Review Question - QID 106399

This patient has rheumatic heart disease and severe mitral stenosis with New York Heart Association (NYHA) class III symptoms. With favorable valvular anatomy, percutaneous mitral balloon valvotomy would be appropriate treatment.

In the majority of cases, mitral stenosis is caused by rheumatic involvement of the mitral valve, but other causes include congenital abnormalities and calcifications. Symptoms of mitral stenosis range from dyspnea due to elevated left atrial pressures and pulmonary congestion, hemoptysis, arial fibrillation due to left atrial enlargement, and right-sided heart failure, among other possibilities. The low-pitched diastolic rumble, loudest at the apex, is characteristic of mitral stenosis (Illustration A). Medical therapy can relieve symptoms of mitral stenosis but does not affect the underlying valvular obstruction to flow, which worsens over time. Surgical approaches include closed commissurotomy, open commissurotomy, mitral valve repair, and percutaneous mitral balloon valvotomy (PMBV). PMBV is currently the preferred treatment for rheumatic mitral stenosis if the valve morphology is favorable and the patient does not have left atrial thrombus or moderate-to-severe mitral regurgitation.

Shipton and Wahba describe cardiac valvular disease from a primary care perspective. They note that there is generally a latent period of 20 to 40 years between the occurrence of rheumatic fever and the onset of symptoms. Regarding surgical therapy, they recommend mitral balloon valvotomy for patients who have NYHA class II, III, or IV symptoms, moderate or severe mitral stenosis, and favorable valve morphology.

Badheka et al. note declining incidence and prevalence of mitral stenosis in the USA. However, concurrent with the declining number of mitral balloon valvuloplasties, they find an increase in the procedural complication rate and costs in recent years, attributed to increasing age of patients and comorbidities.

Illustration A: This illustration captures phonocardiograms of a number of valvular abnormalities; mitral stenosis is marked by a low-pitched diastolic rumble that follows an opening snap (high-frequency sound that results from the stenotic mitral valve that opens at the start of diastole) and is best heard with the bell of the stethoscope.

Incorrect Answers:
Answers 1-3,5: These are all potential treatment approaches; however, in direct trials comparing percutaneous mitral balloon valvotomy to surgical commissurotomy, the former performed as good or better than the latter. There is less data comparing PMBV versus mitral valve repair, but it is still considered a first-line option. Medical therapy can provide symptomatic relief but does not alter the underlying pathophysiology.