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©2013 UpToDate ® Print Email ACC/AHA guideline summary: Surgery for mitral stenosis (MS) Class I - There is evidence and/or generalagreement that surgery (mitral valve repair, if possible), is indicatedin patients with moderate to severe MS* in the following settings • Among patients who are symptomatic (NYHA class III-IV) if: 1. Percutaneous mitral balloon valvotomy (PMBV) is not available. 2. PMBV is contraindicated because of moderate to severe mitral regurgitation or of left atrial thrombus that persists despite anticoagulation. 3. Mitral valve morphology is not favorable for PMBV in patients with an acceptable operative risk. • Symptomatic patients who also have moderate to severe mitral regurgitation. Class IIa - The weight of evidence oropinion is in favor of the usefulness of surgery in patients with MS inthe following setting • Among patients with severe MS, NYHA class I-II symptoms, and severe pulmonary arterial hypertension (pulmonary artery systolic pressure >60 mmHg), mitral valve surgery (repair if possible) is reasonable in those who are not candidates for PMBV. Class IIb - The weight of evidence oropinion is less well established for the usefulness of surgery inpatients with MS in the following setting • Mitral valve repair but not replacement may be considered in patients with asymptomatic moderate to severe MS* who have had recurrent embolic events despite adequate anticoagulation and have favorable valve morphology for repair. Class III - There is evidence and/or general agreement that surgery for MS is not useful in in the following settings • Patients with mild MS. • Among patients undergoing mitral valve repair, closed commissurotomy should not be performed; the preferred approach is open commissurotomy. * There may be variability in the measurement of mitral valve area; as a result, the mean transmitral gradient, pulmonary artery wedge pressure, and pulmonary artery pressure at rest or during exercise should also be taken into consideration. Data from Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines 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 (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2006; 48:e1.