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* 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]].



Revision as of 18:28, 17 April 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]

Mitral Stenosis Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Rheumatic Fever Prophylaxis
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. 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

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 salmon color signify that an urgent management is needed.


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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Appearance of the patient
❑ Plethoric cheeks with bluish patches

Vital signs

Pulse

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

Neck:
Jugular venous distension

❑ Prominent a wave in right heart failure
❑ Absent a wave in AF
❑ Prominent v wave in TR

Chest examination:

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

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:

❑ Perform 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
❑ 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
❑ ST T strain pattern in leads 2,3,aVF
P pulmonale or right atrial enlargement or P congenitale
❑ R wave progression reversal
❑ Inverted T wave in the anterior precordial leads
Right axis deviation
QRS complex is positive in leads III and aVF
QRS complex is negative in leads I and aVL


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


Picture adapted from Wikidoc.org

❑ Perform 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
❑ Perform 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:

Myxoma

❑ Obstruct the mitral orifice
❑ Exclude with echocardiography

Atrial fibrillation

❑ Order echocardiography to exclude mitral stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Shown below is an algorithm summarizing the management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.[2]
MVA: Mitral valve area; PMBC: Percutaneous mitral ballon commissurotomy; PCWP: Pulmonary capillary wedge pressure; ms: milliseconds; NYHA: New York Heart Association; AF: Atrial fibrillation

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

❑ Consider heart rate control in MS patients with:

❑ Normal sinus rhythm and symptoms present on exercise
AF and fast ventricular response

❑ Consider anticoagulation therapy in MS patients with:

AF
❑ Prior embolic event
Left atrial thrombus
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess the presence of symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess the severity of mitral stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess the severity of mitral stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Very severe
❑ MVA ≤ 1 cm2
❑ Pressure half time ≥ 220 ms
Stage D
 
Severe
❑ MVA ≤ 1.5 cm2
❑ Pressure half time ≥ 150 ms
Stage D
 
Progressive
❑ MVA > 1.5 cm2
❑ Pressure half time < 150 ms
 
 
 
Very severe
❑ MVA ≤ 1 cm2
❑ Pressure half time ≥ 220 ms
Stage C
 
 
 
 
 
Severe
❑ MVA ≤ 1.5 cm2
❑ Pressure half time ≥ 150 ms
Stage C
 
 
 
Progressive
❑ MVA > 1.5 cm2
Pressure half time < 150 ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess if valve morphology is favorable for PMBC
 
 
 
❑ Perform exercise testing
 
 
 
❑ Assess if valve morphology is favorable for PMBC
 
 
 
 
 
❑ Assess if the new onset AF is present
 
 
 
❑ Monitor patient periodically
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
❑ Assess PCWP on exercise
 
 
 
Yes
 
No
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with PMBC
 
If patient is severely symptomatic (NYHA III/IV):
❑ Assess the surgical risk of patient
 
 
If PCWP > 25 mm Hg:
❑ Proceed with PMBC
If PCWP< 25 mm Hg :
❑ Monitor patient periodically
 
 
 
❑ Proceed with PMBC
 
 
 
❑ Monitor patient periodically
 
 
 
❑ Assess if the valve morphology is favorable for PMBC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with PMBC
 
❑ Proceed with mitral valve surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with PMBC
 
❑ Monitor patient periodically
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Rheumatic Fever Prophylaxis

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.[3]

Secondary prevention of rheumatic fever
Penicillin G benzathine 1.2 million units IM every day for 4 weeks
Penicillin V potassium 200 mg orally twice a day
Sulfadiazine 1 g orally once a day
Macrolide antibiotics (in patients allergic to penicillin) Varies


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)
Rheumatic fever with carditis but no valvular heart disease 10 years or until the patient is 21 years (whichever is longer)
Rheumatic fever without carditis 5 years or until the patient is 21 years (whichever is longer)

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 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. 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: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000031. PMID 24589853.


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