Mitral Stenosis

Question 1

Symptoms

Answer 1

1. That of heart failure
2. That of AF (palpitations, reduced ET, stroke)
3. Hoarse voice (ortners syndrome - compression of recurrent laryngeal nerve by enlarged LA and/or pulmonary artery
4. Haemoptysis - rupture of bronchial veins
5. Endocarditis

Question 2

Signs

Answer 2

Inspection

• female 2:1. If Caucasian likely to be older as rheum fever not common recently
• stigmata is endocarditis
• bruising from anticoagulation
• irregular pulse
• JVP elevated, prominent A-wave if SR, prominent systolic CV wave if secondary TR
• Malar flush (dusky red discolouration over maxillary eminences sparing nasal bridge . Severe pulmonary hypertension + low cardiac output + raised venous pressure)

Palpation

• Apex - undisplaced (unless mixed disease), tapping (reflecting loud 1st HS). LV has to generate slightly higher pressure to overcome raised LA pressure. While edges of leaflets are rigid and thickened, the rest of scallops remain mobile and bulge briskly towards LA causing tapping sensation and loud S1
• left parasternal heave due to RV pressure overload (can appear apical if RV becomes so enlarged)
• rarely pre-systolic heave due to severe LA dilatation but more likely to be AF by this stage

Auscultation

• loud S1 - closing snap
• loud S2 in context of pulmonary HTN. Loss of S2 splitting due to early closure p valve as increased pulmonary pressure. May also be descrescendo early diastolic murmur due to PR ( Graham-steel murmur)
• Opening snap (OS) heard in early diastole. Diastolic doming of anterior leaflet (not affected same way in rheumati disease, larger leaflet and chordate tendibae mostly on outside. (OS lost as thickening/scarring worsens, not present in congenital MS)
• Mid-Diastolic murmur - just after OS. Low-pitched rumbling loudest with pt in left lateral decubitus position, at end-exhalation with bell.
• signs of heart failure

Question 3

Tips re the murmur

Answer 3

1. If can’t hear get them to do sit ups
2. If I’m SR then murmur May get louder towards end of diastole (pre-systolic accentuation)
3. If AF, listen for long gaps. The longer the mid-diastolic murmur, the more severe stenosis as the murmur only occurs when LA:LV pressure gradient more than 3mmHg
4. 40% of rheumatic mitral stenosis patients have other valves involved, most commonly aortic
5. 40% have mixed MV disease

Question 4

Differential diagnoses of mid-diastolic murmurs

Answer 4

1. Severe MR
2. Complete heart block (coincidental atrial
   Contraction with rapid passive LV-filling

Question 5

Suggestions of mild MS

Answer 5

SR
No signs pulmonary HTN
No signs fluid overload
Short mid-diastolic murmur

Question 6

Suggestions severe MS

Answer 6

1. AF
2. Signs of Pulmonary hypertension
3. Short gap between S2 and OS. Due to raised LA pressure
4. Prolonged mid-diastolic murmur

Question 7

Aetiology

Answer 7

1. Rheumatic fever in >90%
2. Degenerative. Severe mitral annular calcification
3. Non-valvular (atrial myxoma, ball-valve LA thrombus, large vegetation of infective endocarditis
4. Congenital
   - isolated
   - cor triatriatum (division of 1 atria by membrane),
   - shone’s syndrome (supravalvular mitral membrane, parachute MV, subaortic stenosis and aortic coarctation)
   - mucopolysaccharidosis
   - left-sided carcinoid syndrome (metastatic or bronchial carcinoid)
5. Methysergide or ergot alkaloid valvulopathy (ef cabergoline)

Question 8

Investigations

Answer 8

1. 12-lead ECG - AF or P-mistake
2. CXR - pulmonary congestion, haemosiderosis, LA dilatation (splaying of subcarinal angle, loss of pulmonary bay)
3. TTE
   - mitral valve area
   - mean mitral valve gradient
   - suitability for percutaneous balloon mitral valvotomy (PBMV)
   - pulmonary pressures
   - RV function
4. TOE
   - assess valvular and subvalvular anatomy
   - assess LA appendage for thrombus prior to PBMV
5. Right and left heart catheterisationto assess coronary anatomy prior to surgery, assess MVA and to assess pulmonary artery systolic (PASP) and wedge (PAWP) pressures

Question 9

Indications for anticoagulation

Answer 9

1. AF

2. LA >55mm even if SR

Question 10

Management

Answer 10

Asymptomatic

1. Annual follow up if:
   - Asymptomatic and mild MS (MVA >1.5cm2 or mean gradient <5mmHg)
   - asymptomatic but worse than mild MS but not suitable for PBMV
   - asymptomatic, valve amenable to PBMV but PASP <50mmHg and <69 with exercise or PAWP <25mmHg
2. Assess for PBMV if:
   - asymptomatic but moderate (MVA 1-1.5cm2 or mean pressure gradient 5-10mmHg) or severe (MVA <1cm2 or mean gradient >10mmHg)
   - if valve amenable then:
3. Assess pulmonary pressures
   - if PASP >50mmHg, >60mmHg with exercise or PAWP >25mmHg OR new onset AF then PBMV or surgery should be offered

Symptomatic

• NYHA II and mod/severe offer PBMV or if not suitable then offer surgical repair/replacement if severe pulmonary HTN (PASP>60). Otherwise 6monthy follow up
• NYHA II-IV and mild MS do exercise testing. PAP rise above 60, gradient >15 or PAWP >25 offer PBMV, otherwise 6 monthly follow up. If above not met then yearly follow up and Ix other cause breathlessness
• ## NYHA III/IV and mod/severe MS poor prognosis without intervention. PBMV otherwise surgery.

Question 11

Suitability of valve for PBMV

Answer 11

Leaflet mobility, thickening, subvalvular thickening and calcification are each graded 1-4 for Wilkins criteria

• if score 8 or less then amenable
• PBMV increases severity of MR so contraindicated of mod/severe MR
• contraindicated if LA thrombus

Question 12

How do you manage MS in pregnancy?

Answer 12

• advise against pregnancy without intervention if symptomatic, severe MS
• asymptomatic patients present mid-trimester due to increased HR and intravascular volume
• severe MS and NYHA III/IV develop during pregnancy should have PBMV with TOE guidance to reduce radiation exposure

Question 13

Normal MVA

Answer 13

4-5cm2 (body size dependent)