Mitral Stenosis Flashcards
Mitral Stenosis - caused by: (2)
It is caused by:
Rheumatic Heart Disease
Infective Endocarditis
Mitral stenosis - describe the murmur
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.
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?
Mitral stenosis
Mitral stenosis is associated with…
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.
Mitral stenosis causes left … ….
Mitral stenosis causes left atrial hypertrophy.
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.
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.
Assessing a Murmur (SCRIPT mnemonic)
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?
… 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.
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.
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?
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
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.
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.
The other causes of MS are all relatively rare. They include:
Congenital MS Mitral annular calcification Radiation associated MS Carcinoid associated valve disease Fabry's disease
Mitral stenosis results in raised left atrial pressures and atrial ….
Mitral stenosis results in raised left atrial pressures and atrial remodelling.
… stenosis normally presents with exertional dyspnoea.
Mitral stenosis normally presents with exertional dyspnoea.
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?
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
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.
Patients may occasionally present with Ortner syndrome - a horse voice that occurs secondary to left atrial enlargement causing a left recurrent laryngeal nerve palsy.
Symptoms of mitral stenosis:
Breathlessness
Haemoptysis
Chest pain
Signs of mitral stenosis
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
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.
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.
… is used to make the diagnosis of mitral stenosis and assess the severity of disease.
Echocardiogram is used to make the diagnosis of mitral stenosis and assess the severity of disease.
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?
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:
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?
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
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.
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.
Treatment for mitral stenosis
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.
Interventional management for mitral stenosis:
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.
