Mitral Valve Stenosis

Question 1

Causes of mitral valve stenosis.

Answer 1

Rheumatic fever (group A beta-haemolytic strep)

Infective endocarditis

Congenital mitral valve stenosis

Lutembacher’s

Malignant carcinoid

Prostethic valve

Mitral annular calcification

Question 2

Progression of disease in mitral valve stenosis.

Answer 2

Left atrial pressure increases -> left atrial hypertrophy and dilation.

This leads to pulmonary venous, arterial and right heart pressure to increase.

Pulmonary capillary pressure increases leads to pulmonary oedema.

Atrial fibrillation with tachycardia also develops.

All of this leads to reactive pulmonary hypertension -> RV hypertrophy, dilation and failure.

And then tricuspid regurg.

Question 3

Symptoms of mitral valve stenosis.

Answer 3

Normal mitral is 4-6 cm2.

Patient will generally remain asymptomatic until < 2cm2.

SOB (pulm HTN)

Haemoptysis (pink-frothy or frank)

Hoarseness of voice (RLN pressure)

Dysphagia

Fatigue

Palpitations

CHest pain

Systmic emboli

Infective endo

Symptoms of RHF and atrial fibrillation.

Question 4

Murmur in MS

Answer 4

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.

Question 5

Signs of mitral stenosis.

Answer 5

Malar flush on cheeks. (Due to back-pressure of blood into the pulmonary system causing a rise in CO2 and vasodilation.)

Low-volume pulse going to atrial fibrillation pulse.

Tapping

Non-displaced apex beat with tapping

RV heave

Loud S1 opening snap.

Rumblin mid-diastolic murmur.

Loud P2

Question 6

Investigations done in mitral stenosis.

Answer 6

ECG

CXR

Echo (diagnostic)

Cardiac catheterisation

Question 7

Findings on CXR.

Answer 7

Left atrial enlargement with straightening left heart boder.

Pulmonary oedema

Mitral valve calcification

Double shadow in right cardiac silhouette

Question 8

Findings on ECG.

Answer 8

Atrial fibrillation

P-mitrale (left atrial hypertrophy) showing bifid P wave in lead II.

RV hypertrophy with progressive right axis deviation and perhaps tall R waves in lead V1.

Question 9

Indications for cardiac catheterisation.

Answer 9

Previous valvotomy

Signs of other valve disease

Angina

Severe pulm HTN

Calcified mitral valve

Question 10

Management of mitral stenosis.

Answer 10

If in AF rate control (b-blocker or rate-limiting Ca2+) is crucial as well as anticoagulation with warfarin.

Diuretics to reduce preload and pulmonary venous congestion.

If this all fails;

Balloon vavlotomy

Open mitral valvotomy

or

Valve replacement