Station 3.3: Mitral stenosis Flashcards
Mitral stenosis
Clinical signs
What are the clinical signs of Mitral stenosis?
Mitral stenosis
This patient has been complaining of reduced exercise tolerance. Examine his heart and elucidate the cause of his symptoms.
- Malar flush
- Irregular pulse if AF is present
- Tapping apex (palpable first heart sound)
- Left parasternal heave if pulmonary hypertension is present or enlarged left atrium
- Auscultation
Loud first heart sound.
Opening snap (OS) of mobile mitral leaflets opening followed by a mid-diastolic
murmur (MDM), which is best heard at the apex, in the left lateral position in expiration with the bell. Presystolic accentuation of the MDM occurs if the patient is in sinus rhythm.
If the mitral stenosis is severe then the OS occurs nearer A2 and the MDM is longer.
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Haemodynamic significance
⚬ Pulmonary hypertension: functional tricuspid regurgitation, right ventricular heave, loud P2
⚬ LVF: pulmonary oedema, RVF: sacral and pedal oedema. - Endocarditis
- Embolic complications: stroke risk is high if mitral stenosis + AF
Discussion - Causes
What are the causes of Mitral stenosis?
Mitral stenosis
This patient has been complaining of reduced exercise tolerance. Examine his heart and elucidate the cause of his symptoms.
Congenital: (rare)
Acquired
* Rheumatic (commonest)
* Senile degeneration
* Large mitral leaflet vegetation from endocarditis (mitral ‘plop’ and late diastolic murmur)
Discussion - Differential diagnosis
What is the Differential diagnosis of Mitral stenosis?
Mitral stenosis
This patient has been complaining of reduced exercise tolerance. Examine his heart and elucidate the cause of his symptoms.
Left atrial myxoma
Austin–Flint murmur
Discussion - investigations
What is the Investigations are required for Mitral stenosis?
Mitral stenosis
This patient has been complaining of reduced exercise tolerance. Examine his heart and elucidate the cause of his symptoms.
- ECG: p‐mitrale (broad, bifid) and atrial fibrillation
- CXR: enlarged left atrium (splayed of carina), calcified valve, pulmonary oedema
- TTE/TOE: valve area (<1.0cm2 is severe), cusp mobility, calcification and left atrial thrombus, right ventricular failure
Discussion - Management
What method of management do you recommend for Mitral stenosis?
Mitral stenosis
This patient has been complaining of reduced exercise tolerance. Examine his heart and elucidate the cause of his symptoms.
- Medical: + AF: rate control and oral anticoagulants, diuretics
- Mitral valvuloplasty: if pliable, non‐calcified with minimal regurgitation and no left atrial thrombus
- Surgery: closed mitral valvotomy (without opening the heart) or open valvotomy (requiring cardiopulmonary bypass) or valve replacement
Discussion - Prognosis
Whats your prognosis for Mitral stenosis?
Mitral stenosis
This patient has been complaining of reduced exercise tolerance. Examine his heart and elucidate the cause of his symptoms.
Latent asymptomatic phase 15–20 years; NYHA > II – 50% mortality at 5 years
Discussion - Rheumatic fever
What about Rheumatic fever ?
Mitral stenosis
This patient has been complaining of reduced exercise tolerance. Examine his heart and elucidate the cause of his symptoms.
- Immunological cross‐reactivity between Group A β‐haemolytic streptococcal infection, e.g. Streptococcus pyogenes and valve tissue
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Duckett–Jones diagnostic criteria
Proven β‐haemolytic streptococcal infection diagnosed by throat swab, rapid antigen detection test (RADT), anti‐streptolysin O titre (ASOT) or clinical scarlet fever plus 2 major or 1 major and 2 minor:
Major ——————————————————- Minor
Chorea —————————————————– Raised ESR
Erythema marginatum ——————————– Raised WCC
Subcutaneous nodules ——————————- Arthralgia
Polyarthritis ———————————————- Previous rheumatic fever
Carditis —————————————————– Pyrexia
—————————————————————– Prolonged PR interval
* Treatment: Rest, high‐dose aspirin and penicillin
* Prophylaxis:
⚬ Primary prevention: penicillin V (or clindamycin) for 10 days
⚬ Secondary prevention: penicillin V for about 5–10 years
