Mitral Stenosis

Question 1

What are the causes of mitral stenosis

Answer 1

Rheumatic fever - most common
Senile degeneration
Congenital
Malignant - lung carcinoid
SLE

Question 2

What conditions mimic mitral stenosis

Answer 2

Left atrial myxoma
Left arterial thrombus
Hypertrophic cardiomyopathy

Cause obstruction of inflow to left ventricle

Question 3

What are the symptoms of mitral stenosis

Answer 3

Dyspnoea - due pulmonary hypertension of oedema
Haemoptysis - if very high pulmonary pressures
AF - common

Secondary to effects of left atrial enlargement:-
Hoarseness - stretching of recurrent laryngeal nerve
Dysphagia - oesophageal compression
Left lung collapse - compression of left main bronchus

Question 4

What would you expect to find on examination of a patient with mitral stenosis

Answer 4

Malar flush
Irregular pulse (if AF)
Loud first heart sound
Tapping undisplaced apex beat
Left parasternal heave if pulmonary hypertension or enlarged left atrium

Auscultation:-
Opening snap before second heart sound
Low rumbling mid-diastolic murmur, loudest at the apex in expiration with the patient on the left side
Loud p2

Question 5

What are the differentials for mitral stenosis

Answer 5

Left atrial myxoma

Austin-Flint murmur

Question 6

What is an atrial myxoma

Answer 6

Benign tumour of the heart . Commonly found within the atria on the interatrial septum

Question 7

What are the most important investigations you would do in a patient with suspected mitral stenosis

Answer 7

ECG - AF, bifid p waves
CXR - enlarged left atrium, calcified valve, pulmonary oedema
Echo - valve area, left atrial size, may demonstrate thrombus

Question 8

What do bifid p waves indicate in mitral stenosis

Answer 8

Left atrial enlargement

Question 9

How do you determine severe mitral stenosis

Answer 9

Valve area under 1 cm2

Question 10

How would you manage a patient with mitral stenosis

Answer 10

Medical:-
AF - rate control and anticoagulants
Diuretics - symptoms of pulmonary oedema

Surgical:-
PBMV - percutaneous balloon mitral valvuloplasty
Mitral valvotomy - open or closed
Mitral valve replacement

Question 11

What is PBMV

Answer 11

Percutaneous balloon mitral valvuloplasty

Catheter passed across the valve and a balloon inflated to split the fused commisures

Question 12

What are the complications of PBMV

Answer 12

Failure of procedure

New mitral regurgitation

Question 13

What are the indications for valve replacement in mitral stenosis?

Answer 13

Signs of pulmonary congestion
Pulmonary hypertension
Haemoptysis
Recurrent thromboembolic episodes despite therapeutic anticoagulation