Mitral Stenosis

Question 1

Aetiology of MS

Answer 1

Rheumatic fever most common
Others : Carcinoid (bronchogenic cause), Mucopolysaccharidosis, Whipples, SLE, Degenerative calcification, Cabergoline

Question 2

Signs on examination (not auscultation)

Answer 2

AF
Left parasternal heave (pul HTN)
malar flush (spares nasal bridge)
tapping apex undisplaced
thoracotomy scar (?mitral valvoplasty)
giant a waves (pul htn)
bruising from anticoag.
CV waves if functional TR

Question 3

Presentation of M.S

Answer 3

Heart failure
AF (reduced ETT, arrhythmia, embolic events)
Ortners syndrome
Haemoptysis

Question 4

When does malar flush occur?

Answer 4

With severe pulmonary HTN

Question 5

What is Ortner syndrome?

Answer 5

compression of the recurrent laryngeal nerve by enlarged left atrium

Question 6

Why do you get haemoptysis?

Answer 6

Rupture of bronchial veins

Question 7

Differentials of haemoptysis

Answer 7

PE
Bronchiectasis
Pneumonia
Chronic cough
Lung Ca
M.S

Question 8

Signs on auscultation of MS

Answer 8

Mid-diastolic rumbling murmur with opening snap (diastolic doming of the anterior leaflet of the MV)
loud S1
Hear loudest in apex with bell

If pulmonary HTN
- functional TR
- RV heave
- loud P2

Question 9

Signs of severe MS on auscultation

Answer 9

Loss of opening snap (thickened valve)
Longer duration of murmur
OS closer to S2

Question 10

What is a graham steel murmur?

Answer 10

Early diastolic murmur due to pulmonary regurg secondary to pul HTN

Question 11

What does P-Mitrale look like on ECG

Answer 11

II - bifid P
V1 - biphasic P

Question 12

How is severity of MS measured clinically

Answer 12

AF/ Pul HTN/ Short distance between OS and S2, Longer murmur, signs of pulmonary congestions, low pulse pressure

Question 13

Differentials of M.S

Answer 13

Atrial myoxoma
Austin flint murmur

Question 14

Investigations of MS

Answer 14

ECG
XR chest
TTE/TOE
Cardiac catheterisation

Question 15

CXR signs in MS

Answer 15

signs of pulmonary oedema
double heart boarder sign
pulmonary haemosiderosis
Widening of carina
straightening of left heart boarder
cardiomegaly

Question 16

Does MS tend to occur in isolation?

Answer 16

No, 40% of patients who have MS due to rheumatic fever have multi-valvular heart disease with aortic being most common. Mixed MV disease also common

Question 17

Why do a TTE?

Answer 17

Assessment valve area, severity of stenosis and whether there is pul htn

Question 18

What is the valve area is severe MS and what is it normally

Answer 18

Severe = <1cm2
Normal = 4-6 cm2

Question 19

What is the medical management in M.S?

Answer 19

ACEI/ ARBS
Diurectics
Beta blockers
Anticoagulation - warfarin

Question 20

How should patients with MS be followed up

Answer 20

Patients who are asymptomatic and have mild MS (MVA > 1.5cm 2 or mean gradient <5mmHg) should be subject to annual follow-up.

Question 21

What is the indication for anticoagulation in M.S?

Answer 21

AF
Thromboembolic disease
LA appendage thrombus
LA >55mm (even in sinus)

Question 22

What makes a valve unsuitable for balloon mitral valvuloplasty

Answer 22

Calculate wilkins score (if >8 no amenable)

Mod/ Severe MR
Immobile leaflets
Heavily thickened
presence of LA thrombus

Question 23

If the valve IS suitable - who are candidates for percutaneous balloon mitral valvuloplasty?

Answer 23

Mod/ severe MS with heart failure (NHHA >= 3)
High pulmonary artery pressures
New AF
Unfit for valve replacement
Symptomatic NYHA >= 2 with mod/severe MS
Mildly symptomatic MS with increased PA pressures with exercise

Question 24

What are other surgical management options for M.S?

Answer 24

Closed mitral valvotomy
Open valvotomy
Valve replacement

Question 25

Should young women with MS get pregnant

Answer 25

Advised not to get pregnant due to risk of decompensation when circulating volume increases and HR increases.

if develops symptoms may need PBMV with TOE guidance

Question 26

Why is a TOE better than TOE in the context of M.S.

Answer 26

Better views of LA appendage - good if wishing to procedure with percutaneous balloon valvuloplasty

Question 27

Causative organism of rheumatic fever

Answer 27

Streptococcus pyogenes

Question 28

When does rheumatic fever occur

Answer 28

2-4 weeks post strept throat

Question 29

Why does rheumatic fever occur

Answer 29

Type 2 hypersensitivity
Antibodies bind to valves due to molecular mimicry between M protein in pyogenes and valvular cells

Question 30

What is found of histopathology in rheumatic fever

Answer 30

Aschoff Bodies

Question 31

What is the Jones criteria?

Answer 31

Major:
Joint involvement
O (myocarditis)
Nodules (subcut)
Erythema marginartum
Sydenams chlorea

Minor
CRP increase
Arthraglia
Fever
ESR increase
PR prolongation
Anamnesis of rheumatism
Leukiocytosis