Balloon mitral valvuloplasty has, over the last 15 years, become an established interventional procedure. For patients with pliable uncalcified mitral stenosis, dilatation with the Inoue balloon is the intervention of choice, offering results comparable to surgical commissurotomy.1 In the Western world, however, with the gradual extinction of rheumatic fever, patients with mitral stenosis are now almost exclusively elderly. Such patients tend to have calcified, thickened, and relatively immobile valves, often with significant subvalvar disease, and as such are theoretically unsuited to balloon valvuloplasty.2 ,3 But even a small increase in mitral valve orifice may be adequate to allow an elderly person to regain their independence; therefore some have advocated undertaking the interventional option at low risk, with only moderate expectations, rather than opting for mitral valve replacement, with its significant perioperative morbidity and mortality. But is this approach justified?

In this issue of Heart, Sutaria and colleagues describe long term outcome for elderly patients undergoing balloon valvuloplasty at one high volume UK centre.4Patients considered unsuitable for surgery—in whom the decision to offer valvuloplasty was therefore in some respects straightforward—had a relatively poor, though not surprising, event free survival rate of 25% at five years. Among those considered suitable for surgical treatment, one year survival free of death or mitral valve replacement, and with improvement in New York Heart Association class by at least one grade, was 64%, falling to 36% at five years. By this stage, numbers were few. In the absence of a randomised trial of surgical versus interventional management of mitral stenosis in elderly patients (which is never likely to happen, and in which treatment arms could not be strictly comparable anyway5), mitral valvuloplasty would seem on this evidence to be a fair …