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Updated: Dec 9 2021

Mitral Stenosis

  • 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
    • Associated conditions
      • atrial fibrillation
  • 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
  • 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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