Recommendations for Intervention for Rheumatic MS Referenced studies that support the recommendations are summarized in Online Data Supplements 21 to 24. COR LOE Recommendations In symptomatic patients (NYHA class II, III, or IV) with severe rheumatic MS (mitral valve , Stage D) and favorable valve morphology with less than moderate (2+) MR* in the absence of LA thrombus, PMBC is recommended if it can be performed at a Comprehensive Valve Center.1 12 In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral , Stage D) who 1) are not candidates for PMBC, 2) have failed a previous PMBC, 3) require other cardiac procedures, or 4) do not have access to PMBC, mitral valve surgery (repair, commissurotomy, or valve replacement) is indicated.6,7,13 In asymptomatic patients with severe rheumatic MS (mitral valve area 1.5 cm2 , Stage C) and favorable valve morphology with less than 2+ MR in the absence of LA thrombus who have elevated pulmonary pressures (pulmonary artery systolic pressure >50 mmHg), PMBC is reasonable if it can be performed at a Comprehensive Valve Center.14 In asymptomatic patients with severe rheumatic MS (mitral valve area 1.5 cm2 , Stage C) and favorable valve morphology with less than 2+/ MR* in the absence of LA thrombus who have new onset of AF, PMBC may be considered if it can be performed at a Comprehensive Valve Center.15 In symptomatic patients (NYHA class II, III, or IV) with rheumatic MS and an mitral , if there is evidence of hemodynamically significant rheumatic MS on the basis of a pulmonary artery wedge pressure >25 mmHg or a mean mitral valve gradient >15 mmHg during exercise, PMBC may be considered if it can be performed at a Comprehensive Valve Center.16 In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve , Stage D) who have a suboptimal valve anatomy and who are not candidates for surgery or are at high risk for surgery, PMBC may be considered if it can be performed at a Comprehensive Valve Center.17 19 *2+ on a 0 to 4+ scale according to Sellar s criteria or less than moderate by Doppler echocardiography.20 Synopsis The optimal treatment of patients with rheumatic MS is either PMBC or surgery (open or closed commissuroto- my). 