Table 1. Step 1: Diagnosis of severe mitral stenosis¹⁵.

	Characteristics of severe mitral stenosis
Physical examination	Facies mitralis Early opening snap Hyperphonetic first heart sound Hyperphonetic second heart sound Rumbling diastolic murmur, with presystolic reinforcement for patients in sinus rhythm Signs of pulmonary congestion and right heart failure Presence of TR
Electrocardiogram	LA enlargement Right chambers overload AF
Chest radiography	Normal cardiothoracic index Signs of enlarged LA: Elevated left main bronchus (“ballerina sign”) Double atrial contour on the right 4th arch in the cardiac silhouette on the left Signs of pulmonary congestion
Echocardiogram	MVA < 1.5 cm2 Average diastolic transmitral gradient ≥ 10 mmHg Resting SPAP ≥ 50 mmHg SPAP ≥ 60 mmHg during exertion
Hemodynamic study	Indicated in the event of discordance between clinical and echocardiographic findings Diastolic transmitral gradient ≥ 10 mmHg (spontaneous or after atropine and volume) SPAP ≥ 50 mmHg

AF: atrial fibrillation; LA: left atrium; LV: left ventricle; MVA: mitral valve area; SPAP: systolic pulmonary artery pressure; TR: tricuspid regurgitation.