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MITRAL STENOSIS (Case based & Evidence based)
1. Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases(NICVD),
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branch
Honorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi
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2. Case 1
A 52-year-old woman presents with gradually increasing
dyspnoea on exertion over the past 2 years.
Recently she has required 2 pillows at night to alleviate
recumbent dyspnoea.
On examination, she has an apical diastolic murmur.
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3. Case 2
A 36-year-old prima gravida presents with dyspnoea
on exertion and 2 pillow orthopnoea during her
second trimester.
Previous physical examinations had disclosed no
cardiac abnormalities.
On current physical examination, she has a loud S1
and a 2/6 diastolic rumble.
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4. Case 3
A 35 year old lady complained of progressive exertional
shortness of breath in the past two years.
Physical examination revealed a loud first heart
sound, an opening snap and a mid diastolic rumbling
murmur with an irregularly irregular pulse.
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5. Case 4
A 75 year old male with emphysema presents with
increasing dyspnea.
He is noted to have a II/IV diastolic murmur after an
opening snap at the cardiac apex.
An echocardiogram shows thickening of the mitral leaflet
tips and a “hockey stick” appearance of the anterior mitral
leaflet.
The mean pressure gradient across the mitral valve is 7
mmHg and the mitral valve area is 1.2 cm2.
What is the degree of mitral stenosis present?
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6. Case 5
A 25-year-old female who is 33 weeks into her
pregnancy is becoming increasingly short of breath
with some lower extremity edema.
She is afebrile with a heart rate of 110 beats per minute,
respirations 20 per minute and blood pressure 100/60
mm Hg.
Physical examination reveals a II/IV early diastolic
decrescendo murmur at the cardiac apex.
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7. Case 6
2. A 32 year old male presents with dyspnea and
hemoptysis.
He is afebrile, heart rate 100 beats per minute, blood
pressure 120/80, and respirations 22/min.
His cardiac physical examination reveals a soft, II/IV early
diastolic murmur at the cardiac apex.
A bronchoscopy is negative for any lesion or malignancy
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8. Case 7
A 45 year old female presents with dyspnea with a moderate
amount of exertion.
She can walk up two flights of stairs or two blocks before having to
rest which is new for her (New York Heart Association functional
class II).
She has no lower extremity edema, paroxysmal nocturnal dyspnea
or orthopnea.
Physical examination reveals a loud S1 heart sound and an mid-
diastolic decrescendo murmur at the cardiac apex after an opening
snap which has a late-systolic accentuation.
A treadmill exercise echocardiogram is performed and her
pulmonary artery systolic pressure increases to 70 mmHg. Her
mitral valve is only mildly thickened and calcified with well
preserved leaflet motion.
The mean pressure gradient across the mitral valve is 4 mmHg.
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16. Aetiology
Almost always rheumatic
in origin
Older people: can be caused
by heavy calcification of
mitral valve
Congenital (rare)
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18. Mitral stenosis
Commonest cause :rheumatic heart disease
Infections with group A beta hemolytic streptococci
More common in women
Inflammation leads to commissural fusion and a
reduction in mitral valve orifice area
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27. To maintain sufficient cardiac
output
1. Left arterial pressure increases
2. Left arterial hypertrophy and dilation
3. Pulmonary veins, pulmonary arterial and R/ heart
pressure increases
4. Increase of pulmonary capillary pressure
5. Followed by development of
pulmonary oedema
Atrial fibrillation with tachycardia
Loss of coordinated atrial contraction
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28. To maintain sufficient cardiac
output
6. This is prevented by (Reactive pulmonary
hypertension)
Alveolar and capillary thickening
Pulmonary arterial vasoconstriction
7. Pulmonary hypertension leads to
R/ ventricular hypertrophy, dilation and failure
with subsequent tricuspid regurgitation
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35. Mitral Stenosis: Physical
Exam
First heart sound (S1) is accentuated & snapping
Opening snap (OS) after aortic valve closure
Low pitch diastolic rumble at the apex
Pre-systolic accentuation (esp. if in sinus rhythm)
S1 S2 OS S1
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36. Signs (Face)
Severe mitral stenosis with pulmonary
hypertension
Mitral fascies / malar rash
Bilateral
Cyanotic or dusky pink
discolouration
Over the upper cheeks
Due to atriovenous anastomosis &
Vascular stasis
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37. Signs (Pulse)
Small volume pulse
Usually regular in early stages,
If the patient is in sinus rhythem
In severe disease, may develop atrial fibrillation
Irregularly irregular pulse
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38. Signs (Jugular Veins)
If R heart failure develops
obvious distension of jugular veins
If pulmonary hypertension or tricuspid stenosis is
present
‘a’ Wave will be prominent
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39. Signs (Palpation)
Tapping impulse felt parasternally on left side
Palpable 1st heart sound
Combined with left ventricular backward displacement
Produced by an enlarging left ventricle
Sustained parasternal impulse
Due to R ventricular hypertrophy
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40. Signs (Auscultation)
Loud 1st heart sound
If the mitral valve is pliable
It will not occur in calcified mitral stenosis
Opening snap
Valve suddenly opens with the force of the increased L
arterial pressure
Low pitched ‘rumbling’ mid diastolic murmur
Best heard with bell held lightly
At the apex with the patient lying on the left side
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42. Signs (Auscultation)
If the patient is in sinus rhythm
Murmur becomes louder at the end of diastole
As a result of atrial contraction
(Pre- systolic accentuation)
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44. How to determine the severity
of mitral stenosis
Presence of pulmonary hypertension
Recognized by R/ ventricular heave & loud
pulmonary component of 2nd heart sound
And signs with R heart failure : Oedema,
hepatomegaly
Graham Steell murmur
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45. How to determine the severity
of mitral stenosis
Closeness of the opening snap to the 2nd heart
sound ∞ severe MS
Length of mid-diastolic murmur ∞ severity
As the valve cusps become immobile
Loud 1st heart sound softens
Opening snap diasppears
When pulmonary hypertension occurs : P2 intensity
increase, mid diastolic murmur become quieter
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48. Investigations
ECG: - right ventricular hypertrophy tall R waves
Chest x-ray: - enlarged LA & appendage
- signs of pulmonary venous congestion
ECHO: - thickened immobile cusps
- reduced valve area
- enlarged LA
- reduced rate of diastolic filling of LV
Doppler: - pressure gradient across mitral valve
Cardiac catheterization: - coronary artery disease
- pulmonary artery pressure
- mitral stenosis and regurgitation
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49. Investigations –X-ray
Small heart with an enlarged L/ atrium
Pulmonary venous hypertension
Calcified mitral valve– on penetrated or lateral
view
Signs of pulmonary oedema or pulmonary
hypertension
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52. Investigations –ECG
Sinus rhythm in ECG shows a bifid P wave
Owing to delayed L/atrial activation
Atrial fibrillation may be present
ECG features of R/ventricular hypertrophy
Right axis deviation
Perhaps tall R wave in lead V1
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55. Investigations –
Echocardiogram
Transthoracic echocardiography
To determine L/ R/ atrial and ventricular size
The sevirity of MS
Transoesophageal Echocardiography (TOE)
To detect the presence of L/ atrial thrombus
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61. Stages of Mitral Stenosis
Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic
Consequences
Symptoms
A At risk of MS Mild valve doming
during diastole
Normal transmitral
flow velocity
None None
B Progressive
MS
Rheumatic valve
changes with
commissural fusion
and diastolic
doming of the
mitral valve leaflets
Planimetered MVA
>1.5 cm2
Increased transmitral
flow velocities
MVA >1.5 cm2
Diastolic pressure
half-time <150 msec
Mild-to-
moderate LA
enlargement
Normal
pulmonary
pressure at rest
None
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62. Stages of Mitral Stenosis
Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic
Consequences
Symptoms
C Asymptomatic
severe MS
Rheumatic valve
changes with
commissural
fusion and
diastolic doming
of the mitral valve
leaflets
Planimetered
MVA ≤1.5 cm2
(MVA ≤1 cm2 with
very severe MS)
MVA ≤1.5 cm2
(MVA ≤1 cm2 with very
severe MS)
Diastolic pressure
half-time ≥150 msec
(Diastolic pressure
half-time ≥220 msec
with very severe MS)
Severe LA
enlargement
Elevated PASP
>30 mm Hg
None
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63. Stages of Mitral Stenosis
Stage Definition Valve Anatomy Valve
Hemodynamics
Hemodynamic
Consequences
Symptoms
D Symptomatic
severe MS
Rheumatic
valve changes
with
commissural
fusion and
diastolic doming
of the mitral
valve leaflets
Planimetered
MVA ≤1.5 cm2
MVA≤1.5 cm2
(MVA ≤1 cm2 with
very severe MS)
Diastolic pressure
half-time ≥150
msec
(Diastolic pressure
half-time ≥220
msec with very
severe MS)
Severe LA
enlargement
Elevated PASP
>30 mm Hg
Decreased
exercise
tolerance
Exertional
dyspnea
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64. Mitral Stenosis: Diagnosis and Follow-Up
Recommendations COR LOE
TTE is indicated in patients with signs or
symptoms of MS to establish the diagnosis,
quantify hemodynamic severity (mean pressure
gradient, mitral valve area, and pulmonary artery
pressure), assess concomitant valvular lesions, and
demonstrate valve morphology (to determine
suitability for mitral commissurotomy)
I B
TEE should be performed in patients considered
for percutaneous mitral balloon commissurotomy
to assess the presence or absence of left atrial
thrombus and to further evaluate the severity of
mitral regurgitation
I B
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65. Mitral Stenosis: Diagnosis and
Follow-Up
Recommendations COR LOE
Exercise testing with Doppler or invasive
hemodynamic assessment is recommended to
evaluate the response of the mean mitral
gradient and pulmonary artery pressure in
patients with MS when there is a discrepancy
between resting Doppler echocardiographic
findings and clinical symptoms or signs
I C
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66. Mitral Stenosis: Medical Therapy
Recommendations COR LOE
Anticoagulation (vitamin K antagonist [VKA] or
heparin) is indicated in patients with 1) MS and
AF (paroxysmal, persistent, or permanent), or 2)
MS and a prior embolic event, or 3) MS and a left
atrial thrombus
I B
Heart rate control can be beneficial in patients
with MS and AF and fast ventricular response
IIa C
Heart rate control may be considered for patients
with MS in normal sinus rhythm and symptoms
associated with exercise
IIb B
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67. Mitral Stenosis: Intervention
Recommendations COR LOE
PMBC is recommended for symptomatic patients
with severe MS (MVA <1.5 cm2, stage D) and
favorable valve morphology in the absence of
contraindications
I A
Mitral valve surgery is indicated in severely
symptomatic patients (NYHA class III/IV) with severe
MS (MVA <1.5 cm2, stage D) who are not high risk
for surgery and who are not candidates for or failed
previous PMBC
I B
Concomitant mitral valve surgery is indicated for
patients with severe MS (MVA ≤1.5 cm2, stages C or
D) undergoing other cardiac surgery
I C
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68. Mitral Stenosis: Intervention (cont.)
Recommendations COR LOE
PMBC is reasonable for asymptomatic patients
with very severe MS (MVA ≤1 cm2, stage C) and
favorable valve morphology in the absence of
contraindications
IIa C
Mitral valve surgery is reasonable for severely
symptomatic patients (NYHA class III/IV) with
severe MS (MVA ≤1.5 cm2, stage D) provided there
are other operative indications
IIa C
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69. Mitral Stenosis: Intervention (cont.)
Recommendations COR LOE
PMBC may be considered for asymptomatic
patients with severe MS (MVA ≤1.5 cm2, stage C)
and favorable valve morphology who have new
onset of AF in the absence of contraindications
IIb C
PMBC may be considered for symptomatic patients
with MVA >1.5 cm2 if there is evidence of
hemodynamically significant MS during exercise
IIb C
PMBC may be considered for severely
symptomatic patients (NYHA class III-IV) with
severe MS (MVA ≤1.5 cm2, stage D) who have
suboptimal valve anatomy and are not candidates
for surgery or at high risk for surgery
IIb C
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70. Mitral Stenosis: Intervention (cont.)
Recommendations COR LOE
Concomitant mitral valve surgery might be
considered for patients with moderate MS (MVA
1.6–2.0 cm2) undergoing other cardiac surgery
IIb C
Mitral valve surgery and excision of the left atrial
appendage may be considered for patients with
severe MS (MVA ≤1.5 cm2, stages C and D) who
have had recurrent embolic events while receiving
adequate anticoagulation
IIb C
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73. Treatment
Need no treatment other than prompt therapy of
attacks of bronchitis
Early symptoms like dyspnea - diuretics
Onset of atrial fibrillation :digoxin, anticoagulants (to
prevent atrial thrombus and systemic embolism)
If pulmonary hypertension or symptoms of pulmonary
congestion : surgical therapy
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76. Treatment: Trans-septal balloon valvotomy
Catheter introduced into R atriam via femoral vein
Under local anasthesia
Inter atrial septum is punctured
Catheter enter into left atrium then to mitral
valve
Balloon is inflated, briefly to split the valve
commissures
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78. Treatment: Trans-septal balloon valvotomy
Complications
Regurgitation may result
Contraindications
Heavy calcification
More than mild mitral regurgitation & thrombus in
the L/atrium
TOE is done before this procedure
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79. Treatment: Closed valvotomy
For the patients with
mobile,
non calcified and
non regurgitant mitral valves
Fused cusps forced apart by a dilator
(introduced through the apex of L/ ventricle)
Cardiopulmonary bypass is not needed for this
operation
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80. Treatment: Open valvotomy
Often preferred to closed valvotomy
Cusps are carefully dissected apart under direct
vision
Cardiopulmonary bypass is requied
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82. Treatment: Mitral valve replacement
It is necessary if
Mitral regurgitation is present
Badly diseased or badly calcified stenotic valve,
Moderate or severe mitral stenosis & thrombus in L
atrium despite anticoagulation
Artificial valve >20 yrs
Anticoagulants are necessary
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