Beyond the valve: Advances in Mitral Stenosis Diagnosis and Management

Abstract

Mitral stenosis (MS) remains a significant valvular heart condition, even though its incidence is declining worldwide.  In low- and middle-income nations, rheumatic heart disease (RHD) still predominates, but in high-income countries, older adults are increasingly suffering from degenerative mitral stenosis (DMS) caused by mitral annular calcification (MAC). During diastole, MS obstructs left atrial outflow, increasing left atrial pressure and contributing to heart failure, right ventricular strain and pulmonary hypertension.  Echocardiography remains crucial for the diagnosis, evaluation of complications, valve structure and disease severity. Management strategies varies by comorbidities, anatomy, etiology and patient-specific variables.  Medical therapy aims to prevent thromboembolic events and symptom control, particularly in patients with DMS. Percutaneous balloon mitral valvotomy (PBMV) remains as the preferred treatment for rheumatic MS with favorable anatomy and emerging therapies like lithotripsy-assisted PBMV show promise for highly calcified valves along with better outcomes. Surgical interventions such as commissurotomy, transcatheter mitral valve replacement (TMVR) and mitral valve replacement (MVR) are reserved for cases of complicated valve disease or inappropriate PBMV candidates. Valve choice between mechanical or bioprosthetic prostheses depends on comorbidities, patient age and anticoagulation considerations. Special considerations include pregnancy, where multidisciplinary care and selective interventions help reduce maternal fetal risk and the elderly, where the high surgical risk and comorbidity burden must be taken into account. Improvements in imaging, technology and selection criteria are expanding therapy possibilities, despite ongoing challenges in optimizing intervention timing and long-term outcomes.