Track 7: Mitral Stenosis

Question 1

Biggest hemodynamic problem with MS

Answer 1

Elevated LA pressures d/t obstruction of flow

Question 2

Major problem with MS

Answer 2

Elevated LA pressure
Causes gradient between the LA and the LV during diastole

Question 3

Describe the murmur of MS

Answer 3

During diastole opening snap, low pitched diastolic rumble at the apex

Question 4

Main sxs with MS

Answer 4

1 dyspnea (DOE, orthopnea, PND)

Question 5

Name some of the structural consequences of MS

Answer 5

Elevated LA pressures
LA dilation/remodeling
Often develop atrial fibrillation d/t above changes

Question 6

What rhythm should you be concerned about in MS?

Answer 6

Atrial fibrillation (d/t atrial dilation/remodeling)

Question 7

Anticoagulation with atrial fibrillation related to MS?

Answer 7

Warfarin (DOAC have not been proven effective thus far)

Question 8

Name the key factor that makes MS so unique (in comparison to other valve lesions)

Answer 8

LV is unaffected in isolated MS

Question 9

Natural history of MS (graph depiction)-

Answer 9

Disease of plateaus, pt declines in stepwise progression (can have 10-15 years between declines)

Question 10

Main therapeutic goals for MS (prior to intervention)

Answer 10

Rate control
Treat underlying AF if present

Question 11

When is intervention indicated in MS?

Answer 11

Presence of class III-IV sxs (rapid deterioration) with severe stenosis

Question 12

Rapid deterioration tends to occur when in MS

Answer 12

After pt develops class III-IV sxs

Question 13

3 key takeaways for natural history of MS

Answer 13

1. LV is unaffected (not worried about long standing volume/pressure overload, LV remodeling, hypertrophy)
2. Disease of plateau, do not have act immediately
3. Once AF develops, require anticoagulation (with warfarin) and rate control
   *Pt will do well for decades and decades without any intervention

Question 14

Define severe MS

Answer 14

MVA < 1.5 cm^2
Gradient > 10 mmHg (note gradient is dependent on HR and CO)

Question 15

Percutaneous options for MS? Explain process and limitations

Answer 15

D/t fusion of the commissures, can use balloon to open these and restore valve opening
*Dependent on there being a pliable valve leaflet, as pt ages etc may have calcification of the valve leaflets and commissures in which case you can not perform PCI mitral valve valvotomy
*If planning for this approach, can perform when pt develops ANY sxs rather than waiting for class III-IV sxs

Question 16

Name the 2 options for intervention in MS and when this intervention is warranted

Answer 16

1 In select patients with pliable valve leaflets can perform PCI mitral valve valvotomy with balloon. Allows commissures to open back up. Must ensure pt does NOT have any calcification or fibrosis of valve leaflets. I using this approach can perform intervention as soon as pt develops ANY sxs

*Rate control and OAC with warfarin in the meantime if underlying valvular AF