Recommendations G. Recommendations on indications for percutaneous mitral commissurotomy and mitral valve surgery in clinically significant (moderate or severe) mitral stenosis (valve area ≤1.5 cm²).

Recommendations	Classa	Levelb
PMC is recommended in symptomatic patients without unfavourable characteristicsc for PMC. 360,363,364,365,367	I	B
PMC is recommended in any symptomatic patients with a contraindication or a high risk for surgery.	I	C
Mitral valve surgery is recommended in symptomatic patients who are not suitable for PMC in the absence of futility.	I	C
PMC should be considered as initial treatment in symptomatic patients with suboptimal anatomy but no unfavourable clinical characteristics for PMC.c	IIa	C
PMC should be considered in asymptomatic patients without unfavourable clinical and anatomical characteristicsc for PMC and: • High thromboembolic risk (history of systemic embolism, dense spontaneous contrast in the LA, new-onset or paroxysmal AF), and/or • High risk of haemodynamic decompensation (systolic pulmonary pressure >50 mmHg at rest, need for major NCS, desire for pregnancy).	IIa	C
AF: atrial fibrillation; LA: left atrium/left atrial; MVA: mitral valve area; NCS: non-cardiac surgery; PMC: percutaneous mitral commissurotomy. aClass of recommendation. bLevel of evidence. cUnfavourable characteristics for PMC can be defined by the presence of several of the following characteristics. Clinical characteristics: old age, history of commissurotomy, New York Heart Association class IV, permanent AF, severe pulmonary hypertension. Anatomical characteristics: echocardiographic score >8, Cormier score 3 (calcification of mitral valve of any extent as assessed by fluoroscopy), very small MVA, severe tricuspid regurgitation. For the definition of scores, see Supplementary Table 8.