Mitral Stenosis

Cardiovascular

Clinicals - History

Fact Explanation
Progressive worsening Shortness of breath with or without Orthopnea/ Paroxysmal nocturnal dyspnea Due to Pulmonary venous congestion and bronchitis Progressive worsening Shortness of breath with or without Orthopnea/ Paroxysmal nocturnal dyspnea
Due to Pulmonary venous congestion and bronchitis
Cough - Productive with blood tinged, frothy sputum to frank haemoptysis Due to rupture of pulmonary-bronchial
venous connections secondary to pulmonary venous hypertension
Cough - Productive with blood tinged, frothy sputum to frank haemoptysis
Due to rupture of pulmonary-bronchial
venous connections secondary to pulmonary venous hypertension
Weakness and Fatigue Due to development of Right heart failure following Pulmonary hypertension Weakness and Fatigue
Due to development of Right heart failure following Pulmonary hypertension
Lower limb swelling Due to development of Right heart failure following Pulmonary hypertension Lower limb swelling
Due to development of Right heart failure following Pulmonary hypertension
Abdominal swelling Due to development of Right heart failure following Pulmonary hypertension Abdominal swelling
Due to development of Right heart failure following Pulmonary hypertension
Palpitations Due to risk of developing palpitation because of enlarged Left Atrium Palpitations
Due to risk of developing palpitation because of enlarged Left Atrium
Symptoms of Chest infection such as: Fever, Cough, Pleuritc chest pain, Shortness of breath Pulmonary infection commonly complicate untreated Mitral stenosis Symptoms of Chest infection such as: Fever, Cough, Pleuritc chest pain, Shortness of breath
Pulmonary infection commonly complicate untreated Mitral stenosis
Acute Neurological weakness Systemic emboli causing end organ ischaemia following Atrial Fibrillation Acute Neurological weakness
Systemic emboli causing end organ ischaemia following Atrial Fibrillation
Childhood history of Rheumatic fever The most common cause of Mitral stenosis is Rheumatic heart disease secondary to group A beta Haemolytic streptococcus infection Childhood history of Rheumatic fever
The most common cause of Mitral stenosis is Rheumatic heart disease secondary to group A beta Haemolytic streptococcus infection
Hoarseness of Voice Ortner’s syndrome. The enlarged left atrium may impinge on the left recurrent laryngeal nerve, causing hoarseness Hoarseness of Voice
Ortner’s syndrome. The enlarged left atrium may impinge on the left recurrent laryngeal nerve, causing hoarseness

Clinicals - Examination

Fact Explanation
Face - Malar Flush Due to severe Mitral stenosis with pulmonary hypertension that causes development of arteriovenous anastomoses and vascular stasis Face - Malar Flush
Due to severe Mitral stenosis with pulmonary hypertension that causes development of arteriovenous anastomoses and vascular stasis
Pulse - Small volume pulse Mitral stenosis causes reduced blood flow across mitral valve there reduced stroke volume Pulse - Small volume pulse
Mitral stenosis causes reduced blood flow across mitral valve there reduced stroke volume
Pulse - Regular early in the disease, but may become Irregularly irregular Patients develop atrial fibrillation Pulse - Regular early in the disease, but may become Irregularly irregular
Patients develop atrial fibrillation
Jugular veins - Elevated JVP Due to development of Right heart failure. If pulmonary Hypertension develops/ Tricuspid regurgitation develops the 'a' wave will be prominent Jugular veins - Elevated JVP
Due to development of Right heart failure. If pulmonary Hypertension develops/ Tricuspid regurgitation develops the 'a' wave will be prominent
Blood pressure : Pulse pressure may be reduced Mitral stenosis causes reduced blood flow across mitral valve there reduced stroke volume Blood pressure : Pulse pressure may be reduced
Mitral stenosis causes reduced blood flow across mitral valve there reduced stroke volume
Chest - Palpation : Tapping apex beat Due to palpable first heart sound combined with left ventricular backward displacement produced by an enlarging right ventricle Chest - Palpation : Tapping apex beat
Due to palpable first heart sound combined with left ventricular backward displacement produced by an enlarging right ventricle
Cardiac Auscultation :1st heart sound - Loud Valve cusps are widely apart at the onset of systole But will not occur in calcific mitral stenosis Cardiac Auscultation :1st heart sound - Loud
Valve cusps are widely apart at the onset of systole But will not occur in calcific mitral stenosis
Cardiac Auscultation : Opening snap Due to sudden opening of mitral valve with the force of increased left atrial pressure. Closeness of opening snap to second heart sound is proportional to severity of mitral stenosis Cardiac Auscultation : Opening snap
Due to sudden opening of mitral valve with the force of increased left atrial pressure. Closeness of opening snap to second heart sound is proportional to severity of mitral stenosis
Cardiac Auscultation : Murmur - Low pitched, Mid diastolic, rumbling murmur best heard with Bell of stethoscope at the apex with the patient lying onto the left side. Due to turbulent flow across stenotic mitral valve. Length of the mid diastolic murmur is proportional to the severity Cardiac Auscultation : Murmur - Low pitched, Mid diastolic, rumbling murmur best heard with Bell of stethoscope at the apex with the patient lying onto the left side.
Due to turbulent flow across stenotic mitral valve. Length of the mid diastolic murmur is proportional to the severity
Cardiac auscultation : Early diastolic murmur of Pulmonary area Graham Steell murmur resulting due to pulmonary valve regurgitation caused by pulmonary hypertension Cardiac auscultation : Early diastolic murmur of Pulmonary area
Graham Steell murmur resulting due to pulmonary valve regurgitation caused by pulmonary hypertension
Right Ventricular Heave, Loud pulmonary component of second heart sound Signs of Pulmonary hypertension Right Ventricular Heave, Loud pulmonary component of second heart sound
Signs of Pulmonary hypertension
Lower limb oedema, Ascites, Liver enlargement Signs of Right heart failure Lower limb oedema, Ascites, Liver enlargement
Signs of Right heart failure

Investigations - Diagnosis

Fact Explanation
Echocardiogram - Transthoracic echo , , To diagnose valve lesion. To determine severity of valve lesion. Echocardiography also evaluates pulmonary artery pressures,
associated MR, concomitant valve disease, and LA size. Advantage of Trans thoracic route is non invasive. Disadvantage it is less sensitive than TOE.
Echocardiogram - Transthoracic echo , ,
To diagnose valve lesion. To determine severity of valve lesion. Echocardiography also evaluates pulmonary artery pressures,
associated MR, concomitant valve disease, and LA size. Advantage of Trans thoracic route is non invasive. Disadvantage it is less sensitive than TOE.
Echocardiogram - Transoesophageal echo (TOE) , Advantages of TOE include better spatial resolution and superior performance over Trans Thoracic route. Better accuracy of detecting Thrombosis, prosthetic dysfunction, Endocarditis. TOE should be performed to exclude LA thrombus before
PMC or after an embolic episode. . It is used not only as a diagnostic tool but also as a monitoring adjunct for operative and per cutaneous cardiac procedures .
Disadvantages include oral, esophageal, or pharyngeal trauma, arrhythmias, complications of conscious sedation
Echocardiogram - Transoesophageal echo (TOE) ,
Advantages of TOE include better spatial resolution and superior performance over Trans Thoracic route. Better accuracy of detecting Thrombosis, prosthetic dysfunction, Endocarditis. TOE should be performed to exclude LA thrombus before
PMC or after an embolic episode. . It is used not only as a diagnostic tool but also as a monitoring adjunct for operative and per cutaneous cardiac procedures .
Disadvantages include oral, esophageal, or pharyngeal trauma, arrhythmias, complications of conscious sedation
3D Echocardiogram Improves the accuracy of evaluation of valve morphology (especially
visualization of the commissures)
3D Echocardiogram
Improves the accuracy of evaluation of valve morphology (especially
visualization of the commissures)
Cardiac MRI Can accurately show Mitral valve anatomy. But rarely used. Cardiac MRI
Can accurately show Mitral valve anatomy. But rarely used.

Investigations - Management

Fact Explanation
2D Echocardiogram Asymptomatic patients with clinically significant MS, who have not
undergone intervention, should be followed up Annually. Longer intervals
(2 to 3 years) may be done in case of less severe stenosis. Follow up of patients after successful PMC is similar to that of
asymptomatic patients. It should be more stringent if asymptomatic
restenosis occurs.
2D Echocardiogram
Asymptomatic patients with clinically significant MS, who have not
undergone intervention, should be followed up Annually. Longer intervals
(2 to 3 years) may be done in case of less severe stenosis. Follow up of patients after successful PMC is similar to that of
asymptomatic patients. It should be more stringent if asymptomatic
restenosis occurs.
Cardiac Catheterization If co-existing abnormalities such as Mitral regurgitation, Aortic valvular disease or coronary artery disease is suspected, In
patients who have undergone PMBV or previous mitral valve surgery
and who have redeveloped serious symptoms
Cardiac Catheterization
If co-existing abnormalities such as Mitral regurgitation, Aortic valvular disease or coronary artery disease is suspected, In
patients who have undergone PMBV or previous mitral valve surgery
and who have redeveloped serious symptoms
Stress testing Indicated in patients with or without
symptoms equal to or discordant with the severity of MS. Exercise echocardiography is the preferred option.
Assessment of changes in mitral
gradient and pulmonary pressures can be done in response to stress.
Stress testing
Indicated in patients with or without
symptoms equal to or discordant with the severity of MS. Exercise echocardiography is the preferred option.
Assessment of changes in mitral
gradient and pulmonary pressures can be done in response to stress.
Chest X-ray Small heart with enlarged left atrium. Pulmonary venous congestion could be seen. In sever disease pulmonary edema can be seen Chest X-ray
Small heart with enlarged left atrium. Pulmonary venous congestion could be seen. In sever disease pulmonary edema can be seen
Electrocardiogram In sinus rhythm P wave is bifid can be seen - due to delayed atrial activation. Atrial fibrillation can be frequently seen. Features of Right ventricular hypertrophy can be seen Electrocardiogram
In sinus rhythm P wave is bifid can be seen - due to delayed atrial activation. Atrial fibrillation can be frequently seen. Features of Right ventricular hypertrophy can be seen

Management - Supportive

Fact Explanation
Protussive or Antitussive medication For management episodes of bronchitis , Protussive or Antitussive medication
For management episodes of bronchitis ,
Low dose diuretics For management of early symptoms of mitral stenosis such as mild dyspnoea Low dose diuretics
For management of early symptoms of mitral stenosis such as mild dyspnoea
Long acting nitrates Transiently ameliorate dyspnoea Long acting nitrates
Transiently ameliorate dyspnoea
Beta blockers Improve exercise tolerance Beta blockers
Improve exercise tolerance
Calcium channel blockers Improve exercise tolerance Calcium channel blockers
Improve exercise tolerance
Anticoagulant therapy A target INR between 2 to 3 is to be maintained in
patients with either permanent or paroxysmal AF
Anticoagulant therapy
A target INR between 2 to 3 is to be maintained in
patients with either permanent or paroxysmal AF
Pregnancy Mild symptoms - diuretics, For advanced disease relief of Mitral stenosis by Balloon Mitral Valvotomy Pregnancy
Mild symptoms - diuretics, For advanced disease relief of Mitral stenosis by Balloon Mitral Valvotomy

Management - Specific

Fact Explanation
Percutaneous mitral commissurotomy (PMC) Intervention should only be performed in patients with clinically
significant MS (valve area ≤1.5 cm). Contraindications for PMC include, Mitral valve area >1.5 cm², Thrombus in left atrium, mitral regurgitation which is moderate or more, Severe or bicommissural calcification, Severe concomitant aortic valve disease, Absence of commissural fusion, or severe combined
tricuspid stenosis and regurgitation, Concomitant coronary artery disease requiring bypass surgery. Surgery is preferable in patients who are unsuitable for PMC
Percutaneous mitral commissurotomy (PMC)
Intervention should only be performed in patients with clinically
significant MS (valve area ≤1.5 cm). Contraindications for PMC include, Mitral valve area >1.5 cm², Thrombus in left atrium, mitral regurgitation which is moderate or more, Severe or bicommissural calcification, Severe concomitant aortic valve disease, Absence of commissural fusion, or severe combined
tricuspid stenosis and regurgitation, Concomitant coronary artery disease requiring bypass surgery. Surgery is preferable in patients who are unsuitable for PMC
Open Commissurotomy Done under direct vision. The valve can be conserved, it avoids the risks inherent to prosthetic valves and also avoids the need for anticoagulation in patients in sinus rhythm Open Commissurotomy
Done under direct vision. The valve can be conserved, it avoids the risks inherent to prosthetic valves and also avoids the need for anticoagulation in patients in sinus rhythm
Mitral Valve Replacement If unfavorable valve characteristics preventing repair of damaged valve. Elderly presentation of Mitral stenosis. Needs anticoagulation if Mechanical valves are chosen. Mitral Valve Replacement
If unfavorable valve characteristics preventing repair of damaged valve. Elderly presentation of Mitral stenosis. Needs anticoagulation if Mechanical valves are chosen.

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