3. Mitral stenosis
• Commonest cause :rheumatic heart
disease
• Infections with group A beta hemolytic
streptococci
• More common in women
• Inflammation leads to commissural
fusion and a reduction in mitral valve
orifice area
JMJ 3
4. Pathophysiology
• Normal valve area: 4-6 cm2
• Mild mitral stenosis:
– MVA 1.5-2.5 cm2
– Minimal symptoms
• Moderate mitral stenosis
– MVA 1.0-1.5 cm2 usually does not produce
symptoms at rest
• Severe mitral stenosis
– MVA < 1.0 cm2
JMJ 4
5. To maintain sufficient cardiac
output
1. Left arterial pressure increases
2. Left arterial hypertrophy and dilation
3. Pulmonary veins, pulmonary arterial and R/
heart pressure increases
4. Increase of pulmonary capillary pressure
5. Followed by development of
– pulmonary oedema
– Atrial fibrillation with tachycardia
– Loss of coordinated atrial contraction
JMJ 5
6. To maintain sufficient cardiac
output
6. This is prevented by (Reactive
pulmonary hypertension)
– Alveolar and capillary thickening
– Pulmonary arterial vasoconstriction
7. Pulmonary hypertension leads to
– R/ ventricular hypertrophy, dilation and
failure with subsequent tricuspid
regurgitation
JMJ 6
9. Mitral Stenosis: Physical
Exam
• First heart sound (S1) is accentuated & 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
10. Signs (Face)
• Severe mitral stenosis with pulmonary
hypertension
• Mitral fascies / malar rash
• Bilateral
• Cyanotic or dusky pink
discolouration
• Over the upper cheeks
• Due to atriovenous anastomosis &
• Vascular stasis
JMJ 10
11. Signs (Pulse)
• Small volume pulse
• Usually regular in early stages,
• If the patient is in sinus rhythem
• In severe disease, may develop atrial
fibrillation
• Irregularly irregular pulse
JMJ 11
12. Signs (Jugular Veins)
• If R heart failure develops
• obvious distension of jugular veins
• If pulmonary hypertension or tricuspid
stenosis is present
• ‘a’ Wave will be prominent
JMJ 12
13. Signs (Palpation)
• Tapping impulse felt parasternally on
left side
• Palpable 1st heart sound
• Combined with left ventricular backward
displacement
• Produced by an enlarging left ventricle
• Sustained parasternal impulse
• Due to R ventricular hypertrophy
JMJ 13
14. Signs (Auscultation)
• Loud 1st heart sound
– If the mitral valve is pliable
– It will not occur in calcified mitral stenosis
• Opening snap
– Valve suddenly opens with the force of the
increased L arterial pressure
• Low pitched ‘rumbling’ mid diastolic murmur
– Best heard with bell held lightly
– At the apex with the patient lying on the left side
JMJ 14
15. Signs (Auscultation)
• If the patient is in sinus rhythm
– Murmur becomes louder at the end of
diastole
– As a result of atrial contraction
– (Pre- systolic accentuation)
JMJ 15
16. How to determine the severity of
mitral stenosis
• Presence of pulmonary hypertension
– Recognized by R/ ventricular heave & loud
pulmonary component of 2nd heart sound
– And signs with R heart failure : Oedema,
hepatomegaly
– Graham Steell murmur
JMJ 16
17. How to determine the severity of
mitral stenosis
• Closeness of the opening snap to the 2nd
heart sound ∞ severe MS
• Length of mid-diastolic murmur ∞ severity
• As the valve cusps become immobile
– Loud 1st heart sound softens
– Opening snap diasppears
– When pulmonary hypertension occurs : P2
intensity increase, mid diastolic murmur
become quieter
JMJ 17
19. Investigations –X-ray
• Small heart with an enlarged L/ atrium
• Pulmonary venous hypertension
• Calcified mitral valve– on penetrated or
lateral view
• Signs of pulmonary oedema or pulmonary
hypertension
JMJ 19
20. Investigations –ECG
• Sinus rhythm in ECG shows a bifid P wave
– Owing to delayed L/atrial activation
• Atrial fibrillation may be present
• ECG features of R/ventricular hypertrophy
– Right axis deviation
– Perhaps tall R wave in lead V1
JMJ 20
23. Investigations –Echocardiogram
• Transthoracic echocardiography
– To determine L/ R/ atrial and ventricular
size
– The sevirity of MS
• Transoesophageal Echocardiography
(TOE)
– To detect the presence of L/ atrial
thrombus
JMJ 23
24. Treatment
• Need no treatment other than prompt therapy
of attacks of bronchitis
• Early symptoms like dyspnea - diuretics
• Onset of atrial fibrillation :digoxin,
anticoagulants (to prevent atrial thrombus and
systemic embolism)
• If pulmonary hypertension or symptoms of
pulmonary congestion : surgical therapy
JMJ 24
26. Treatment: Trans-septal balloon
valvotomy
• Catheter introduced into R atriam via femoral
vein
• Under local anasthesia
• Inter atrial septum is punctured
• Catheter enter into left atrium then to mitral
valve
• Balloon is inflated, briefly to split the valve
commissures
JMJ 26
28. Treatment: Trans-septal balloon
valvotomy
• Complications
– Regurgitation may result
• Contraindications
– Heavy calcification
– More than mild mitral regurgitation &
thrombus in the L/atrium
• TOE is done before this procedure
JMJ 28
29. Treatment: Closed valvotomy
• For the patients with
– mobile,
– non calcified and
– non regurgitant mitral valves
• Fused cusps forced apart by a dilator
(introduced through the apex of L/ ventricle)
• Cardiopulmonary bypass is not needed for this
operation
JMJ 29
30. Treatment: Open valvotomy
• Often preferred to closed valvotomy
• Cusps are carefully dissected apart
under direct vision
• Cardiopulmonary bypass is requied
JMJ 30
31. Treatment: Mitral valve replacement
• It is necessary if
– Mitral regurgitation is present
– Badly diseased or badly calcified stenotic
valve,
– Moderate or severe mitral stenosis &
thrombus in L atrium despite anticoagulation
• Artificial valve >20 yrs
• Anticoagulants are necessary
JMJ 31