TY - JOUR T1 - Heartbeat: early intervention for rheumatic mitral stenosis JF - Heart JO - Heart SP - 1925 LP - 1927 DO - 10.1136/heartjnl-2021-320535 VL - 107 IS - 24 AU - Catherine M Otto Y1 - 2021/12/01 UR - http://heart.bmj.com/content/107/24/1925.abstract N2 - Rheumatic mitral stenosis (MS) remains the most common type of valvular heart disease worldwide yet there are few studies on optimal timing of intervention in asymptomatic patients. Postulated benefits of intervention before symptom onset include prevention of left atrial dilation, atrial fibrillation (AF) and pulmonary hypertension leading to fewer thromboembolic events, less heart failure, preserved exercise capacity and in improved quality of life. In this issue of Heart, Kang and colleagues1 report a randomised clinical trial of in 374 patients with severe MS (valve area 1.0–1.5 cm2) comparing early percutaneous mitral commissurotomy (PMC) to conventional care. The primary composite endpoint of PMC-related complications, cardiovascular mortality, cerebral infarction and systemic thromboembolic events occurred in seven patients in the early PMC group (8.3%) compared with nine patients in the conventional care group (10.8%) (HR 0.77; 95% CI 0.29 to 2.07; p=0.61) at a median follow-up of 6 years (figure 1).Figure 1 Summary of the MITIGATE (mitral intervention vs conventional management in asymptomatic mitral stenosis) trial. MS, mitral stenosis; PMC, percutaneous mitral commissurotomy.Karthikeyan2 points out that there is only a sparse evidence base for management of mitral stenosis. Although this study by Kang and colleagues1 is commendable, replication in larger studies in countries with endemic rheumatic heart disease is needed. In the meanwhile, ‘even minimally symptomatic patients … ER -