Mitral stenosis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]; Mohamed Moubarak, M.D. [3]

Mitral Stenosis Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Medical Therapy
Summary for Mitral Stenosis Intervention
Rheumatic Fever Prophylaxis
Do's

Overview

Mitral stenosis refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from left atrium to left ventricle most commonly as a complication of rheumatic fever. The most common presentations of mitral stenosis are dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. Mitral stenosis has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for mitral stenosis include percutaneous balloon valvotomy, surgical mitral valve repair, or mitral valve replacement.

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

Click here for the complete list of causes

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the red color signify that an urgent management is needed.

 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of mitral stenosis

Mid diastolic murmur
❑ Low-pitched diastolic rumble
❑ Associated with an opening snap
❑ Best heard at the cardiac apex
❑ Radiating to the axilla
❑ Increases with lying down, raising the legs and with exercise
❑ Decreases with valsalva maneuver and amyl nitrate
❑ Reduced pulse pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings of decompensated mitral stenosis that require urgent management?
Tachycardia
Hypotension
Severe dyspnea
Loss of consciousness
Chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the complication of mitral stenosis that is causing decompensation?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Suspect in case of:
❑ Sudden weakness or paralysis - face, arm or leg
❑ Speech or visual difficulties
Altered level of consciousness
❑ Sudden severe headache
 

❑ Suspect in case of palpitations
❑ Order an ECG immediately looking for
❑ Irregularly irregular rhythm, and
❑ Absent P waves
 

❑ Suspect in case of:
❑ Acute onset of exertional dyspnea or dyspnea at rest
❑ Pleuritic or substernal chest pain
Hemoptysis
 

❑ Suspect in case of severe dyspnea
❑ Increased jugular venous pressure immediately

Hepatomegaly ± pulsatile liver

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat the complications of mitral stenosis that lead to decompensation
❑ Order a TTE to evaluate the severity of the mitral stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
When to consider intervention in mitral stenosis ?
Continue with the treatment algorithm below
 
 
 
 
 
 
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2].
Abbreviations: AF: Atrial fibrillation; PMBC: Percutaneous mitral ballon commissurotomy; TR: Tricuspid regurgitation; S1: First heart sound; P2: Pulmonary component of second heart sound; EKG: Electrocardiogram; TTE: Transthoracic echocardiography; MS: Mitral stenosis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Appearance of the patient
❑ Plethoric cheeks with bluish patches

Vital signs

Pulse

❑ Rate
Tachycardia
❑ Rhythm
Irregularly irregular (suggestive of AF)
❑ Strength
❑ Reduced pulse pressure
❑ Reduced in volume

Neck:
Jugular venous distension

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

Chest examination:

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

Mid diastolic murmur (low pitched, rumbling)
Holosystolic murmur (suggestive of TR)
Graham-Steell murmur (suggestive of pulmonary regurgitation)

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Video adapted from Youtube.com

Rales
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

❑ Perform EKG

Left atrial enlargement
❑ Broad, bifid P wave in lead II (P mitrale)


Picture adapted from en.ecgpedia.org

❑ Biphasic P wave with terminal negative portion

Left atrial enlargement as seen in lead V1
Picture adapted from en.ecgpedia.org

Right ventricular hypertrophy
Right axis deviation of +90 degrees or more
❑ RV1 = 7 mm or more
❑ RV1 + SV5 or SV6 = 10 mm or more
❑ R/S ratio in V1 = 1.0 or more
❑ S/R ratio in V6 = 1.0 or more
❑ Incomplete RBBB pattern
❑ ST T strain pattern in leads 2,3,aVF
P pulmonale or right atrial enlargement or P congenitale
❑ R wave progression reversal
❑ Inverted T wave in the anterior precordial leads
Right axis deviation
QRS complex is positive in leads III and aVF
QRS complex is negative in leads I and aVL


Atrial fibrillation
❑ Absence of P waves
❑ Irregularly irregular heart rate


Picture adapted from Wikidoc.org

❑ Perform chest X-ray

❑ Double right heart border (suggestive of left atrial hypertrophy)
❑ Prominent pulmonary artery
Kerley lines (suggestive of interstitial pulmonary edema)


Picture adapted from Radiopedia.org
❑ Perform transthoracic echocardiography

❑ Assess valve area
❑ Assess disease of other valves
❑ Assess mean pressure gradient
❑ Assess pulmonary artery pressure
❑ Assess suitability of valve morphology for PMBC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:

Myxoma

❑ Obstruct the mitral orifice
❑ Exclude with echocardiography

Atrial fibrillation

❑ Order echocardiography to exclude mitral stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify mitral stenosis based on the following findings on TTE:
❑ Valve anatomy
❑ Valve hemodynamics gradient
❑ Hemodynamic consequences
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stage A

❑ No symptoms
❑ Patient at risk of developing mitral stenosis
❑ Mild valve doming during diastole
❑ Normal transmitral flow velocity
 
Stage B

❑ No symptoms
❑ Progressive mitral stenosis
❑ Valve area > 1.5 cm²
❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets
❑ Increased transmitral flow velocities
❑ Diastolic pressure half-time < 150 ms
❑ Mild to moderate left atrial enlargement
❑ Normal pulmonary pressure at rest
 
Stage C

❑ Asymptomatic severe mitral stenosis
❑ Valve area ≤ 1.5 cm² (≤ 1 cm² in severe mitral stenosis)
❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets
❑ Diastolic pressure half-time ≥ 150 ms (≥ 220 ms with very severe mitral stenosis)
❑ Elevated pulmonary artery systolic pressure > 30 mmHg
❑ Severe left atrial enlargement
 
Stage D

❑ Symptomatic severe mitral stenosis
❑ Valve area ≤ 1.5 cm² (≤ 1 cm² in severe mitral stenosis)
❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets
❑ Diastolic pressure half-time ≥ 150 ms (≥ 220 ms with very severe mitral stenosis)
❑ Elevated pulmonary artery systolic pressure > 30 mmHg
❑ Severe left atrial enlargement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Shown below is an algorithm summarizing the management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.[2]
MVA: Mitral valve area; PMBC: Percutaneous mitral ballon commissurotomy; PCWP: Pulmonary capillary wedge pressure; ms: milliseconds; NYHA: New York Heart Association; AF: Atrial fibrillation

Medical Therapy

The filling of the left ventricle depends upon the diastole time which is limited by mitral stenosis. Therefore, slowing the heart rate is crucial in the initial management of mitral stenosis in order to improve the diastole time and consequently improve the filling of the left ventricle.

 
 
 
 
Classify mitral stenosis based on TTE:
❑ Valve anatomy
❑ Valve hemodynamics gradient
❑ Hemodynamic consequences
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stage A
 
Stage B
 
Stage C
 
Stage D
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Yearly follow up is recommended with history and physical examination in asymptomatic patients with mild MS
❑ For mild MS repeat echocardiography every 3-5 years[3]
❑ For moderate MS repeat echocardiography every 1-2 years[3]
❑ The onset of symptoms require medical therapy and re-evaluation of the stage as the patient may also need intervention in moderate and severe disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The presence of symptoms is an indication for intervention

Indications for pharmacotherapy:
❑ Alleviate symptoms before surgery
❑ Control symptoms precipitated by intercurrent illness or during pregnancy
❑ Persistent symptoms after intervention
Medications:
Diuretics: used to relieve symptoms of pulmonary vascular congestion (shortness of breath, orthopnea and paroxysmal nocturnal dyspnea) and in case of right sided heart failure
Beta blockers: useful to control exertional symptoms as it decreases heart rate and cardiac output during exercise, thus decreasing the rise in transmitral gradient
Digoxin: used in case of right or left ventricular systolic dysfunction and also during atrial fibrillation (not the first line)
Statin therapy: slower progression of rheumatic mitral stenosis[4]
Antithrombotic recommendations:
Consider anticoagulation therapy in MS patients with:
AF
❑ Prior embolic event
❑ Left atrial thrombus
Long term oral anticoagulation (2.0-3.0 INR)

Prevention of endocarditits:
No longer require antimicrobial prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Summary for Mitral Stenosis Intervention

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 the new onset AF is present
 
 
 
❑ Monitor patient periodically
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
❑ Assess PCWP on exercise
 
 
 
Yes
 
No
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with PMBC
 
If patient is severely symptomatic (NYHA III/IV):
❑ Assess the surgical risk of patient
 
 
If PCWP > 25 mm Hg:
❑ Proceed with PMBC
If PCWP< 25 mm Hg :
❑ Monitor patient periodically
 
 
 
❑ Proceed with PMBC
 
 
 
❑ Monitor patient periodically
 
 
 
❑ Assess if the valve morphology is favorable for PMBC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with PMBC
 
❑ Proceed with mitral valve surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with PMBC
 
❑ Monitor patient periodically
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Summary of Recommendations for Mitral Stenosis Intervention

Rheumatic Fever Prophylaxis

Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease.[5]

Secondary prevention of rheumatic fever
Penicillin G benzathine 1.2 million units IM every day for 4 weeks
Penicillin V potassium 200 mg orally twice a day
Sulfadiazine 1 g orally once a day
Macrolide antibiotics (in patients allergic to penicillin) Varies


Indications Duration of prophylaxis
Rheumatic fever with carditis and persistent valvular heart disease 10 years or until the patient is 40 years (whichever is longer)
Rheumatic fever with carditis but no valvular heart disease 10 years or until the patient is 21 years (whichever is longer)
Rheumatic fever without carditis 5 years or until the patient is 21 years (whichever is longer)

Do'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. 2.0 2.1 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.
  3. 3.0 3.1 "2008 Focused update incorporated into the ACC/AH... [Circulation. 2008] - PubMed - NCBI".
  4. "Effect of hydroxymethylglutaryl coenzyme-a reduc... [Circulation. 2010] - PubMed - NCBI".
  5. 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: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000031. PMID 24589853.


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