Mitral stenosis — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 32-year-old woman with rheumatic mitral stenosis wants to start a family. She has NYHA class II exertional dyspnoea. Echocardiography shows commissural fusion and diastolic doming, a planimetered mitral valve area of 1.2 cm², a diastolic pressure half-time of 180 ms, severe LA enlargement and an estimated PASP of 42 mm Hg.^[2] Her echocardiographic score is 6, there is no calcification, MR is mild and there is no tricuspid or aortic valve disease. She is in sinus rhythm and has never had a commissurotomy.^[1]

1. Classify her mitral stenosis using ACC/AHA 2020 Table 16 and the ESC/EACTS 2025 definition. (2)^[2][1]
2. Which test should be done before percutaneous commissurotomy, and what is it looking for? Give the ACC/AHA 2020 row with its COR and LOE. (2)^[1][3]
3. If that test is clear, which ESC/EACTS 2025 Recommendation Table 8 row applies to her, with class and level? (2)^[1]
4. What do the ESC 2025 pregnancy guideline and the ESC/EACTS 2025 valve guideline say about intervention before pregnancy? (2)^[7][1]
5. She later develops atrial fibrillation. Which anticoagulant, and why, according to ESC/EACTS 2025? (2)^[1]

Model answers — SAQ 1

1. ACC/AHA 2020 Stage D, symptomatic severe MS: planimetered mitral valve area ≤1.5 cm², diastolic pressure half-time ≥150 ms, severe LA enlargement and exertional dyspnoea (1 mark).^[2] ESC/EACTS 2025: an MVA of ≤1.5 cm² with symptoms is indicative of clinically severe MS (1 mark).^[1]
2. TOE: ESC/EACTS 2025 says it should be systematically performed in PMC candidates to exclude LA thrombus (1 mark).^[1] ACC/AHA 2020: in patients considered for PMBC, TEE should be performed to assess the presence or absence of LA thrombus and to evaluate the severity of MR (COR 1, LOE C-LD) (1 mark).^[3]
3. ESC/EACTS 2025 Recommendation Table 8: PMC is recommended in symptomatic patients in the absence of unfavourable characteristics for PMC (1 mark).^[1] ESC/EACTS 2025 Class I, Level B; she has none of the footnote c characteristics (old age, history of commissurotomy, NYHA class IV, permanent AF, severe PH, echocardiographic score >8, Cormier score group 3, severe TR) (1 mark).^[1]
4. ESC 2025 (pregnancy): intervention is recommended before pregnancy in women with mitral stenosis and a valve area <1.5 cm² (Class I, Level C) (1 mark).^[7] ESC/EACTS 2025: the first therapeutic option for MS in a woman considering pregnancy should be PMC (1 mark).^[1]
5. A VKA with a target INR between 2 and 3, which ESC/EACTS 2025 says is indicated in patients with AF (1 mark).^[1] ESC/EACTS 2025 says the use of DOACs is not recommended in patients with AF and rheumatic MS with an MVA ≤2.0 cm² (Class III, Level B) (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 79-year-old woman with severe mitral annular calcification has NYHA class III breathlessness despite diuretics. TOE with 3D planimetry estimates the mitral valve area at 1.2 cm², with severe MV dysfunction from extensive calcification; there is no commissural fusion, and she has permanent atrial fibrillation.^[3][1] The Heart Team at an experienced Heart Valve Centre with expertise in complex MV surgery and transcatheter interventions judges her surgical risk high.^[1]

1. How does the anatomy of degenerative MS differ from rheumatic MS? (2)^[1][3]
2. Why is imaging difficult, and which tests does ESC/EACTS 2025 advise? (2)^[1]
3. Why is percutaneous commissurotomy not an option? (1)^[1]
4. Give the ESC/EACTS 2025 and ACC/AHA 2020 intervention rows that apply, with class or COR. (2)^[1][3]
5. What do the guidelines say about prognosis in calcific or degenerative MS? (2)^[3][1]
6. Which anticoagulant for her AF, according to the AF guidelines? (1)^[4][5]

Model answers — SAQ 2

1. ESC/EACTS 2025: MS generally occurs due to calcific extension into the MV leaflets or subvalvular apparatus, and in some patients it is associated with combined MR (1 mark).^[1] ACC/AHA 2020: in contrast to rheumatic MS, there is no commissural fusion, and the leaflet tips are usually unaffected (1 mark).^[3]
2. Echocardiography is frequently limited by acoustic shadowing due to severe calcification, and planimetry of the MVA is less reliable than in rheumatic MS, so TOE should be used liberally (1 mark).^[1] Electrocardiogram-gated CT is necessary to assess the degree and locations of calcifications, especially if an intervention is planned (1 mark).^[1]
3. ESC/EACTS 2025 says degenerative MS is not amenable to PMC because commissural fusion is absent (1 mark).^[1]
4. ESC/EACTS 2025: TMVI may be considered in symptomatic patients with extensive MAC and severe MV dysfunction at experienced Heart Valve Centres with expertise in complex MV surgery and transcatheter interventions (Class IIb, Level C) (1 mark).^[1] ACC/AHA 2020: in severely symptomatic patients (NYHA class III or IV) with severe MS (mitral valve area ≤1.5 cm², Stage D) attributable to extensive MAC, valve intervention may be considered only after discussion of the high procedural risk and the individual patient’s preferences and values (COR 2b, LOE C-LD) (1 mark).^[3]
5. ACC/AHA 2020: the prognosis of calcific MS is poor, with a 5-year survival rate <50%, most likely because of advanced age and other comorbidities (1 mark).^[3] ESC/EACTS 2025: mortality remains high even after successful treatment (10%–30% within 1 year), so Heart Team evaluation should guide the choice of treatment avoiding futility (1 mark).^[1]
6. A VKA: ESC 2024 (AF) recommends DOACs in preference to VKAs to prevent ischaemic stroke and thromboembolism, except in patients with mechanical heart valves or moderate-to-severe mitral stenosis (Class I, Level A), and ACC/AHA/ACCP/HRS 2023 recommends long-term warfarin over DOACs in MS of moderate or greater severity with a history of AF, to prevent cardiovascular events, including stroke or death (COR 1, LOE B-R) (1 mark).^[4][5] The ESC/EACTS 2025 Class III, Level B DOAC row is written for rheumatic MS, so for her the AF guideline rows are the ones to quote.^[1][4][5]