Mitral stenosis resident survival guide: Difference between revisions

Jump to navigation Jump to search
Line 74: Line 74:


==Management==
==Management==
Shown below is an algorithm summarizing the approach to management of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
Line 82: Line 83:
{{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}
{{familytree | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | |D01=❑ Assess the severity of [[mitral stenosis]]|D02=❑ Assess the severity of [[mitral stenosis]]}}
{{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}
{{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | }}
{{familytree | | C01 | | C02 | | C03 | | | | C01 | | | | | | C02 | | | | C03 | | | | | |C01=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br></div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|D01=Very severe|D02=Severe|D03=Moderate}}
{{familytree | | C01 | | C02 | | C03 | | | | C04 | | | | | | C05 | | | | C06 | | | | | |C01=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C02=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage D]]</div>|C03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>|C04=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Very severe'''<br>❑ MVA ≤ 1 cm<sup>2</sup><br>❑ Pressure half time ≥ 220 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C05=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Severe'''<br>❑ MVA ≤ 1.5 cm<sup>2</sup><br>❑ Pressure half time ≥ 150 ms<br>❑ [[Mitral stenosis stages|Stage C]]</div>|C06=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''Progressive'''<br>❑ MVA > 1.5 cm<sup>2</sup><br>Pressure half time < 150 ms </div>}}
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}
{{familytree | | |`|-|v|-|'| | | |!| | | | | |!| | | | | | | |!| | | | | |!| | | | | }}
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform exercise testing </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}
{{familytree | | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | | | D05 | | | | | | | |D01= <div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Perform [[exercise testing]] </div>|D03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D04=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if valve morphology is favorable for [[PMBV|PMBC]]</div>|D05=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Monitor patient periodically</div>}}
{{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}
{{familytree | |,|-|-|^|.| | | | |!| | | | | |)|-|-|-|.| | | |)|-|-|-|.| | | | | | | }}
{{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess if [[PCWP]] > 25 mm Hg on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}
{{familytree | E01 | | E02 | | | E03 | | | | E04 | | E05 | | E06 | | E07 | | | |E01=Yes|E02=No|E03=❑ Assess if [[PCWP]] > 25 mm Hg on exercise|E04=Yes|E05=No|E06=No|E07=Yes}}
{{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}
{{familytree | |!| | | |!| | | | |!| | | | | |!| | | |`|-|v|-|'| | | |!| | | | | }}
{{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if patient is severely symptomatic (NYHA III/IV)<br>❑ Assess if the risk of surgery is high</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with PMBC if [[PCWP]] > 25 mm Hg<br>❑ Monitor patient periodically if [[PCWP]]< 25 mm Hg  </div>|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess for the presence of new onset [[AF]]|F07=❑ Monitor patient periodically}}
{{familytree | F01 | | F02 | | | F03 | | | | F04 | | | | F05 | | | | F06 | | | |F01=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Proceed with [[PMBV|PMBC]] </div>|F02=<div style="float: left; text-align: left; width: 8em; padding:1em;">❑ Assess if patient is severely symptomatic ([[NYHA class|NYHA III/IV]])<br>❑ Assess if the risk of surgery is high</div>|F03=<div style="float: left; text-align: left; width: 8em; padding:1em;">'''If [[PCWP]] > 25 mm Hg:'''<br> ❑ Proceed with [[PMBV|PMBC]] <br>'''If [[PCWP]]< 25 mm Hg''' :<br>❑ Monitor patient periodically   </div>|F04=❑ Proceed with [[PMBV|PMBC]]|F05=❑ Monitor patient periodically|F06=❑ Assess for the presence of new onset [[AF]]|F07=❑ Monitor patient periodically}}
{{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}
{{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | }}
{{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=[[AF]] present|G04= No [[AF]]}}
{{familytree | | | G01 | | G02 | | | | | | | | | | | | | | | | | G03 | | G04 | |G01= Yes|G02=No|G03=[[AF]] present|G04= No [[AF]]}}
{{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}
{{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | |!| | | |!| | | }}
{{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}
{{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | H03 | | H04 | |H01=❑ Proceed with [[PMBV|PMBC]] |H02=❑ Proceed with [[mitral valve surgery]]|H03=❑ Proceed with [[PMBV|PMBC]]|H04=❑ Monitor patient periodically }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
{{familytree/end}}
<span style="font-size:85%">'''MVA''': Mitral valve area; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''PCWP''': Pulmonary capillary wedge pressure; '''ms''': milliseconds; '''NYHA''': New York Heart Association; '''AF''': Atrial fibrillation </span> <br>


==Additional Management==
==Additional Management==

Revision as of 23:25, 10 March 2014


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Definition

Mitral stenosis refers to abnormal narrowing of mitral orifice which leads to obstruction of blood flow from left atrium to left ventricle and development of a pressure gradient between the two chambers.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Initial Evaluation

Shown below is an algorithm summarizing the approach to [[disease name]].

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Pulse

Tachycardia
❑ Reduced pulse pressure
Irregularly irregular (with onset of AF)
❑ Reduced in volume

Head:
❑ Mitral facies

❑ Plethoric cheeks with bluish patches

Neck:
Jugular venous distension

❑ Prominent a wave in right heart failure
❑ Absent a wave in AF
❑ Prominent v wave in TR

Chest:
❑ Left parasternal heave
❑ Loud S1
❑ Loud P2 (indicates pulmonary hypertension)
❑ Opening snap
Murmur

Mid diastolic murmur (low pitched, rumbling)
Holosystolic murmur indicates TR
Graham-Steell murmur indicates pulmonary regurgitation
Rales
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform EKG
❑ Perform chest X-ray
❑ Perform transthoracic echocardiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess the following on TTE:

❑ Valve area
❑ Disease of other valves
❑ Left ventricular function
❑ Suitability of valve morphology for PMBC

❑ Wilkins score < 9 PLUS
❑ Less than moderate MR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Management

Shown below is an algorithm summarizing the approach to management of mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.[2]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess the presence of symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess the severity of mitral stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess the severity of mitral stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Very severe
❑ MVA ≤ 1 cm2
❑ Pressure half time ≥ 220 ms
Stage D
 
Severe
❑ MVA ≤ 1.5 cm2
❑ Pressure half time ≥ 150 ms
Stage D
 
Progressive
❑ MVA > 1.5 cm2
Pressure half time < 150 ms
 
 
 
Very severe
❑ MVA ≤ 1 cm2
❑ Pressure half time ≥ 220 ms
Stage C
 
 
 
 
 
Severe
❑ MVA ≤ 1.5 cm2
❑ Pressure half time ≥ 150 ms
Stage C
 
 
 
Progressive
❑ MVA > 1.5 cm2
Pressure half time < 150 ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess if valve morphology is favorable for PMBC
 
 
 
❑ Perform exercise testing
 
 
 
❑ Assess if valve morphology is favorable for PMBC
 
 
 
 
 
❑ Assess if valve morphology is favorable for PMBC
 
 
 
❑ Monitor patient periodically
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
❑ Assess if PCWP > 25 mm Hg on exercise
 
 
 
Yes
 
No
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with PMBC
 
❑ Assess if patient is severely symptomatic (NYHA III/IV)
❑ Assess if the risk of surgery is high
 
 
If PCWP > 25 mm Hg:
❑ Proceed with PMBC
If PCWP< 25 mm Hg :
❑ Monitor patient periodically
 
 
 
❑ Proceed with PMBC
 
 
 
❑ Monitor patient periodically
 
 
 
❑ Assess for the presence of new onset AF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AF present
 
No AF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with PMBC
 
❑ Proceed with mitral valve surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with PMBC
 
❑ Monitor patient periodically
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

MVA: Mitral valve area; PMBC: Percutaneous mitral ballon commissurotomy; PCWP: Pulmonary capillary wedge pressure; ms: milliseconds; NYHA: New York Heart Association; AF: Atrial fibrillation

Additional Management

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical therapy

❑ Consider heart rate control in MS patients with:

❑ Normal sinus rhythm and symptoms present on exercise
AF and fast ventricular response

❑ Consider anticoagulation therapy in MS patients with:

AF
❑ Prior embolic event
Left atrial thrombus
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

Dont's

References

  1. Tadele, H.; Mekonnen, W.; Tefera, E. (2013). "Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients". BMC Cardiovasc Disord. 13 (1): 95. doi:10.1186/1471-2261-13-95. PMID 24180350. Unknown parameter |month= ignored (help)
  2. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.


Template:WikiDoc Sources