For patients with symptomatic severe mitral stenosis (MS), percutaneous transvenous mitral commissurotomy (PTMC) using an Inoue (or Inoue-like) balloon is the most reasonable initial treatment option.1 For asymptomatic patients, however, there are no reliable data to guide therapy. Guideline recommendations are therefore based largely on consensus, and have varied over time, due perhaps to differing interpretations of the existing data (table 1). The greatest uncertainty pertains to the management of asymptomatic patients with mitral valve area (MVA) between 1 and 1.5 cm2. Kang and colleagues attempt to address this knowledge gap. They randomly allocated 167 asymptomatic patients with rheumatic MS and MVA 1–1.5 cm2, to either undergo PTMC within 3 months of randomisation or to remain on medical treatment.2 Over a median follow-up of just over 6 years, the composite primary outcome, consisting of PTMC-related complications, cardiovascular mortality, ischaemic stroke and systemic embolism, occurred in 7/84 (8.3%) patients in the PTMC arm and 9/83 (10.8%) patients (HR 0.77, 95% CI 0.29 to 2.07; p=0.61). The authors conclude that a strategy of initial PTMC does not reduce the incidence of adverse cardiovascular events and suggest that medical treatment with careful follow-up should continue to remain the standard of care for these patients. View this table: Table 1 Guideline recommendations for the management of asymptomatic patients with significant mitral stenosis (mitral valve area ≤1.5 cm2) These are important data in a field almost bereft of evidence from randomised trials. However, these results should be interpreted with caution for several reasons. First, the authors powered their study on the assumption of an unrealistically large (about 85%) relative risk reduction with PTMC, based on event rates from their previous observational cohort.3 The effect of PTMC, if any, in this population is likely to be modest …

中文翻译：

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无症状二尖瓣狭窄的早期干预：及时缝针？

对于有症状的重度二尖瓣狭窄 (MS) 患者，使用 Inoue（或 Inoue 样）球囊的经皮经静脉二尖瓣连合切开术 (PTMC) 是最合理的初始治疗选择。1 然而，对于无症状患者，没有可靠的数据来指导治疗。因此，指南推荐主要基于共识，并且随着时间的推移而变化，这可能是由于对现有数据的不同解释（表 1）。最大的不确定性与二尖瓣面积 (MVA) 在 1 到 1.5 cm2 之间的无症状患者的管理有关。Kang 及其同事试图解决这一知识差距。他们将 167 名无症状的风湿性 MS 和 MVA 1-1.5 cm2 患者随机分配到随机分组后的 3 个月内接受 PTMC 或继续接受药物治疗。2 在超过 6 年的中位随访期间，PTMC 组 7/84 (8.3%) 患者和 9 /83 (10.8%) 名患者（HR 0.77，95% CI 0.29 至 2.07；p=0.61）。作者得出结论，初始 PTMC 策略不会降低心血管不良事件的发生率，并建议谨慎随访的药物治疗应继续作为这些患者的标准治疗。查看此表： 表 1 治疗严重二尖瓣狭窄（二尖瓣面积 ≤ 1.5 cm2）的无症状患者的指南建议 这些是几乎缺乏随机试验证据的领域中的重要数据。然而，出于多种原因，应谨慎解释这些结果。首先，作者基于之前观察队列的事件发生率，假设 PTMC 的相对风险降低了不切实际的大（约 85%），为他们的研究提供了动力。 3 PTMC 对这一人群的影响（如果有的话）很可能谦虚点……