Mitral stenosis resident survival guide: Difference between revisions

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{{CMG}}; {{AE}} {{TS}}; {{MM}}; {{AM}}; {{Rim}}


{{CMG}}; {{AE}} {{TS}}; {{MM}}
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{{SK}} Mitral valve stenosis; narrowing of mitral valve
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Mitral Stenosis Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Mitral stenosis resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Mitral stenosis resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Mitral stenosis resident survival guide#Stages|Stages]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Mitral stenosis resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Mitral stenosis resident survival guide#Complete Diagnostic Approach|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Mitral stenosis resident survival guide#Treatment|Treatment]]
: [[Mitral stenosis resident survival guide#Medical Therapy|Medical Therapy]]
: [[Mitral stenosis resident survival guide#Intervention|Intervention]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Mitral stenosis resident survival guide#Secondary Prevention of Rheumatic Fever|Secondary Prevention of Rheumatic Fever]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Mitral stenosis resident survival guide#Do's|Do's]]
|}


==Overview==
==Overview==
[[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]].  The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]].  [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination.  The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].
[[Mitral stenosis]] refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from [[left atrium]] to [[left ventricle]] most commonly as a complication of [[rheumatic fever]].  The most common presentations of [[mitral stenosis]] are [[dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]].  [[Mitral stenosis]] has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination.  The definitive therapy for [[mitral stenosis]] include [[Aortic stenosis valvuloplasty|percutaneous balloon valvotomy]], surgical [[mitral valve repair]], or [[mitral valve replacement]].


==Causes==
==Causes==
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*[[Mitral annular calcification]]
*[[Mitral annular calcification]]
*[[Rheumatic fever]]<ref name="Tadele-2013">{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}</ref>
*[[Rheumatic fever]]<ref name="Tadele-2013">{{Cite journal | last1 = Tadele | first1 = H. | last2 = Mekonnen | first2 = W. | last3 = Tefera | first3 = E. | title = Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients. | journal = BMC Cardiovasc Disord | volume = 13 | issue = 1 | pages = 95 | month = Nov | year = 2013 | doi = 10.1186/1471-2261-13-95 | PMID = 24180350 }}</ref>
==Diagnosis==
 
Shown below is an algorithm summarizing the approach to the initial evluation of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>.<br>
Click '''[[Mitral stenosis causes|here]]''' for the complete list of causes
<span style="font-size:85%">'''Abbreviations:''' '''AF''': atrial fibrillation; '''PMBC''': percutaneous mitral ballon commissurotomy; '''TR''': tricuspid regurgitation; '''S1''': First heart sound; '''P2''': Pulmonary component of second heart sound; '''EKG''': Electrocardiogram; '''TTE''': Transthoracic echocardiography; '''MS''': mitral stenosis </span> <br>
 
==Stages==
Shown below is a table depicting the 4 stages of mitral stenosis, adapted from 2014 AHA/ACC guidelines for management of valvular heart diseases.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>
 
<span style="font-size:85%">'''Abbreviations:''' '''MS: ''' mitral stenosis; '''MVA: '''mitral valve area; '''PASP: ''' pulmonary artery systolic pressure</span>
 
{|Class="wikitable"
|-
|style="background:#DCDCDC;"|'''Stage'''||style="background:#DCDCDC;"|'''Definition'''||style="background:#DCDCDC;"|'''Valve anatomy'''||style="background:#DCDCDC;"|'''Valve hemodynamics'''||style="background:#DCDCDC;"|'''Hemodynamic consequences'''||style="background:#DCDCDC;"|'''Symptoms'''
|-
|'''A'''||At risk of [[MS]]||❑ Mild diastolic doming of mitral valve leaflets||❑ Normal transmitral velocity||Absent||Absent
|-
|'''B'''||Progressive [[MS]]|| ❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of [[mitral valve]]<br>❑ MVA > 1.5 cm<sup>2</sup> (planimetered)||❑ Increased transmitral flow velocities<br>❑ MVA > 1.5 cm<sup>2</sup> <br>❑ Pressure half time during diastole < 150 ms||❑ Mild to moderate [[left atrial]] enlargement<br>❑ Normal pulmonary pressure at rest ||None
|-
|'''C'''||Asymptomatic severe [[MS]]||❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of [[mitral valve]]<br> ❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ MVA ≤ 1 cm<sup>2</sup> in very severe [[MS]]|| ❑ MVA ≤ 1.5 cm<sup>2</sup> (planimetered)<br>❑ MVA ≤ 1 cm<sup>2</sup> (planimetered) in very severe [[MS]]<br>❑ Diastolic pressure half time ≥ 150 ms<br> ❑ Diastolic pressure half time ≥ 220 ms with very severe [[MS]]||❑ Severe [[left atrial]] enlargement<br>❑ PASP > 30 mm Hg||Absent
|-
|'''D'''||Symptomatic severe [[MS]]||❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of [[mitral valve]]<br> ❑ MVA ≤ 1.5 cm<sup>2</sup> (planimetered)||❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ MVA ≤ 1 cm<sup>2</sup> in very severe [[MS]]<br>❑ Diastolic pressure half time ≥ 150 ms<br> ❑ Diastolic pressure half time ≥ 220 ms with very severe [[MS]]||❑ Severe left atrial enlargement<br>❑ PASP > 30 mm Hg||❑ [[Dyspnea]] on exertion<br>❑ Decreased exercise tolerance
|}
 
==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
 
<span style="font-size:85%">Boxes in the red color signify that an urgent management is needed.</span>
 
{{Family tree/start}}
{{familytree  | | | | | | | A00 | | | | | | | | | A00=<div style="width:22em">'''Identify cardinal findings that increase the pretest probability of [[mitral stenosis]]'''</div><br><div style="width:22em; text-align:left">❑ [[Mid diastolic murmur]]
:❑ Low-pitched diastolic rumble
:❑ Associated with an opening snap
:❑ Best heard at the cardiac apex
:❑ Radiating to the [[axilla]]
:❑ Increases with lying down, raising the legs and with exercise
:❑ Decreases with [[valsalva maneuver]] and [[amyl nitrate]] <br>
❑ Reduced [[pulse pressure]]</div> }}
{{familytree  | | | | | | | |!| | | | | | | | | | }}
{{familytree  | | | | | | | A01 | | | | | | | | | | A01= <div style="text-align: left; width: 18em; padding: 1em;">'''Does the patient have any of the following findings of decompensated [[mitral stenosis]] that require urgent management?'''<br>
❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br> ❑ [[Dyspnea|Severe dyspnea]]<br> ❑ [[Loss of consciousness]]<br>❑ [[Chest pain]]<br>❑ Sudden [[weakness]] or [[paralysis]]</div>}}
{{familytree  | | | | |,|-|-|^|-|-|.| | | | |}}
{{familytree  |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | B01 | | | | | B02 | | | |B01={{fontcolor|#F8F8FF|'''Yes'''}}| B02=<div style="text-align: center; background: #FFFFFF; height: 25px; line-height: 25px;">'''No'''</div>}}
{{familytree  | | | | |!| | | | | |!| }}
{{familytree  |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | C01 | | | | | C02 | C01=<div style="padding: 5px; text-align: center; color: #F8F8FF;">What is the complication of [[mitral stenosis|<span style="color:white;">mitral stenosis</span>]] that is causing decompensation?</div>| C02=<div style="text-align: center; background: #FFFFFF; height: 77px; line-height: 30px; padding: 5px;">'''[[Mitral stenosis resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]'''</div> }}
{{familytree  | |,|-|-|+|-|-|-|-|v|-|-|.| | | |}}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| H01| |H02 | | H03 | | H04 | | | | | | | | | H01=<div style=" text-align: center; width:15em">'''[[Stroke|<span style="color:white;">Stroke</span>]]'''</div><br><div style=" text-align: left">❑ Suspect in case of:
:❑ Sudden weakness or [[paralysis|<span style="color:white;">paralysis</span>]] - face, arm or leg<br>
:❑ Speech or visual difficulties<br>
:❑ [[Altered level of consciousness|<span style="color:white;">Altered level of consciousness</span>]] <br>
:❑ Sudden severe [[headache|<span style="color:white;">headache</span>]]<br> </div>|H02=<div style=" text-align: center; width:15em">'''[[Atrial fibrillation|<span style="color:white;">Atrial fibrillation</span>]]'''</div><br><div style=" text-align: left"> ❑ Suspect in case of [[palpitations|<span style="color:white;">palpitations</span>]] <br> ❑ Order an [[ECG|<span style="color:white;">ECG</span>]] immediately looking for
:❑ Irregularly irregular rhythm, and
:❑ Absent [[P waves|<span style="color:white;">P waves</span>]]
</div> |H03= <div style=" text-align: center; width: 15em">[[Pulmonary embolism|<span style="color:white;">'''Pulmonary embolism'''</span>]]</div> <br><div style=" text-align: left"> ❑ Suspect in case of:
:❑ Acute onset of exertional [[dyspnea|<span style="color:white;">dyspnea</span>]] or [[dyspnea|<span style="color:white;">dyspnea</span>]] at rest<br>
:❑ Pleuritic or substernal [[chest pain|<span style="color:white;">chest pain</span>]] <br>
:❑ [[Hemoptysis|<span style="color:white;">Hemoptysis</span>]] <br> </div>|H04=<div style=" text-align: center; width:15em">[[Pulmonary hypertension|<span style="color:white;">'''Pulmonary hypertension'''</span>]] ± '''right sided [[heart failure|<span style="color:white;">heart failure</span>]]'''</div><br> <div style=" text-align: left"> ❑ Suspect in case of severe [[dyspnea|<span style="color:white;">dyspnea</span>]] <br>❑ Increased [[jugular venous pressure|<span style="color:white;">jugular venous pressure</span>]] immediately<br>
❑ [[Hepatomegaly|<span style="color:white;">Hepatomegaly </span>]] ± pulsatile [[liver|<span style="color:white;">liver</span>]]
</div>}}
{{familytree  | |!| | |!| | | | | |!| | |!| | | | }}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| J01| |J02 | | J03 | | J04 | | | | | | | | | J01= <div style=" background: #FA8072; text-align: left; width: 15em">[[Stroke resident survival guide#First Initial Rapid Evaluation of Suspected Stroke|<span style="color:white;"> '''Click here for stroke resident survival guide'''</span>]] </div>| J02= <div style=" background: #FA8072; text-align: left; width: 15em">[[Atrial fibrillation resident survival guide|<span style="color:white;">'''Click here for atrial fibrillation resident survival guide'''</span>]] </div> | J03=<div style=" background: #FA8072; text-align: left; width: 15em">[[Pulmonary embolism resident survival guide|<span style="color:white;">'''Click here for pulmonary embolism resident survival guide'''</span>]] </div>| J04= <div style=" background: #FA8072; text-align: left; width: 15em">[[Pulmonary hypertension resident survival guide|<span style="color:white;">'''Click here for Pulmonary hypertension resident survival guide'''</span>]], or<br>[[Acute heart failure resident survival guide|<span style="color:white;">'''Click here for Acute heart failure resident survival guide'''</span>]] </div>}}
{{familytree  | |L|~|~|A|~|~|V|~|~|A|~|~|J| | |}}
{{familytree  | | | | | | | |:| | | | | | | | |}}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | | G01 | | | | G01= <div style=" background: #FA8072; text-align: left; width: 20em"> {{fontcolor|#F8F8FF| ❑ Treat the complications of [[mitral stenosis|<span style="color:white;">mitral stenosis</span>]] that lead to decompensation <br> ❑ Order a [[TTE|<span style="color:white;">TTE</span>]] to evaluate the severity of the [[mitral stenosis|<span style="color:white;">mitral stenosis</span>]]}}</div>}}
{{familytree  | | | | | | | |!| | }}
{{familytree  | | | | | | | H01 | | | | | | | | | H01=<div style=" background: ; text-align: left; width: 20em"> '''When to consider intervention in [[mitral stenosis]] ?''' <br>
❑ '''[[Mitral stenosis resident survival guide#Treatment|<span style="color:navy;">Continue with the treatment algorithm below</span>]]'''</div> }}
{{Family tree/end}}
 
==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>.<br>
<span style="font-size:85%">'''Abbreviations:''' '''AF''': [[Atrial fibrillation]]; '''[[PMBV|PMBC]]''': Percutaneous mitral ballon commissurotomy; '''TR''': [[Tricuspid regurgitation]]; '''[[S1]]''': First heart sound; '''[[P2]]''': Pulmonary component of second heart sound; '''EKG''': [[Electrocardiogram]]; '''TTE''': [[Transthoracic echocardiography]]; '''MS''': [[Mitral stenosis]] </span> <br>
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br>
{{familytree | | | | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br>
 
❑ History of [[rheumatic fever]]<br>
❑ [[Exercise intolerance]]<br>
❑ [[Exercise intolerance]]<br>
❑ [[Dyspnea on exertion]]<br>
❑ [[Dyspnea on exertion]]<br>
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❑ [[Hemoptysis]]<br>
❑ [[Hemoptysis]]<br>
❑ [[Thromboembolism]]<br>
❑ [[Thromboembolism]]<br>
:❑ [[Stroke]]
:❑ [[Pulmonary embolism]]
❑ [[Respiratory infections]]<br>
❑ [[Respiratory infections]]<br>
❑ [[Fatigue]]<br>
❑ [[Fatigue]]<br>
❑ [[Right heart failure|Right heart failure signs]]:
❑ [[Right heart failure]]</div>}}
: ❑ [[Peripheral edema]]<br>
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
: ❑ [[Ascites]]<br>
{{Family tree| | | | | Y01 | | | | | | | | | | Y01=<div style="float: left; text-align: Left; width:25em ">'''Inquire about past medical history:''' <br>❑ [[Rheumatic fever]] <br> ❑ [[Respiratory infection]] <br> ❑ Congenital [[MS]] </div> }}
: ❑ [[Hepatomegaly]]</div>}}
{{family tree| | | | | |!| | | | | | | | | | | }}
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
 
{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br>
{{familytree | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Examine the patient:'''<br>


'''Appearance of the patient'''<br>
'''Appearance of the patient'''<br>
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:❑ Rhythm<br>
:❑ Rhythm<br>
: ❑ [[Irregularly irregular pulse|Irregularly irregular]] (with onset of [[AF]])<br>
::❑ [[Irregularly irregular pulse|Irregularly irregular]] (suggestive of [[AF]])<br>


:❑ Strength
:❑ Strength
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'''Neck''':<br>
'''Neck''':<br>
❑ [[Jugular venous distension]]<br>
❑ [[Jugular venous distension]]<br>
: ❑ Prominent [[a wave]] in [[right heart failure]]<br>
: ❑ Prominent [[a wave]] (suggestive of [[right heart failure]])<br>
: ❑ Absent [[a wave]] in [[AF]]<br>
: ❑ Absent [[a wave]] (suggestive of [[AF]])<br>
: ❑ Prominent [[v wave]] in [[TR]]<br>
: ❑ Prominent [[v wave]] (suggestive of [[TR]])<br>
 
'''Extremities''': <br>
❑ [[Peripheral edema]] (suggestive of right sided [[heart failure]])<br>
 
'''Abdominal examination''': <br>
❑ [[Ascites]] (suggestive of right sided [[heart failure]])<br>
❑ [[Hepatomegaly]] (suggestive of right sided [[heart failure]])<br>


'''Chest examination''':<br>
'''Cardiovascular examination''':<br>


'''Auscultation'''
'''Auscultation'''
Line 72: Line 166:
❑ Opening snap<br>
❑ Opening snap<br>
❑ [[Murmur]]<br>
❑ [[Murmur]]<br>
: ❑ Most prominent at the apex and best heard using the bell of the stethoscope <br>
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br>
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br>
: ❑ [[Holosystolic murmur]] indicates [[TR]]<br>
: ❑ [[Holosystolic murmur]] (suggestive of [[TR]])<br>
: ❑ [[Graham-Steell murmur]] indicates [[pulmonary regurgitation]]<br>
: ❑ [[Graham-Steell murmur]] (suggestive of [[pulmonary regurgitation]])<br>
{{#ev:youtube|HW2pk1icYdM|250}}<br>
{{#ev:youtube|HW2pk1icYdM|250}}<br>
<SMALL>''Video adapted from Youtube.com''</SMALL><br>
<SMALL>''Video adapted from Youtube.com''</SMALL><br>
❑ [[Rales]]</div>}}
❑ [[Rales]]</div>}}
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:'''
{{familytree | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Order tests:''' <br>
❑ [[Transthoracic echocardiography]] <br>
:❑ Assess valve area<br>
:❑ Assess disease of other valves <br>
:❑ Assess mean [[pressure gradient]]<br>
:❑ Assess [[pulmonary artery]] pressure<br>
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br>


❑ Exercise testing with [[Doppler]] or invasive hemodynamic assessment in case of discrepancy between resting Doppler echocardiographic findings and clinical symptoms or signs
:❑ Assess the response of the mean mitral gradient
:❑ Assess the pulmonary artery pressure


Perform [[EKG]]<br>
❑ [[EKG]]<br>
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br>
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br>
::❑ Broad, bifid P wave in lead II (P mitrale)<br>
::❑ Broad, bifid [[P wave]] in lead II (P mitrale)<br>
[[Image:P mitrale.gif|200px]]<br>
[[Image:P mitrale.gif|200px]]<br>
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br>
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br>
::❑ Biphasic P wave with terminal negative portion<br>
::❑ Biphasic [[P wave]] with terminal negative portion<br>
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br>
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br>
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br>
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br>
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::❑ [[Right axis deviation]] of +90 degrees or more
::❑ [[Right axis deviation]] of +90 degrees or more
::❑ RV1 = 7 mm or more
::❑ RV1 + SV5 or SV6 = 10 mm or more
::❑ R/S ratio in V1 = 1.0 or more
::❑ S/R ratio in V6 = 1.0 or more
::❑ Incomplete [[RBBB]] pattern
::❑ Incomplete [[RBBB]] pattern
::❑ ST T strain pattern in leads 2,3,aVF
::❑ ST T strain pattern in leads 2,3,aVF
::❑ [[P pulmonale]] or [[right atrial enlargement]] or P congenitale
::❑ [[P pulmonale]] or [[right atrial enlargement]] or P congenitale
::❑ R wave progression reversal
::❑ Inverted [[T wave]] in the anterior precordial leads <br>
::❑ Inverted [[T wave]] in the anterior precordial leads
''Click [[Electrocardiographic findings in right ventricular hypertrophy|here]] for the rest of the EKG findings in right ventricular hypertrophy''


:❑ [[Right axis deviation]]<br>
:❑ [[Right axis deviation]]<br>
::❑ [[QRS complex]] is positive in leads III and aVF<br>
::❑ [[QRS complex]] is positive in leads III and aVF<br>
::❑ [[QRS complex]] is negative in leads I and aVL<br>
::❑ [[QRS complex]] is negative in leads I and aVL<br>
''Shown below an [[ECG]] depicting [[right axis deviation]]'' <br>
[[File:De-Rightaxis.jpg|200px]]<br>
[[File:De-Rightaxis.jpg|200px]]<br>


:❑ [[Atrial fibrillation]]<br>
:❑ [[Atrial fibrillation]]<br>
::❑ Absence of [[P waves]]<br>
::❑ Absence of [[P waves]]<br>
::❑ Irregularly irregular [[heart rate]]<br>
::❑ Irregularly irregular [[heart rate]]<br>
''Shown below an [[ECG]] depicting [[atrial fibrillation]]'' <br>
[[Image:AFIB_06.jpg|200px]]<br>
[[Image:AFIB_06.jpg|200px]]<br>
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br>
<SMALL>''Picture adapted from Wikidoc.org''</SMALL><br>


Perform [[chest X-ray]]<br>
❑ [[Chest X-ray]]<br>
:❑ Double right heart border (suggestive of [[left atrial hypertrophy]])
:❑ Double right heart border (suggestive of [[left atrial hypertrophy]])
:❑ Prominent pulmonary artery
:❑ Prominent [[pulmonary artery]]
:❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])
:❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]])
[[File:M.S chest X-ray.jpg|200px]]<br>
[[File:M.S chest X-ray.jpg|200px]]<br>
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br>
<SMALL>''Picture adapted from Radiopedia.org''</SMALL><br>
❑ Perform [[transthoracic echocardiography]]
:❑ Assess valve area<br>
:❑ Assess disease of other valves <br>
:❑ Assess mean pressure gradient<br>
:❑ Assess pulmonary artery pressure<br>
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br>
</div>}}
</div>}}


{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | E01 | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Consider alternative diagnosis:'''<br>
{{Family tree | | | | | Z01 | | | | | | | | | | Z01=<div style="float: left; text-align: left; width:25em "> '''Classify [[mitral stenosis]] based on the following findings on [[TTE]]:'''<br> Valve anatomy <br> ❑ Valve hemodynamics gradient <br> ❑ Hemodynamic consequences</div>}}
[[Myxoma]]
{{Family tree | |,|-|-|-|+|-|-|v|-|-|-|.| | | | | |}}
:❑ Obstruct the mitral orifice
{{Family tree |C01 | | C02 | |C03 | | C04| | | | |C01=<div style="float: left; text-align: center; width:15em">'''[[Mitral stenosis resident survival guide#Classification|Stage A]]'''</div>|C02=<div style="float: left; text-align: center; width:25em">'''[[Mitral stenosis resident survival guide#Classification|Stage B]]'''</div>|C03=<div style="float: left; text-align: center; width:15em">'''[[Mitral stenosis resident survival guide#Classification|Stage C]]'''</div>|C04=<div style="float: left; text-align: center; width:15em">'''[[Mitral stenosis resident survival guide#Classification|Stage D]]'''</div>}}
:❑ Exclude with echocardiography
[[Atrial fibrillation]]
:❑ Order echocardiography to exclude [[mitral stenosis]]
</div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Treatment==
The filling of the [[left ventricle]] depends upon the [[diastole]] time which is limited by [[mitral stenosis]].  Therefore, slowing the [[heart rate]] is crucial in the initial management of [[mitral stenosis]] in order to improve the diastole time and consequently improve the filling of the [[left ventricle]].
===Medical Therapy===
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree/start}}
{{familytree | | F01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F01=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Medical therapy'''<br>
{{Family tree | A01 | | A01=<div style="float: left; text-align: left; padding:1em;">
❑ Consider [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] in [[MS]] patients with:<br>
'''Treatment of Acute Decompensation'''<br>
: ❑ Normal [[sinus rhythm]] and symptoms present on exercise<br>
❑ Digoxin <br>
: ❑ [[AF]] and fast ventricular response<br>
In the following cases:<br>
Consider [[anticoagulation therapy]] in [[MS]] patients with:<br>
:❑ Symptomatic [[right ventricular]] or [[left ventricular]] dysfunction ([[digitalis]] increases [[myocardial]] contractility)
: ❑ [[AF]]<br>
:❑ [[Atrial fibrillation]] ([[digitalis]] slows the ventricular response which prolongs the diastolic filling time)<ref name="pmid11907022">{{cite journal| author=Boon NA, Bloomfield P| title=The medical management of valvar heart disease. | journal=Heart | year= 2002 | volume= 87 | issue= 4 | pages= 395-400 | pmid=11907022 | doi= | pmc=PMC1767079 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11907022 }} </ref>
: ❑ Prior embolic event<br>
❑ Diuretics (In the following cases fluid overload)<br>
: ❑ [[Left atrial thrombus]] </div> }}
❑ Low sodium diet <br>
{{familytree/end}}
❑ Activity restriction <br>
 
 
'''Systemic Embolization Prevention'''<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref> <br>
In the following cases:<br>
❑ Paroxysmal, persistent, or permanent [[atrial fibrillation]] ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence B]]) <br>
❑ Prior [[embolization]] event ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence B]]) <br>
❑ [[Left atrial]] thrombus ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence B]]) <br>
 
 
'''Rate Control'''<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref><br>
In the following cases:<br>
❑ [[Atrial fibrillation]] associated with fast ventricular response ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa, Level of Evidence C]])
❑ Normal [[sinus rhythm]] plus symptoms associated with exercise ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb, Level of Evidence B]]) </div>}}
{{Family tree/end}}
 
===Intervention===
Shown below is an algorithm depicting the indications for mitral stenosis intervention according to the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>
 
<span style="font-size:85%">'''Abbreviations:''' '''AF''': [[atrial fibrillation]]; '''MR:''' [[mitral regurgitation]]; '''MS:''' [[mitral stenosis]]; '''MVA:''' mitral valve area ; '''PCWP:''' [[pulmonary capillary wedge pressure]]; '''PMBC:''' [[percutaneous mitral balloon commissurotomy]]; '''T<sub>1/2</sub>:''' pressure half-time</span>
{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 8em; padding:1em;">'''Determine the severity of rheumatic [[mitral stenosis]] (MS)'''</div>}}
{{Family tree | | | | | | | | |,|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | }}
{{Family tree | | | | | | | | B01 | | | | | | | | B02 | | | | | | | | | | | B03 | | | B01= <div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe MS''' <br> ❑ MVA ≤1 cm2 <br> ❑ T<sub>1/2</sub> ≥220 ms </div>| B02=  <div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe MS''' <br> ❑ MVA ≤1.5 cm2 <br> ❑ T<sub>1/2</sub> ≥150 ms </div>| B03= <div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive MS''' <br> MVA >1.5 cm2 <br> T<sub>1/2</sub> <150 ms </div>}}
{{Family tree | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | | B04 | | | | | | | | B05 | | | | | | | | | | | B06 | B04= <div style="float: left; text-align: left; width: 8em; padding:1em;">Is the patient symptomatic? </div>| B05= <div style="float: left; text-align: left; width: 8em; padding:1em;">Is the patient symptomatic?</div>| B06=<div style="float: left; text-align: left; width: 8em; padding:1em;">Is the patient symptomatic? </div>}}
{{Family tree | | | |,|-|-|-|-|^|-|-|.| |,|-|-|-|-|^|-|-|-|-|-|-|.| | | | | |!| | | | }}
{{Family tree | | | C01 | | | | | | | C02 | | | | | | | | | | | C03 | | | | C04 | | | C01= No <br> ([[Mitral stenosis resident survival guide#Classification| Stage C]])| C02= Yes <br> ([[Mitral stenosis resident survival guide#Classification|Stage D]])| C03= No <br> ([[Mitral stenosis resident survival guide#Classification|Stage C]])| C04= <div style="float: left; text-align: left; width: 8em; padding:1em;">Yes <br> With no other cause for the symptoms </div>}}
{{Family tree | | | |!| | | | | | | | |!| | | | | | | | | | | | |!| | | | | |!| | | | }}
{{Family tree | | | D01 | | | | | | | D02 | | | | | | | | | | | |!| | | | | |!| | | | D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">Does the patient have: <br> Favorable valve morphology <br> ''AND'' <br>❑ No [[left atrial]] clot <br> ''AND'' <br>❑ No or mild [[MR]] </div>| D02= <div style="float: left; text-align: left; width: 8em; padding:1em;">Does the patient have: <br> Favorable valve morphology <br> ''AND'' <br>❑ No [[left atrial]] clot <br> ''AND'' <br> ❑ No or mild [[MR]] </div>}}
{{Family tree | | | |!| | | | | | | | |!| | | | | | | | | | | | |!| | | | | |!| | | | }}
{{Family tree | | | |!| | | | | | | | |!| | | | | | | | | | | | D03 | | | | D04 | | | | D03= <div style="float: left; text-align: left; width: 8em; padding:1em;">Is there a new onset of [[AF]]? </div>| D04= <div style="float: left; text-align: left; width: 8em; padding:1em;">Order an exercise treadmill test </div>}}
{{Family tree | |,|-|^|-|.| | | |,|-|-|^|-|-|.| | | | | | | |,|-|^|-|.| | | |!| | | | }}
{{Family tree | E01 | | E02 | | E03 | | | | E04 | | | | | | E05 | | E06 | | E07 | | | E01= No| E02= Yes| E03= Yes| E04= No| E05= Yes| E06= No| E07= Is [[PCWP]]> 25 mm Hg?}}
{{Family tree | |!| | | |!| | | |!| | | | | |!| | | | | | | |!| | | |!| |,|-|^|-|.| | }}
{{Family tree | |!| | | |!| | | |!| | | | | F01 | | | | | | F02 | | |!| |!| | | |!| F01= <div style="float: left; text-align: left; width: 8em; padding:1em;">Does the patient have: <br> ❑ [[NYHA class]] III-IV symptoms <br> ''AND'' <br> ❑ High surgical risk </div>| F02= <div style="float: left; text-align: left; width: 8em; padding:1em;">Does the patient have: <br> Favorable valve morphology <br> ''AND'' <br>❑ No [[left atrial]] clot <br> ''AND'' <br>❑ No or mild [[MR]] </div>}}
{{Family tree | |!| | | |!| | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| |!| |!| | | |!| | }}
{{Family tree | |!| | | |!| | | |!| | | G01 | | G02 | | G03 | | G04 |!| G05 | | G06 | | G01= No| G02= Yes| G03= Yes| G04= No| G05= Yes| G06= No}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | |!| |!| | | | |!| |!| |!| | | |!| | }}
{{Family tree | H01 | | H02 | | H03 | | H04 | | | | H05 | | | | | H06 | | H07 | | H08 | H01= Periodic monitoring| H02= [[PMBC]] (Class IIa)| H03= [[PMBC]] (Class I)| H04= Mitral valve surgery (Class I)| H05= [[PMBC]] (Class IIb)| H06= Periodic monitoring| H07= [[PMBC]] (Class IIb)| H08= Periodic monitoring}}
{{Familytree/end}}


Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><br>
==Secondary Prevention of Rheumatic Fever==
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br>
===Indications===
{{familytree/start |summary=PE diagnosis Algorithm.}}
Shown below is the table depicting the indication for secondary prophylaxis of [[rheumatic fever]].<ref name="pmid19246689">{{cite journal| author=Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST et al.| title=Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. | journal=Circulation | year= 2009 | volume= 119 | issue= 11 | pages= 1541-51 | pmid=19246689 | doi=10.1161/CIRCULATIONAHA.109.191959 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19246689 }} </ref>
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |A01= ❑ '''Assess the presence of symptoms'''}}
{{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | }}
{{familytree | | | | | | B01 | | | | | | | | | | | | | | | | B02 | | | | | | | | | | | |B01='''Symptomatic'''|B02='''Asymptomatic'''}}
{{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}
{{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}
{{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if the new onset [[AF]] is present</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}
{{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}
{{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess [[PCWP]] on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}
{{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}
{{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;"> '''If patient is severely symptomatic ([[NYHA class|NYHA III/IV]]):'''<br>❑ Assess the surgical risk of patient</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically  </div>|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess if the valve morphology is favorable for [[PMBV|PMBC]]|F07=❑ Monitor patient periodically}}
{{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}
{{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=Yes|G04= No}}
{{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}
{{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}


==Rheumatic Fever Prophylaxis==
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:<ref name="pmid24589853">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589853 | doi=10.1161/CIR.0000000000000031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589853  }} </ref>
{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center; colspan="2"| {{fontcolor|#FFF|Secondary prevention of rheumatic fever}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Penicillin G benzathine]]''''' ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''1.2 million units IM every day for 4 weeks'''''
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Duration of prophylaxis'''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Penicillin V potassium]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''200 mg orally twice a day'''''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''''[[Rheumatic fever]] with [[carditis]] and persistent [[valvular heart disease]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)''''' ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence C]])
|-
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Sulfadiazine]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''1 g orally once a day'''''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''''[[Rheumatic fever]] with [[carditis]] but no [[valvular heart disease]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)''''' ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence C]])
|-
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Macrolide]] antibiotics (in patients allergic to [[penicillin]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Varies'''''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)''''' ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence C]])
|-
|-
|}
|}
|}
 
<br>
===Antibiotic Regimens===
Shown below is the table depicting the antibiotic regimens for secondary prophylaxis of [[rheumatic fever]].<ref name="pmid19246689">{{cite journal| author=Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST et al.| title=Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. | journal=Circulation | year= 2009 | volume= 119 | issue= 11 | pages= 1541-51 | pmid=19246689 | doi=10.1161/CIRCULATIONAHA.109.191959 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19246689  }} </ref>
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
|-
| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Indications'''|| style="padding: 0 5px; font-size: 100%; background: #DCDCDC;" align=center | '''Duration of prophylaxis'''
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Antibiotics'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Dosage'''
|-
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''''[[Penicillin G benzathine]]''''' <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence A]])||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left| ▸ '''''Weight >27 Kg (60 lb): 1.2 million units IM every day for 4 weeks'''''<br>▸ '''''Weight ≤27 Kg (60 lb): 600,000 units IM every day for 4 weeks'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | '''''[[Rheumatic fever]] with [[carditis]] and persistent valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 40 years (whichever is longer)'''''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''''[[Penicillin V]]''''' <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence B]])|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |▸ '''''200 mg orally twice a day'''''
|-
|-
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | '''''[[Rheumatic fever]] with [[carditis]] but no valvular heart disease || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''10 years or until the patient is 21 years (whichever is longer)'''''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left|'''''[[Sulfadiazine]]''''' <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence B]])|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left|▸ '''''Weight >27 Kg (60 lb): 1 g orally once a day''''' <br> ▸ '''''Weight ≤27 Kg (60 lb): o.5 g orally once a day'''''
|-
|-
|style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | '''''[[Rheumatic fever]] without [[carditis]] || style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |▸ '''''5 years or until the patient is 21 years (whichever is longer)'''''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left|'''''[[Macrolide]] or [[azalide]] antibiotics (in patients allergic to [[penicillin]])''''' <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of Evidence C]])|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left|▸ '''''Varies'''''
|-
|-
|}
|}


==Do's==
==Do's==
* Perform [[transesophageal echocardiography]] (TEE) in patients considered for [[PMBV|PMBC]] to rule out left atrial thrombus and to determine [[mitral regurgitation]] severity.
* Perform [[transesophageal echocardiography]] ([[TEE]]) in patients considered for [[PMBV|PMBC]] to rule out left atrial [[thrombus]] and to determine [[mitral regurgitation]] severity.
* Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.
* Perform [[exercise testing]] or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with [[echocardiographic]] findings.
* Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis, if patient is undergoing cardiac surgery for some other indication.
* Perform [[mitral valve surgery]] in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] [[mitral stenosis]], if patient is undergoing cardiac surgery for some other indication.
* Perform [[mitral valve surgery]] in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm<sup>2</sup>) if the patient is undergoing cardiac surgery for other indications.
* Perform [[mitral valve surgery]] in moderate [[mitral stenosis]] (mitral valve area: 1.6 - 2 cm<sup>2</sup>) if the patient is undergoing cardiac surgery for other indications.
* Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] mitral stenosis patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].
* Perform [[mitral valve surgery]] with excision of left atrial appendage in [[Mitral stenosis stages|stage C]] and [[Mitral stenosis stages|stage D]] [[mitral stenosis]] patients who have had recurrent embolic events despite being on [[anticoagulation therapy]].
* Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm<sup>2</sup> .
* Perform [[TTE]] every 3-5 years in asymptomatic [[Mitral stenosis stages|stage B]] [[MS]] patients and every 1-2 years in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area 1-1.5 cm<sup>2</sup> .
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.
* Perform [[TTE]] once every year in asymptomatic [[Mitral stenosis stages|stage C]] [[MS]] patients who have mitral valve area < 1 cm<sup>2</sup>.
* In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].
* In cases of senile calcific [[mitral stenosis]], intervention is done only when symptoms are severe and cannot be controlled with [[Atrial fibrillation resident survival guide#Heart rate control|heart rate control]] and [[diuretics]].


==References==
==References==
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</div>

Latest revision as of 22:36, 22 July 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]; Mohamed Moubarak, M.D. [3]; Amr Marawan, M.D. [4]; Rim Halaby, M.D. [5]

Mitral Stenosis Resident Survival Guide Microchapters
Overview
Causes
Stages
FIRE
Diagnosis
Treatment
Medical Therapy
Intervention
Secondary Prevention of Rheumatic Fever
Do's

Overview

Mitral stenosis refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from left atrium to left ventricle most commonly as a complication of rheumatic fever. The most common presentations of mitral stenosis are dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. Mitral stenosis has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for mitral stenosis include percutaneous balloon valvotomy, surgical mitral valve repair, or mitral valve replacement.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Click here for the complete list of causes

Stages

Shown below is a table depicting the 4 stages of mitral stenosis, adapted from 2014 AHA/ACC guidelines for management of valvular heart diseases.[2]

Abbreviations: MS: mitral stenosis; MVA: mitral valve area; PASP: pulmonary artery systolic pressure

Stage Definition Valve anatomy Valve hemodynamics Hemodynamic consequences Symptoms
A At risk of MS ❑ Mild diastolic doming of mitral valve leaflets ❑ Normal transmitral velocity Absent Absent
B Progressive MS ❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of mitral valve
❑ MVA > 1.5 cm2 (planimetered)
❑ Increased transmitral flow velocities
❑ MVA > 1.5 cm2
❑ Pressure half time during diastole < 150 ms
❑ Mild to moderate left atrial enlargement
❑ Normal pulmonary pressure at rest
None
C Asymptomatic severe MS ❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of mitral valve
❑ MVA ≤ 1.5 cm2
❑ MVA ≤ 1 cm2 in very severe MS
❑ MVA ≤ 1.5 cm2 (planimetered)
❑ MVA ≤ 1 cm2 (planimetered) in very severe MS
❑ Diastolic pressure half time ≥ 150 ms
❑ Diastolic pressure half time ≥ 220 ms with very severe MS
❑ Severe left atrial enlargement
❑ PASP > 30 mm Hg
Absent
D Symptomatic severe MS ❑ Rheumatic valve changes characterized by commissural fusion and diastolic doming of mitral valve
❑ MVA ≤ 1.5 cm2 (planimetered)
❑ MVA ≤ 1.5 cm2
❑ MVA ≤ 1 cm2 in very severe MS
❑ Diastolic pressure half time ≥ 150 ms
❑ Diastolic pressure half time ≥ 220 ms with very severe MS
❑ Severe left atrial enlargement
❑ PASP > 30 mm Hg
Dyspnea on exertion
❑ Decreased exercise tolerance

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the red color signify that an urgent management is needed.

 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of mitral stenosis

Mid diastolic murmur
❑ Low-pitched diastolic rumble
❑ Associated with an opening snap
❑ Best heard at the cardiac apex
❑ Radiating to the axilla
❑ Increases with lying down, raising the legs and with exercise
❑ Decreases with valsalva maneuver and amyl nitrate
❑ Reduced pulse pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings of decompensated mitral stenosis that require urgent management?
Tachycardia
Hypotension
Severe dyspnea
Loss of consciousness
Chest pain
❑ Sudden weakness or paralysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the complication of mitral stenosis that is causing decompensation?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Suspect in case of:
❑ Sudden weakness or paralysis - face, arm or leg
❑ Speech or visual difficulties
Altered level of consciousness
❑ Sudden severe headache
 

❑ Suspect in case of palpitations
❑ Order an ECG immediately looking for
❑ Irregularly irregular rhythm, and
❑ Absent P waves
 

❑ Suspect in case of:
❑ Acute onset of exertional dyspnea or dyspnea at rest
❑ Pleuritic or substernal chest pain
Hemoptysis
 

❑ Suspect in case of severe dyspnea
❑ Increased jugular venous pressure immediately

Hepatomegaly ± pulsatile liver

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat the complications of mitral stenosis that lead to decompensation
❑ Order a TTE to evaluate the severity of the mitral stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
When to consider intervention in mitral stenosis ?
Continue with the treatment algorithm below
 
 
 
 
 
 
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2].
Abbreviations: AF: Atrial fibrillation; PMBC: Percutaneous mitral ballon commissurotomy; TR: Tricuspid regurgitation; S1: First heart sound; P2: Pulmonary component of second heart sound; EKG: Electrocardiogram; TTE: Transthoracic echocardiography; MS: Mitral stenosis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about past medical history:
Rheumatic fever
Respiratory infection
❑ Congenital MS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Appearance of the patient
❑ Plethoric cheeks with bluish patches

Vital signs

Pulse

❑ Rate
Tachycardia
❑ Rhythm
Irregularly irregular (suggestive of AF)
❑ Strength
❑ Reduced pulse pressure
❑ Reduced in volume

Neck:
Jugular venous distension

❑ Prominent a wave (suggestive of right heart failure)
❑ Absent a wave (suggestive of AF)
❑ Prominent v wave (suggestive of TR)

Extremities:
Peripheral edema (suggestive of right sided heart failure)

Abdominal examination:
Ascites (suggestive of right sided heart failure)
Hepatomegaly (suggestive of right sided heart failure)

Cardiovascular examination:

Auscultation
❑ Left parasternal heave
❑ Loud S1
❑ Loud P2 (indicates pulmonary hypertension)
❑ Opening snap
Murmur

❑ Most prominent at the apex and best heard using the bell of the stethoscope
Mid diastolic murmur (low pitched, rumbling)
Holosystolic murmur (suggestive of TR)
Graham-Steell murmur (suggestive of pulmonary regurgitation)

{{#ev:youtube|HW2pk1icYdM|250}}
Video adapted from Youtube.com

Rales
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

Transthoracic echocardiography

❑ Assess valve area
❑ Assess disease of other valves
❑ Assess mean pressure gradient
❑ Assess pulmonary artery pressure
❑ Assess suitability of valve morphology for PMBC

❑ Exercise testing with Doppler or invasive hemodynamic assessment in case of discrepancy between resting Doppler echocardiographic findings and clinical symptoms or signs

❑ Assess the response of the mean mitral gradient
❑ Assess the pulmonary artery pressure

EKG

Left atrial enlargement
❑ Broad, bifid P wave in lead II (P mitrale)


Picture adapted from en.ecgpedia.org

❑ Biphasic P wave with terminal negative portion

Left atrial enlargement as seen in lead V1
Picture adapted from en.ecgpedia.org

Right ventricular hypertrophy
Right axis deviation of +90 degrees or more
❑ Incomplete RBBB pattern
❑ ST T strain pattern in leads 2,3,aVF
P pulmonale or right atrial enlargement or P congenitale
❑ Inverted T wave in the anterior precordial leads

Click here for the rest of the EKG findings in right ventricular hypertrophy

Right axis deviation
QRS complex is positive in leads III and aVF
QRS complex is negative in leads I and aVL

Shown below an ECG depicting right axis deviation

Atrial fibrillation
❑ Absence of P waves
❑ Irregularly irregular heart rate

Shown below an ECG depicting atrial fibrillation

Picture adapted from Wikidoc.org

Chest X-ray

❑ Double right heart border (suggestive of left atrial hypertrophy)
❑ Prominent pulmonary artery
Kerley lines (suggestive of interstitial pulmonary edema)


Picture adapted from Radiopedia.org

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify mitral stenosis based on the following findings on TTE:
❑ Valve anatomy
❑ Valve hemodynamics gradient
❑ Hemodynamic consequences
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Medical Therapy

Treatment of Acute Decompensation
❑ Digoxin
In the following cases:

❑ Symptomatic right ventricular or left ventricular dysfunction (digitalis increases myocardial contractility)
Atrial fibrillation (digitalis slows the ventricular response which prolongs the diastolic filling time)[3]

❑ Diuretics (In the following cases fluid overload)
❑ Low sodium diet
❑ Activity restriction


Systemic Embolization Prevention[2]
In the following cases:
❑ Paroxysmal, persistent, or permanent atrial fibrillation (Class I, Level of Evidence B)
❑ Prior embolization event (Class I, Level of Evidence B)
Left atrial thrombus (Class I, Level of Evidence B)


Rate Control[2]
In the following cases:
Atrial fibrillation associated with fast ventricular response (Class IIa, Level of Evidence C)

❑ Normal sinus rhythm plus symptoms associated with exercise (Class IIb, Level of Evidence B)
 

Intervention

Shown below is an algorithm depicting the indications for mitral stenosis intervention according to the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.[2]

Abbreviations: AF: atrial fibrillation; MR: mitral regurgitation; MS: mitral stenosis; MVA: mitral valve area ; PCWP: pulmonary capillary wedge pressure; PMBC: percutaneous mitral balloon commissurotomy; T1/2: pressure half-time

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the severity of rheumatic mitral stenosis (MS)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Very severe MS
❑ MVA ≤1 cm2
❑ T1/2 ≥220 ms
 
 
 
 
 
 
 
Severe MS
❑ MVA ≤1.5 cm2
❑ T1/2 ≥150 ms
 
 
 
 
 
 
 
 
 
 
Progressive MS
MVA >1.5 cm2
T1/2 <150 ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
( Stage C)
 
 
 
 
 
 
Yes
(Stage D)
 
 
 
 
 
 
 
 
 
 
No
(Stage C)
 
 
 
Yes
With no other cause for the symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have:
❑ Favorable valve morphology
AND
❑ No left atrial clot
AND
❑ No or mild MR
 
 
 
 
 
 
Does the patient have:
❑ Favorable valve morphology
AND
❑ No left atrial clot
AND
❑ No or mild MR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is there a new onset of AF?
 
 
 
Order an exercise treadmill test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
Yes
 
 
 
No
 
 
 
 
 
Yes
 
No
 
Is PCWP> 25 mm Hg?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have:
NYHA class III-IV symptoms
AND
❑ High surgical risk
 
 
 
 
 
Does the patient have:
❑ Favorable valve morphology
AND
❑ No left atrial clot
AND
❑ No or mild MR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
Yes
 
No
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Periodic monitoring
 
PMBC (Class IIa)
 
PMBC (Class I)
 
Mitral valve surgery (Class I)
 
 
 
PMBC (Class IIb)
 
 
 
 
Periodic monitoring
 
PMBC (Class IIb)
 
Periodic monitoring

Secondary Prevention of Rheumatic Fever

Indications

Shown below is the table depicting the indication for secondary prophylaxis of rheumatic fever.[4]

Indications Duration of prophylaxis
Rheumatic fever with carditis and persistent valvular heart disease 10 years or until the patient is 40 years (whichever is longer) (Class I, Level of Evidence C)
Rheumatic fever with carditis but no valvular heart disease 10 years or until the patient is 21 years (whichever is longer) (Class I, Level of Evidence C)
Rheumatic fever without carditis 5 years or until the patient is 21 years (whichever is longer) (Class I, Level of Evidence C)

Antibiotic Regimens

Shown below is the table depicting the antibiotic regimens for secondary prophylaxis of rheumatic fever.[4]

Antibiotics Dosage
Penicillin G benzathine
(Class I, Level of Evidence A)
Weight >27 Kg (60 lb): 1.2 million units IM every day for 4 weeks
Weight ≤27 Kg (60 lb): 600,000 units IM every day for 4 weeks
Penicillin V
(Class I, Level of Evidence B)
200 mg orally twice a day
Sulfadiazine
(Class I, Level of Evidence B)
Weight >27 Kg (60 lb): 1 g orally once a day
Weight ≤27 Kg (60 lb): o.5 g orally once a day
Macrolide or azalide antibiotics (in patients allergic to penicillin)
(Class I, Level of Evidence C)
Varies

Do's

References

  1. Tadele, H.; Mekonnen, W.; Tefera, E. (2013). "Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients". BMC Cardiovasc Disord. 13 (1): 95. doi:10.1186/1471-2261-13-95. PMID 24180350. Unknown parameter |month= ignored (help)
  2. 2.0 2.1 2.2 2.3 2.4 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
  3. Boon NA, Bloomfield P (2002). "The medical management of valvar heart disease". Heart. 87 (4): 395–400. PMC 1767079. PMID 11907022.
  4. 4.0 4.1 Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST; et al. (2009). "Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics". Circulation. 119 (11): 1541–51. doi:10.1161/CIRCULATIONAHA.109.191959. PMID 19246689.


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