballon valvotomy

(no LA clot, MR ≤2+)

Symptoms?

Class I

Fig. 18.3 Management strategy for patients with mitral stenosis.
AF, atrial fi brillation; MVA, mitral valve area; PAP, pulmonary artery systolic pressure; PMBV, percutaneous mitral balloon valvotomy. Adapted
from Otto CM, Bonow RO. Valvular heart disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald’s Heart Disease: A Textbook of
Cardiovascular Medicine, 8th edn. Philadelphia: Elsevier Science, 2007:1625–1693.

* See Table 18.1.