Mitral Stenosis

Question 1

Mitral Stenosis - caused by: (2)

Answer 1

It is caused by:

Rheumatic Heart Disease
Infective Endocarditis

Question 2

Mitral stenosis - describe the murmur

Answer 2

It causes a mid-diastolic, low pitched “rumbling” murmur due to a low velocity of blood flow. There will be a loud S1 due to thick valves requiring a large systolic force to shut, then shutting suddenly. You can palpate a tapping apex beat due to loud S1.

Question 3

It causes a mid-diastolic, low pitched “rumbling” murmur due to a low velocity of blood flow. There will be a loud S1 due to thick valves requiring a large systolic force to shut, then shutting suddenly. You can palpate a tapping apex beat due to loud S1. - what is this?

Answer 3

Mitral stenosis

Question 4

Mitral stenosis is associated with…

Answer 4

Malar flush. This is due to back-pressure of blood into the pulmonary system causing a rise in CO2 and vasodilation.

Atrial fibrillation. This is caused by the left atrium struggling to push blood through the stenotic valve causing strain, electrical disruption and resulting fibrillation.

Question 5

Mitral stenosis causes left … ….

Answer 5

Mitral stenosis causes left atrial hypertrophy.

Question 6

Valvular heart disease can cause …. (thickening both outwards and into the chamber) or …. (thinning and expanding – think of blowing up a balloon) of the myocardium in different heart areas.

Answer 6

Valvular heart disease can cause hypertrophy (thickening both outwards and into the chamber) or dilatation (thinning and expanding – think of blowing up a balloon) of the myocardium in different heart areas.

Question 7

Assessing a Murmur (SCRIPT mnemonic)

Answer 7

S – Site: where is the murmur loudest?
C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter)
R – Radiation: can you hear the murmur over the carotids (AS) or left axilla (MR)?
I – Intensity: what grade is the murmur?
P – Pitch: is it high pitched or low and grumbling? Pitch indicates velocity.
T – Timing: is it systolic or diastolic?

Question 8

… heart disease is by far the most common cause of MS. Obstruction of flow to the left ventricle results in raised atrial and pulmonary pressures and eventual right sided failure.

Answer 8

Rheumatic heart disease is by far the most common cause of MS. Obstruction of flow to the left ventricle results in raised atrial and pulmonary pressures and eventual right sided failure.

Question 9

Symptomatic disease tends to present with dyspnoea and reduced exercise tolerance. Complications include atrial fibrillation and thromboembolic events. Interventional management, when indicated, is typically via percutaneous means. - what is this describing?

Answer 9

Symptomatic disease tends to present with dyspnoea and reduced exercise tolerance. Complications include atrial fibrillation and thromboembolic events. Interventional management, when indicated, is typically via percutaneous means - mitral stenosis

Question 10

Acute … … is a non-suppurative complication of infection by group A Streptococcus (GAS) pharyngitis (‘strep throat’). Though increasingly uncommon in the western world due to wide-spread antibiotic use, it is still a significant cause of illness in the developing world.

Answer 10

Acute rheumatic fever is a non-suppurative complication of infection by group A Streptococcus (GAS) pharyngitis (‘strep throat’). Though increasingly uncommon in the western world due to wide-spread antibiotic use, it is still a significant cause of illness in the developing world.

Question 11

The other causes of MS are all relatively rare. They include:

Answer 11

Congenital MS
Mitral annular calcification
Radiation associated MS
Carcinoid associated valve disease
Fabry's disease

Question 12

Mitral stenosis results in raised left atrial pressures and atrial ….

Answer 12

Mitral stenosis results in raised left atrial pressures and atrial remodelling.

Question 13

… stenosis normally presents with exertional dyspnoea.

Answer 13

Mitral stenosis normally presents with exertional dyspnoea.

Question 14

A mid-diastolic murmur is characteristic - best heard with the bell of the stethoscope with the patient lying on their left side whilst breath is in held expiration - what murmur?

Answer 14

A mid-diastolic murmur is characteristic - best heard with the bell of the stethoscope with the patient lying on their left side whilst breath is in held expiration - mitral stenosis

Question 15

Patients with mitral stenosis may occasionally present with … syndrome - a horse voice that occurs secondary to left atrial enlargement causing a left recurrent laryngeal nerve palsy.

Answer 15

Patients may occasionally present with Ortner syndrome - a horse voice that occurs secondary to left atrial enlargement causing a left recurrent laryngeal nerve palsy.

Question 16

Symptoms of mitral stenosis:

Answer 16

Breathlessness
Haemoptysis
Chest pain

Question 17

Signs of mitral stenosis

Answer 17

Mid-diastolic murmur
Atrial fibrillation
Mitral facies (malar flush)
Pulmonary hypertension:
Right ventricular heave
Prominent a-wave
Right heart failure:
Raised JVP
Peripheral oedema
Hepatomegaly

Question 18

Patients with … are at greatly increased risk of thromboembolic events. Clots that develop in a dilated left atrium, often in the presence of atrial fibrillation, may throw off emboli into the systemic circulation. As such patients may present with a stroke. Other organs are less commonly affected.

Answer 18

Patients with MS are at greatly increased risk of thromboembolic events. Clots that develop in a dilated left atrium, often in the presence of atrial fibrillation, may throw off emboli into the systemic circulation. As such patients may present with a stroke. Other organs are less commonly affected.

Question 19

… is used to make the diagnosis of mitral stenosis and assess the severity of disease.

Answer 19

Echocardiogram is used to make the diagnosis of mitral stenosis and assess the severity of disease.

Question 20

On the CXR left atrial enlargement can be seen. In those with pulmonary hypertension signs of this and right sided heart failure may also feature. The CXR shown below has a number of signs indicative of left atrial enlargement - what murmur is this describing?

Answer 20

On the CXR left atrial enlargement can be seen. In those with pulmonary hypertension signs of this and right sided heart failure may also feature. The CXR shown below has a number of signs indicative of left atrial enlargement:

Question 21

Atrial fibrillation is common but the ECG may be normal or reflect remodelling. In those in sinus rhythm signs of left atrial enlargement may be seen with p-mitrale - a broad, notched p-wave with a negative component in V1. If right sided hypertrophy has developed right axis deviation and tall R-waves in V1 can be seen - which murmur?

Answer 21

Atrial fibrillation is common but the ECG may be normal or reflect remodelling. In those in sinus rhythm signs of left atrial enlargement may be seen with p-mitrale - a broad, notched p-wave with a negative component in V1. If right sided hypertrophy has developed right axis deviation and tall R-waves in V1 can be seen - mitral stenosis

Question 22

Stress testing is somtimes used in those who are asymptomatic with mitral stenosis or have minor symptoms as well as those whose symptoms are discordant with echo findings. This may take the form of an … stress echo or .. stress test.

Answer 22

Stress testing is somtimes used in those who are asymptomatic or have minor symptoms as well as those whose symptoms are discordant with echo findings. This may take the form of an exercise stress echo or dobutamine stress test.

Question 23

Treatment for mitral stenosis

Answer 23

ESC/EACTS guidelines advise percutaneous mitral commissurotomy (PMC) as the treatment of choice in patients who meet the criteria for intervention and have favourable anatomy.

Question 24

Interventional management for mitral stenosis:

Answer 24

percutaneous mitral commissurotomy (PMC)

PMC refers to a minimally invasive approach that uses a balloon delivered by a catheter which enters at the right femoral vein. This balloon is then inflated in various stages to help alleviate the stenosis.

PMC tends to be reserved for patients with clinically significant MS and a valve area < 1.5cm2 in those who are symptomatic or at high-risk of embolism or haemodynamic decompensation. Contra-indications for PMC include:

Valve area >1.5cm2
Left atrial thrombus
Absence of commissural fusion
Severe or bi-commissural calcification
More than mild mitral regurgitation
Severe concomitant aortic stenosis requiring surgery
Severe combined tricuspid regurgitation/stenosis requiring surgery
Concomitant coronary artery disease requiring surgery

In those not suitable for PMC, open surgery may be considered and discussed with the patient.

Question 25

What is percutaneous mitral commissurotomy (PMC)?

Answer 25

PMC refers to a minimally invasive approach that uses a balloon delivered by a catheter which enters at the right femoral vein. This balloon is then inflated in various stages to help alleviate the stenosis.

PMC tends to be reserved for patients with clinically significant MS and a valve area < 1.5cm2 in those who are symptomatic or at high-risk of embolism or haemodynamic decompensation.

Question 26

Contra-indications for PMC include: (mitral stenosis)

Answer 26

Valve area >1.5cm2
Left atrial thrombus
Absence of commissural fusion
Severe or bi-commissural calcification
More than mild mitral regurgitation
Severe concomitant aortic stenosis requiring surgery
Severe combined tricuspid regurgitation/stenosis requiring surgery
Concomitant coronary artery disease requiring surgery

In those not suitable for PMC, open surgery may be considered and discussed with the patient.

Question 27

Medical management of mitral stenosis:

Answer 27

Patient with AF or paroxysmal AF can tend to follow the routine management of this condition. In stable patients pre-intervention, cardioversion is not indicated as the results are not sustained. Patients should receive appropriate anticoagulation.

ESC/EACTS advise that in patients with ‘moderate to severe mitral stenosis and persistent atrial fibrillation should be kept on vitamin K antagonist (VKA) treatment and not receive NOACs’.

In patient in sinus rhythm anticoagulation may still be advised if:

Thrombus in the left atrium
History of systemic embolism
It may also be considered in those with an enlarged LA or with dense spontaneous echocardiographic contrast.

Question 28

ESC/EACTS advise that in patients with ‘moderate to severe mitral stenosis and persistent atrial fibrillation should be kept on vitamin K antagonist (VKA) treatment and not receive …’.

Answer 28

ESC/EACTS advise that in patients with ‘moderate to severe mitral stenosis and persistent atrial fibrillation should be kept on vitamin K antagonist (VKA) treatment and not receive NOACs’.

Question 29

In patient in sinus rhythm with mitral stenosis anticoagulation may still be advised if:

Answer 29

Thrombus in the left atrium
History of systemic embolism

It may also be considered in those with an enlarged LA or with dense spontaneous echocardiographic contrast.

Question 30

Common ECG findings in moderate-to-severe mitral stenosis are…(2)

Answer 30

Common ECG findings in moderate-to-severe mitral stenosis are P Mitrale and atrial fibrillation.

Question 31

P Mitrale refers to a bifid P wave on an ECG that is suggestive of ..

Answer 31

P Mitrale refers to a bifid P wave on an ECG that is suggestive of left atrial enlargement

Question 32

MS is usually a consequence of …

Answer 32

MS is usually a consequence of rheumatic heart disease. There are other rarer causes of MS. MS causes an increase in left atrial pressures. This can lead to atrial hypertrophy and development of arrhythmias, such as atrial fibrillation. Continued increases in atrial pressure lead to pulmonary congestion and shortness of breath.

Question 33

The classical murmur of MS is a low pitched mid-diastolic murmur, often described as …

Answer 33

The classical murmur of MS is a low pitched mid-diastolic murmur, often described as rumbling.