This document discusses mitral stenosis, including its causes, pathophysiology, symptoms, physical exam findings, investigations, severity classifications, complications, differential diagnosis, and treatment options. The main points are: - Mitral stenosis is usually caused by rheumatic fever and leads to scarring and narrowing of the mitral valve. This restricts blood flow from the left atrium to the left ventricle. - Symptoms include dyspnea, palpitations, fatigue and hemoptysis due to elevated left atrial pressures. Physical exam may reveal an accentuated S1, opening snap, and mid-diastolic murmur. - Severity is classified by valve area (

1. Dr. Swarnalatha Devi MD
Professor of Medicine

2. MITRA VALVULAR DISEASE

3. MITRAL STENOSIS
 Aetiology and pathophysiology
 Mitral stenosis is almost always rheumatic in origin,
although in the elderly it can be caused by heavy
calcification of the mitral valve apparatus.
 There is also a rare from of congenital mitral
stenosis.

4. AETIOLOGY
 Rheumatic heart disease.
 Congenital—parachute mitral valve.
 Hunter”, hurler” syndrome.
 Drugs---methysergide.
 Carcinoid syndrome.

5. PATHO PHYSIOLOGY
 In rheumatic mitral stenosis, the mitral valve orifice is
slowly diminished by progressive fibrosis, calcification of
the valve leaflets, and fusion of the cusps and subvalvular
apparatus.
 The flow of blood from left atrium to left ventricle is
restricted and left atrial pressure rises, leading to pulmonary
venous congestion and breathlessness.
 There is dilatation and hypertrophy of the left atrium, and
left ventricular filling becomes more dependent on left atrial
contraction.

6. PATHOPHYSIOLOGY
 Any increase in heart rate shortens diastole when
the mitral valve has to open it produces further
rise in left atrial pressure;
 Situations that demand an increase in cardiac
output will also increase left atrial pressure.
 Exercise and pregnancy are therefore poorly
tolerated.

7.  The mitral valve orifice is 4 -5 cm2 in diastole and
may be reduced to 1 cm2 or less in severe mitral
stenosis.
 Patients usually remain asymptomatic until the
stenosis is approximately 2 cm2 or less.
 At first, symptoms may occur only on exercise, in
severe stenosis, left atrial pressure is permanently
elevated so breathlessness occurs even at rest due
to.Chronic pulmonary venous congestion.
 Low cardiac output may cause fatigue.

8.  Pulmonary hypertension may lead to right ventricular
hypertrophy and dilatation, tricuspid regurgitation and
right heart failure.
 Less than 20% of patients remain in sinus rhythm;
many of these have a small fibrotic left atrium and
severe pulmonary hypertension.
 All patients with mitral stenosis, and particularly those
with atrial fibrillation, are at risk from left atrial
thrombosis and systemic thromboembolism.
.

9. SYMPTOMS
 Dyspnoea.
 Palpitations.
 Fatigue.
 Hemoptysis.
 Recurrent bronchitis.

10. CLINICAL EXAMINATION
 MITRAL FACIES.
 SMALL VOLUME PULSE.
 LEFT PARASTERNAL HEAVE.
 TAPPING APICAL IMPULSE (PALPABLE S1)

11.  Loud S1 ,opening snap,(in pliable valve). This is due
to diastolic buckling of anterior mitral or tricuspid
leaflet due to elevated left or right atrial pressure.
 A low pitched ,rough ,rumbling mid diastolic murmur
with pre systolic accentuation best heard over apex,
with bell of stethoscope in left lateral position,in
expiration.
 ESM over pulmonary area if there is PAH. Pan
systolic murmur in tricuspid area in functional TR.

12. © Continuing Medical
Implementation
…...bridging the care gap
Mitral Stenosis: Physical Exam
 First heart sound (S1) is accentuated and snapping
 Opening snap (OS) after aortic valve closure
 Low pitch diastolic rumble at the apex
 Pre-systolic accentuation (esp. if in sinus rhythm)
S1 S2 OS S1

13. INVESTIGATIONS
 ECG—”P” MITRALE AND RIGHT
VENTRICULAR HYPERTROPHY.
 ATIAL FIBRILLATION ---ABSENT P WAVES
,VARYING R-R INTERVALS.
 X—RAY CHEST—LEFT ATRIAL
ENLARGEMENT
 STRAIGHTENING OF LEFT BORDER
 KERLY A, B LINES
 R A O WITH BARIUM SWALLOW-
COMPRESSION BY LEFT ATRIUM

14. © Continuing Medical
Implementation
…...bridging the care gap
A 75 year old woman with loud first heart
sound and mid-diastolic murmer

15.  ECHO CARDIOGRAM—THICKENED
,IMMOBILE CUSPS, REDUCED RATE OF
DIASTOLIC FILLING. REDUCED VALVE
AREA.
 CARDIAC CATHETERISATION—
PRESSURE GRADIENT BETWEEN LA AND
LV

17. Mitral Stenosis

18. SEVERITY
 ACCORDING TO VALVE AREA----
 -4-6 cm2-----------NORMAL
 > 2.5 cm2-----------NO SYMPTOMS
 1.5—2.5 cm2---MILD -DYSPNOEA ON EXERTION
 1-1.5 cm2---MODERATE- PND +P .EDEMA
 <1cm2---SEVERE /CRITICAL -ORTHOPNEA –CLASS 1V

19.  ACCORDING TO A2—OS INTERVAL
 IN SEVERE MS---- THIS PERIOD IS
SHORTENED.—0.05-0.07 SEC
 MILD MS— 0.10-0.12 SEC
 ACCORDING TO PRESSURE GRADIENT
ACROSS MITRAL VALVE—
 MILD-<5 mm Hg
 MODERATE—5—15 mm Hg
 SEVERE-->15 mm Hg
 DURATION OF DIASTOLIC MURMUR IS
DIRECTLY PROPORTIONAL TO THE
SEVERITY

20. COMPLICATIONS
 HEMOPTYSIS---
 Due to pulmonary apoplexy.
 Acute LVF—pulmonary edema.
 Pulmonary congestion.
 Recurrent bronchitis.
 Pulmonary infarction.

21.  ATRIAL FIBRILLATION--
 2/3 will have AF
 Pulse is irregularly irregular
 No a waves in JVP
 Intensity of S1 is variable
 AF precipitates---CCF, thrombo embolic
phenomenon

22.  Infective endocarditis.
 Pressure symptoms----ortners syndrome----
compression of recurrent laryngeal nerve by left
atrium.
 Left bronchus--bronchiectasis.

23. DIFFERENTIAL DIAGNOSIS
 Left atrial myxoma.
 Cortriatritum.
 Ball valve thrombus of left atrium.
 Flow murmurs of VSD, ASD, PDA.
 Carey-coombs murmur.

24. Medical Management
 Anti failure measures.
 Anticoagulation in atrial fibrillation.
 Rheumatic fever prophylaxis.
 Infective endocarditis prophylaxis.

25. SURGICAL TREATMENT
 Closed mitral valvotomy/commissurotomy—(with
out cardio pulmonary by pass).
 Open mitral valvotomy/commissurotomy (with aid
of cardio pulmonary by pass).
 Per cutaneous balloon valvuloplasty.
 Mitral valve replacement.

26.  Closed mitral valvotomy—in pliable valve and ,no
mitral regurtitation
 Open mitral valvotomy---in this valve, sub valvular.
C hordae tendinae are loosened,
calcific deposits removed
Thrombi if present are removed.

27.  Percutaneous balloon valvuloplasty---in pregnant
women, Severe extracardiac disease.
 Criteria-
 -Significant symptoms
 Isolated MS.
 No mitral regurgitation.
 Mobile, non calcified valve.
Normal sub valvular apparatus
No thrombus in left atrium

28. VALVE REPLACEMENT----
 Associated MITRAL REGURGITATION
 Valve rigid, and calcified.
 Mechanical prosthesis—
 Caged ball valve(starr-edward prosthesis).
 TILTING DISK valves(st jude.Bjork-shiely valves)

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