A review of the guidelines of the American College of Cardiology and the American Heart Association for the management of patients with valvular heart disease, published in 1998, is presented. The therapeutical advances introduced during the past decade, percutaneous mitral balloon valvotomy and surgical ablation of atrial fibrillation, have modified the therapeutical approach to patients with mitral stenosis. In this article some controversial aspects are examined with a review of the recent literature. The definition of "valve morphology favorable for percutaneous balloon valvotomy", which is based on echocardiographic examination, is still debatable. Different echocardiographic scores published until now are reported. Some patients, who have no or mild symptoms, develop irreversible pulmonary hypertension: in order to avoid this complication early interventional procedure is suggested, but only in those patients at low post-procedural risk. In symptomatic patients, NYHA class II/III, with atrial fibrillation it is possible to consider a conservative surgical approach combined to crioablation of atrial fibrillation. The possibility of maintaining sinus rhythm and avoiding anticoagulation leads to a revaluation of surgical repair as option to valve replacement and percutaneous mitral balloon valvotomy.