Updated: 12/21/2019

Mitral Stenosis

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Snapshot
  • A 50-year-old man presents to his cardiologist for dyspnea on exertion, fatigue, and swollen legs. He reports that these symptoms have worsened over the past few weeks. He has a past medical history of rheumatic fever when he was a young adult. He is currently taking no medications. On physical exam, he is noted to have a hoarse voice. On cardiac exam, there is a diastolic rumble following an opening snap and peripheral edema. An echo reveals thickened mitral valve leaflets.
Introduction
  • Clinical definition
    • a valvular disorder characterized by thickened mitral valve leaflets and fused leaflet tips
  • Epidemiology
    • demographics
      • women > men
    • risk factors
      • rheumatic fever
  • Etiology
    • rheumatic fever (most common)
    • congenital defect (rare)
    • infective endocarditis
  • Pathogenesis
    • inflammation and scarring from rheumatic fever or other disease process causes thickening of the mitral valve leaflets
    • leaflets are thickened and tips are fused, causing an abrupt halt in leaflet motion after diastole
      • manifests clinically as opening snap
      • impedes left ventricular filling
    • left atrium (LA) pressure > left ventricular pressure during diastole
      • ↑ LA pressure causes pulmonary congestion
    • over time, can result in LA dilatation and right ventricular failure
  • Associated conditions
    • atrial fibrillation
Presentation
  • Symptoms
    • signs of heart failure
      • dyspnea
      • paroxysmal nocturnal dyspnea
      • fatigue
      • orthopnea
      • hemoptysis
    • hoarseness
      • enlarged left atrium compresses the recurrent laryngeal nerve
  • Physical exam
    • pulmonary rales
    • cardiac exam 
      • opening snap after S2
      • diastolic rumble
      • may have atrial fibrillation
      • ↓ pulse pressure
    • right-sided heart failure
      • hepatomegaly
      • ascites
      • peripheral edema
Imaging
  • Chest radiography
    • indication
      • initial test
    • findings
      • left atrial enlargement
      • posterior displacement of the esophagus
      • straightening of the left heart border
      • increased pulmonary vasculature
  • Echocardiography
    • indication
      • diagnostic test
    • findings
      • thickening of mitral valve leaflets
      • ↓ area of valve leaflets
      • left atrial enlargement
Studies
  • Electrocardiogram
    • indication
      • for all patients
    • findings
      • right ventricular hypertrophy
      • may have atrial fibrillation
  • Making the diagnosis
    • based on clinical presentation and imaging
Differential
  • Aortic regurgitation 
    • distinguishing factor
      • no opening snap in diastolic murmur
      • no hoarseness on clinical presentation
  • Atrial myxoma
    • distinguishing factor
      • mass seen on imaging
Treatment
  • Management approach
    • standard therapy for atrial fibrillation in patients with the arrhythmia
  • Conservative
    • salt restriction
      • indication
        • for all patients
  • Medical
    • diuretics
      • indication
        • patients with heart failure
    • β-blockers   
      • indication
        • patients with exercise intolerance
  • Operative  
    • balloon valvuloplasty or valve replacement
      • indications
        • patients refractory to medical therapy
        • severe stenosis
Complications
  • Infective endocarditis
  • Heart failure
  • Pulmonary hypertension

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