Mitral stenosis general approach to mitral stenosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]

Overview

Mitral stenosis is a valvular disease characterized by a narrowing in the heart valve between the two left chambers of the heart (left atrium and left ventricle).

Pathophysiology

• Commisural fusion is the hallmark anatomic finding in mitral stenosis.
• The narrowing in the mitral valve causes build up of pressures in the left atrium, and eventually in the pulmonary bed.
• The build up of pressures in the pulmonary bed leads to pulmonary hypertension which results in right heart failure.
• The left ventricle is unaffected in pure mitral stenosis.

Causes

The cause of mitral stenosis is almost always rheumatic heart disease.

Differentiating Mitral stenosis from other Diseases

Mitral stenosis should be differentiated from:

• Cor triatriatum
• Atrial myxoma
• Pulmonary vein obstruction

Natural History and Complications

Natural History

Mitral stenosis is intermittently progressive and has a prolonged clinical course before becoming severe.

Complications

Complications occur in the late stages of mitral stenosis. They include:

• Atrial fibrillation
• Pulmonary hypertension
• Right heart failure
• Stroke - due to thrombus formation in the left atrium

Diagnosis

Symptoms

Symptoms of mitral stenosis occur late in the course of the disease as the disease progresses slowly over decades. Common symptoms include:

• Dyspnea
• Paroxysmal nocturnal dyspnea
• Orthopnea
• Hemoptysis
• Palpitations
• Emboli

Physical Examination

• A high pitched additional sound called opening snap (OS) may be heard after the A₂ component of S₂ and it signifies the forceful opening of the mitral valve.
• The S₂ - OS interval determines the severity of mitral stenosis.
  • Mild: >110 msec
  • Moderate: 70-110 msec
  • Severe: <70 msec

The closer the gap between S₂ and OS the severe the stenosis is.

Imaging

Echocardiography

• ECHO is the gold standard for diagnosis and quantification of mitral stenosis. It is a better diagnostic tool than cardiac catheterization.
• To define the anatomy of the stenotic lesion a 2D echocardiography is used and to define the hemodynamics of blood flow through the stenotic valve a Doppler ECHO is preferred.
  • Doppler is the gold standard for quantifying the transmitral pressure gradient.

Treatment

• General principles in the management of mitral stenosis include:
  • Anticoagulation - if atrial fibrillation is present
  • For class I and II symptoms observing is the preferred treatment.
  • Replacement of mitral valve - if class III and IV symptoms.

Percutaneous mitral balloon valvotomy

Indications

• Class II, III and IV symptoms
• Asymptomatic patients with:
  • Pulmonary artery pressure >60mm Hg
  • New onset atrial fibrillation