Mitral Stenosis

Valvular heart disease characterised by the narrowing of the mitral valve orifice. Most common cause is rheumatic heart disease.

Presentation

Dyspnoea is the most common presenting feature
Fatigue, palpitations, chest pain and haemoptysis
Patients may present with symptoms of heart failure
Later stages of the disease increase the risk of thromboembolism as atrial fibrillation is more likely.

History

Duration and type of symptoms
Chest pain - angina history
Syncope - frequency, associated features, warning signs, postal hypotension, movement
Dyspnoea - Dyspnoea - onset, aggravating and relieving factors. Normal exercise tolerance.
Does the patient have any risk factors for developing vascular disease - Hypertension, hypercholesterolaemia, obesity, diabetes, previous acute coronary event/stroke, smoker, lifestyle/occupation, family history of ischaemic heart disease?
Childhood infections - rheumatic fever
PMHx - previous MI, COPD, pneumonia, valvular disease as a child
FH - history of congenital valve problems. Williams syndrome.

Vital signs / observations

Normal

Examination

Malar flush on cheeks due to decreased cardiac output. Low-volume pulse
AF common
Tapping non-displaced apex beat

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On auscultation: loud S1; opening snap, rumbling mid diastolic murmur (heard best in expiration, with patient on left side). Graham steel murmur may be present due to pulmonary hypertension creating pulmonary regurgitation.
The more severe the stenosis then the longer the diastolic murmur will be. If sever the opening snap will be closer to S2.
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Are there features of cardiac failure - pulmonary oedema, peripheral oedema

Bedside test

ECG - AF, P-mitrale if in sinus rhythm, right ventricular hypertrophy therefore right axis deviation

Laboratory investigations

FBC - anaemia may worsen symptoms

Radiological investigations

CXR - cardiomegaly with left atrial enlargement. Pulmonary oedema. Mitral valve calcification.
Echo - diagnostic and doppler may determine the gradient across the valves. Significant stenosis exists if the valve orrifice is <1cm2/m2 body surface area. Symptoms usually occur when the orifice <2cm2

Cardiac catheterisation

Indicated if previous valve surgery, signs of other valvular pathology, angina, severe pulmonary hypertension and calcified mitral valve.
This can assess the valve gradient, LV function and coronary artery disease
Risk of emboli with investigation

Management

If the patient is in atrial fibrillation then rate control is important
Diuretics will reduce cardiac preload and aid any pulmonary venous congestion.

Indications for mitral valve replacement or valvuloplasty is NYHA class III-IV
Balloon valvuloplasty may be an option if the valve is pliable and non-calcified

Surgical

Open mitral valvotomy or valve replacement if symptoms not controlled by medication and valvuloplasty is not an option

Follow up

Complications

Pulmonary hypertension is the most common complication
Emboli from AF
Pressure symptoms due to enlarged right atrium - hoarseness, dysphagia, bronchial obstruction
Infective endocarditis

Prognosis

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