Mitral stenosis

Question 1

Define Mitral Stenosis

Answer 1

Narrowing of the opening of the mitral valve

Question 2

Aetiology of Mitral Stenosis

Answer 2

Rheumatic fever (Streptococcal infection=> chronic scarring)
Congenital mitral stenosis
Carcinoid syndrome
SLE
Mitral annular calcification due to ageing
Amyloidosis

Question 3

Symptoms of Mitral Stenosis

Answer 3

Asymptomatic

Fatigue
SOB, orthopnoea
Palpitations or chest pain
Dysphagia
Red cheeks/flushing
PNDm haemoptysis, hoarseness, lower limb swelling, ascites

Question 4

Signs of Mitral Stenosis on examination

Answer 4

Malar flush or facial cyanosis
Low volume, thready pulse OR AF (irregularly irregular)
Tapping (non-displaced) apex beat
Mid-diastolic murmur ever the mitral valve (accentuated by left lateral position) + opening snap, radiates to axilla
Loud S1
± Graham-Steell murmur (EDM 2nd to PR)

Decompensated → Bi-basal lung crops (pulmonary oedema)

Question 5

Investigations for Mitral Stenosis

Answer 5

ECG - P-mitrale (broad, bifid P wave), may show AF, Right ventricular hypertrophy (RAD)

FBC
U&Es
NT-proBNP
Lipids
GLucose

Echo - Diagnosis, shows narrowing
CXR - Left atrial enlargement (double shadow in cardiac silhouette), prominent pulmonary artery, Kerley B lines (Pulmonary oedema), mitral valve calcification
Coronary angiography

Question 6

Management for mitral stenosis

Answer 6

General:
- MDT (Cardio, GP, specialist nurse, cardiothoracics, dietician, OP/PT)
- RF modification: QRISK,
- Regular follow up: echo every 6-12 months if moderate

Medical [RAD]:
- RhF prophylaxis (benzylpenicillin)
- AF (rate control + DOAC)
- Diuretics (symptomatic relief)

Surgical; indication = moderate-severe MS (symptomatic or non-symptomatic):
1. balloon valvuloplasty (CI: left atrial appendage thrombus, calcified valve)
2. Valvotomy / commissurotomy (valve repair)
3. Valve replacement (if repair not possible)