This patient has severe symptomatic mitral stenosis with a valve that by description appears amenable to percutaneous balloon mitral valvuloplasty (PBMV). Classifying mitral stenosis as moderate or severe can be difficult owing to variance in heart rate and forward flow on transmitral gradient. As such, mean gradients are no longer included in the severity criteria. However, the mean gradient is usually greater than 5 mm Hg to 10 mm Hg in severe mitral stenosis, and the mitral valve area is usually less than 1.5 cm² in severe mitral stenosis and 1.0 cm² or less in very severe mitral stenosis.

PBMV is indicated for symptomatic patients (New York Heart Association [NYHA] functional class II, III, or IV) with severe mitral stenosis and valve morphology favorable for PBMV in the absence of left atrial thrombus or moderate to severe mitral regurgitation. Valve morphology is evaluated by assessing the degree of valvular calcification, valve thickening, degree of leaflet restriction, and extent of subchordal thickening. The most common cause of mitral stenosis is rheumatic heart disease, in which valve inflammation leads to progressive degenerative changes including leaflet thickening, calcification, and impaired valve function, as seen in this patient.

Given that this patient has severe symptomatic mitral stenosis and that there are no obvious contraindications to therapy, a conservative approach would not be appropriate.

Mitral valve replacement is indicated in patients with symptomatic (NYHA functional class III–IV) severe mitral stenosis when PBMV is unavailable or contraindicated or valve morphology is unfavorable.

Generally, rheumatic mitral valve disease is not as amenable to surgical repair as that from degenerative causes, such as myxomatous mitral valve disease. Moreover, the percutaneous option is preferable in a patient when available.