Mitral stenosis differential diagnosis: Difference between revisions

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|style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Atrial Septal Defect
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* Frequent respiratory or lung infections
* Frequent respiratory or lung infections
* Dyspnea
* Dyspnea

Revision as of 19:00, 6 December 2016

Mitral Stenosis Microchapters

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Pathophysiology

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Differentiating Mitral Stenosis from other Diseases

Epidemiology and Demographics

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2];Yamuna Kondapally, M.B.B.S[3]

Overview

The possible causes, and other conditions that may present similarly, should be evaluated for when there is suspicion of mitral stenosis.

Differentiating Mitral Stenosis from other Diseases

Mitral stenosis must be differentiated from the following:[1][2][3][4][5][6][7][8][9]

Diseases History Symptoms Physical Examination Murmur Diagnosis Other Findings
ECG CXR Echocardiogram Cardiac Catheterization
Mitral Stenosis
  • Age ( Mitral annular calcification in older patients)
  • Rheumatic fever
  • Endocarditis
  • Dyspnea on exertion
  • Paroxysmal nocturnal dyspnea
  • Orthopnea
  • New onset atrial fibrillation
  • Mitral facies
  • Heart murmur
  • Jugular vein distension
  • Apical impulse displaced laterally or not palpable
  • Diastolic thrill at the apex
  • Signs of heart failure in severe cases
  • Diastolic murmur
  • Low pitched
  • Opening snap followed by decrescendo-crescendo rumbling murmur
  • Best heard with the bell of the stethoscope at apex at end-expiration in left lateral decubitus position
  • Intensity increases after a valsalva maneuver, after exercise and after increased after load (eg., squatting, isometric hand grip)
  • P mitrale
  • Atrial fibrillation: No P waves and irregularly irregular rhythm
  • Right axis deviation
  • Right ventricular hyppertropy: Dominant R wave in V1 and V2
  • Straightening of the left border of the heart suggestive of enlargement of the left atrium
  • Double right heart border (Enlarged left atrium and normal right atrium)
  • Prominent left atrial appendage
  • Splaying of subcarinal angle (>120 degrees)
  • Calcification of mitral valve
  • Kerley B lines
  • Reduced valve leaflet mobility
  • Valve calcification
  • Doming of mitral valve
  • Valve thickening
  • Enlargement of left atrium
Right heart catheterization:
  • Pulmonary capillary wedge pressure (left atrial pressure)

Left heart catheterization:

  • Pressures in left ventricle
  • Determines the gradient between the left and right atrium during ventricular diastole (marker of the severity of mitral stenosis)
  • Heamoptysis (heart failure)
  • Ortner's syndrome
Mitral Regurgitation
  • CAD
  • MI
  • Rheumatic fever
  • Endocarditis
  • Mitral valve prolapse
  • Cardiomyopathy
  • Radiation therapy
  • Trauma
  • Palpitations
  • Symptoms of heart failure in severe cases
Palpation
  • Brisk carotid upstroke and hyperdymanic carotid impulse on palpation
  • Apical impulse is displaced to left
  • S3 and a palpable thrill

Auscultation

  • Murmur
  • Holosystolic murmur
  • High pitched, blowing
  • Radiates to axilla
  • Best heard with the diaphragm of the stethoscope at apex in left lateral decubitus position
  • Intensity increases with hand grip or squatting
  • Decrease in intensity on standing or valsalva maneuver
  • P mitrale in lead II
  • Increased QRS voltage
  • Right axis deviation
  • Atrial fibrillation
Acute MR
  • Kerley B lines
  • No enlargement of cardiac silhouette

Chronic MR

  • Enlarged cardiac silhouette
  • Straightening of left heart border
  • Splaying of subcarinal angle
  • Calcification of mitral annulus
  • Double right heart border
  • Enlargement of left atrium and ventricle
  • Identify valve abnormality
  • Valve calcification
  • Severity of regurgitation
  • Grading of MR is done with left ventriculography
  • Decompensated and acute MR may lead to heart failure
Mitral Regurgitation
  • Frequent respiratory or lung infections
  • Dyspnea
  • Tiring when feeding (Infants)
  • Shortness of breath on exertion
  • Palpitations
  • Edema of feet
  • Shortness of breath
  • Fatigue
  • Failure to thrive
  • Swelling of feet and abdomen (Right heart failure)
  • Palpitations
  • Respiratory infections
Inspection
  • Precordial bulge
  • Precordial lift

Palpation

  • Right ventricular impulse
  • Pulmonary artery pulsations
  • Thrill

Auscultation

  • Murmur
  • Midsystolic (ejection systolic) murmur
  • Widely split, fixed S2
  • Upper left sternal border
  • Normal
  • Prolonged PR interval
  • Right bundle branch block
  • ECG findings varies according to the underlying type of ASD
  • Increased pulmonary markings
  • Cardiomegaly
  • Triangular appearance of heart
  • Schimitar sign
  • Defect size
  • Pulmonary venous return
  • Pulmonary vascular resistance
  • Pulmonary artery hypertension
  • Asymptomatic until later part of their life
  • May be associated with migraine with aura
Left Atrial Myxoma
  • Dyspnea
  • Orthopnea
  • Pulmonary edema
  • Hyperpigmentation of skin and endocrine activity
  • Cerebral embolism
  • Symptoms may mimic mitral stenosis
Skin
  • Signs of an embolic phenomenon
  • Raynaud's phenomenon
  • Swelling
  • Clubbing

Auscultation:

  • Lung: Fine crepitations
  • Heart: Characteristic "tumor plop"
  • Early diastolic sound as "tumor plop"
  • Low frequency diastolic murmur may be heard if the tumor obstructing mitral valve
  • Often normal
  • Often normal

Rare findings:

  • cardiomegaly
  • Left atrial enlargement
  • tumor calcification etc.,
  • Useful to detect vascular supply of the tumor by the coronary arteries
  • Associated with Carney complex (genetic predisposition)
Prosthetic Valve Obstruction
  • History of valve replacement
  • Systemic embolism
  • Shortness of breath
  • Fatigue
Ausculation

Muffling of murmur

  • Muffling or disappearance of prosthetic sounds
  • Appearance of new regurgitant or obstructive murmur
  • Degree of stenosis
  • Assess thrombus size and location
  • Differentiate between thrombus, pannus and vegetations
Causes:
  • Thrombus
  • Pannus formation
Cor Triatriatum
  • Dyspnea on exertion
  • Recent onset of congestive heart failure
  • Dsypnea on exertion
  • Orthopnea
  • Tachypnea
  • Palpitations
  • Growth failure
Auscultation
  • Murmur

Other findings

  • Signs of heart failure
  • Diastolic murmur with loud P2
  • No opening snap or a loud S1
Non specific but may have
  • Right axis deviation
  • Right atrial enlargement
  • Right ventricular hypertrophy
  • Normal cardiac silhouette
  • Hemodynamic changes similar to mitral stenosis (non specific findings)
  • Direct visualization of membrane through the atrium
  • +/- visualization of accessory chamber
  • Normal left ventricular hemodynamic profile with a trans atrial gradient
Types
  • Cor triatrium sinistrum
  • Cor triatrium dextrum
Congenital Mitral Stenosis
  • Respiratory distress shortly after birth
  • Recurrent severe pulmonary infections
  • Other associated congenital cardiovascular anamolies
  • Atrial fibrillation

Infants:

  • Exhaustion and sweating on feeding
  • Rapid breathing
  • Failure to thrive
  • Pulmonary infections
  • Chronic cough

Older patients:

  • Dyspnea
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Peripheral edema
  • Fatigue
Auscultation
  • Murmur

Other findings

  • Signs of heart failure
Mild-Moderate
  • Loud S1
  • Loud P2
  • Low frequency diastolic murmur best heard at the apex

Severe

  • Soft S1
  • Loud pulmonic component of S2 with minimal respiratory splitting of S2
  • Holodiastolic murmur with presystolic accentuation best heard at the apex
  • Early diastolic murmur of pulmonic valve regurgitation
  • Sharp P waves in leads I and II
  • Inversion of P wave in lead III
  • Marked Q waves in leads II and III
  • Left atrial dilation
  • Moderate enlargement of right heart
  • Pulmonary venous congestion
  • Esophageal compression
  • Reduced valve leaflet mobility
  • Left atrial size
  • Severity of mitral stenosis
Very rare condition
Supravalvular Ring Mitral Stenosis
  • Other associated congenital heart defects
  • Fatigue
  • Frequent respiratory infections
  • Failure to thrive
  • Poor feeding
  • Precocious congestive heart failure
  • Shortness of breath
  • Tachypnea
  • Dyspnea
  • Nocturnal cough
  • Heamoptysis
  • Syncope
Auscultation:

Lungs: Fine, crepitant rales and rhonchi or wheezes may be present

Heart: Murmur

  • An apical mid diastolic murmur with presystolic accentuation
  • No opening snap
  • The murmur is more prominent if associated with VSD or PDA
  • Left atrial and ventricular enlargement
  • Alveolar edema
Supramitral ring:
  • Associated with normal mitral valve apparatus

Intramitral ring:

  • Hypomobility of the posterior leaflet
  • Reduced interpapillary muscle distance
  • Reduced chordal length
  • Dominant papillary muscle
  • Hypoplastic mitral annulus

(Difficult to visualize membrane <1mm in size)

  • Persistently elevated pulmonary venous pressures
  • Increased pulmonary artery pressure
Types
  • Supramitral
  • Intramitral

It is attached between the opening of the atrial appendage and the mitral annulus which helps in differentiating with Cor triatriatum sinister.

  • Intramitral type is associated with shone complex

References

  1. Nassar PN, Hamdan RH (2011). "Cor Triatriatum Sinistrum: Classification and Imaging Modalities". Eur J Cardiovasc Med. 1 (3): 84–87. doi:10.5083/ejcm.20424884.21. PMC 3286827. PMID 22379596.
  2. Roudaut R, Serri K, Lafitte S (2007). "Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations". Heart. 93 (1): 137–42. doi:10.1136/hrt.2005.071183. PMC 1861363. PMID 17170355.
  3. Apostolakis EE, Baikoussis NG (2009). "Methods of estimation of mitral valve regurgitation for the cardiac surgeon". J Cardiothorac Surg. 4: 34. doi:10.1186/1749-8090-4-34. PMC 2723095. PMID 19604402.
  4. Alboliras ET, Edwards WD, Driscoll DJ, Seward JB (1987). "Cor triatriatum dexter: two-dimensional echocardiographic diagnosis". J Am Coll Cardiol. 9 (2): 334–7. PMID 3805524.
  5. Gibson DG, Honey M, Lennox SC (1974). "Cor triatriatum. Diagnosis by echocardiography". Br Heart J. 36 (8): 835–8. PMC 458901. PMID 4412638.
  6. Cor triatrium https://radiopaedia.org/articles/cor-triatriatum (2016) Accessed on November 29, 2016
  7. Sosland RP, Vacek JL, Gorton ME (2007). "Congenital mitral stenosis: a rare presentation and novel approach to management". J Thorac Cardiovasc Surg. 133 (2): 572–3. doi:10.1016/j.jtcvs.2006.10.025. PMID 17258606.
  8. Driscoll DJ, Gutgesell HP, McNamara DG (1978). "Echocardiographic features of congenital mitral stenosis". Am J Cardiol. 42 (2): 259–66. PMID 685838.
  9. Bonou M, Lampropoulos K, Barbetseas J (2012). "Prosthetic heart valve obstruction: thrombolysis or surgical treatment?". Eur Heart J Acute Cardiovasc Care. 1 (2): 122–7. doi:10.1177/2048872612451169. PMC 3760527. PMID 24062899.

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