FN: Mitral Stenosis

Question 1

Causes

Answer 1

Rheumatic Fever
Prosthetic Valve
Congenital

Question 2

Pathophysiology

Answer 2

1. Valve narrowing –> increased left atrial pressure –> loud S1 and atrial hypertrophy –> AF
2. –> pulmonary oedema and PHT –> loud P2, PR
3. –> RVH –left parasternal heave
   - -> TR –> large v waves
   - -> RHF –> increased JVP, oedema, ascites

Question 3

symptoms

Answer 3

Dyspnoea
Fatigue
Chest pain
AF --> palpitations + emboli
Haemoptysis: rupture of bronchial veins

Question 4

Signs

Answer 4

1. Symptoms manifest when orifice backpressure + vasoconstriction)
2. JVP may be raised late on
3. Left parasternal heave (RVH secondary to PHT)
4. Apex: Tapping (palpable s1), non-displaced
5. Heart sounds
6. Murmur

Question 5

JVP may be raised late on

Answer 5

Prominent a waves: PTH
Large v waves: TR
Absent a waves: AF

Question 6

Heart sounds

Answer 6

Loud S1
Loud P2 (if PHT)
Early diastolic opening snap

Question 7

Murmur

Answer 7

Rumbling MDM
Apex
eft lateral position in end expiration
Radiates to the axilla
± Graham Steell murmur (EDM secondary to PR)

Question 8

Clinical Indicators of Severe MS

Answer 8

Mitral facies
Longer murmur
Opening snap closer to 2nd heart sound - high LA pressure forcing valve open early
Decompensation

Question 9

Complications

Answer 9

Pulmonary HTN
Emboli: TIA, CVA, PVD, ischaemic collitis
Hoarseness
dysphagia (oesophageal compression
Bronchial obstruction

Question 10

Ortner’s Sign

Answer 10

Hoarseness rec laryngeal N. palsy

Question 11

Investigations

Answer 11

Bloods
ECG
CXR
Echo + Doppler
Cardiac Catheterisation

Question 12

Bloods done

Answer 12

FBC
U + E
LFTs
Glucose
Lipids

Question 13

ECG

Answer 13

AF
P mitrale ( if in sinus)
RVH with strain: ST depression and T wave inverion in V1 - V2

Question 14

CXR

Answer 14

LA enlargement
Pulmonary oedema: ABCDE
Mitral valve calcification

Question 15

Echo + Doppler

Answer 15

Severe MS (AHA 2006 Criteria)
Use TOE to look for left atrial thrombus if intervention considered

Question 16

Severe MS (AHA 2006 Classification)

Answer 16

1. Valve orifice 10 mmHg

3. Pulmonary artery systolic pressure > 50 mmHg

Question 17

Cardiac Catheterisation

Answer 17

Assess coronary arteries

Question 18

Management Medical

Answer 18

Optimise RFs: statins, antihypertensives, DM
Monitor: regular f/up with echo
Consider prophylaxis vs. rheumatic fever e.g. Pen V
AF: rate control and anticoagulate
Diuretics provide symptoms relief

Question 19

Management surgical

Answer 19

1. Indicated in mod-severe MS (asympto and symptomatic)
2. Percutaneous balloon valvuloplasty
   Treatment of choice
   Suitability depends on valve characteristics: pliable, minimally calcified
   CI if left atrial mural thrombus
3. Surgical valvotomy/commissurotomy: valve repair
4. Valve replacement if repair not possible