Mitral Stenosis
- epidemiology
- signs and symptoms
- diagnosis
- pathophysiology
- causes and risk factors
- treatments
- course
- follow-up
- patient education
- community resources
- references
Normal mitral is 4-6 cm2
Epidemiology
2/3 of people with mitral stenosis are female.
Signs and Symptoms
- dyspnea (#1 complaint)
- exercise intolerance
- cough, hemoptysis
- fatigue
- orthopnea, PND
- syncope
- palpitations
- peripheral edema
- hoarseness (enlarged LA pressing on recurrent laryngeal nerve)
palpation
- low pulse volume
- tapping apex with palpable S1
- opening snap
- RV lift
- palpable S2/P2
auscultation
- loud S1 - as loud as S2 in aortic area
- opening snap
- A2 to OS interval inversely proportional to severity
- diastolic murmur
(aka rumble)
- stretches from the opening snap (after S2) to S1, with pre-systolic accentuation (which would disappear in atrial fibrillation)
- in severe mitral stenosis, S1, OS, and rumble may be inaudible
ECG (not very specific)
- LAE: biphasic P waves in V1
- RVH: R waves bigger than S waves in V1 and V2
- premature contractions
- atrial flutter/fibrillation
CXR
- LA enlargement
- pulmonary vascular redistribution
echocardiogram
- smoke in LA visible on ECHO - bad sign
Diagnosis
Echocardiography is diagnostic.
symptoms show up below 2.0 cm2
severity |
opening diameter |
mean gradient (mm Hg) |
mild |
> 1.5 cm2 |
< 5 |
moderate |
1.0 - 1.5 cm2 |
5 - 10 |
severe |
< 1.0 cm2 |
> 10 |
Pathophysiology
Thickening, fibrosis, and calcifiaction of the valves.
Causes and Risk Factors
rheumatic fever, on average 20 years before cardiovascular symtoms, is the primary cause.
rarely congenital.
occasionally due to endocarditis, mitral annular calcification, or rare metabolic or enzymatic problems.
Treatments
diuretics for LHF/RHF
digoxin/betab blockers/CCB for rate control of AF
anticoagulation for thrombus
- often given chronically
- prophylactic ASA
If symptoms persist beyond
balloon valvuloplasty
- only for some people: but can provide effective LT improvement for many
- development of pulmonary hypertension
- ok for people with pliable
- less indicated for people with thrombi
mitral valve replacement
Course
Conditions can worsen with
- pregancy, hyperthyroidism, infection, anemia
- atrial fibrillation or arrhythmia
Complications can include:
- atrial arrhythmiasm especially fibrillation
- systemic embolization (10-25%)
- congestive heart failure
- pulmonary infarcts (ie from CHF)
- hemoptysis
- streaking/pink froth from pulmonary edema or infection
- massive bleeding from ruptured broncial veins due to pulmonary hypertension
Survival is correlated with symptoms.
At 10 years, survival based on NYHA class:
- I: 84%
- II: 42%
- III: 40%
- IV: 0% (42% at one year, 10% at 5 years)
Follow-Up
For people who are asymptomatic, yearly history, physical, ECG, and CXR
Patient Education
Community Resources