The document discusses mitral stenosis (MS), a narrowing of the mitral valve that restricts blood flow from the left atrium to the left ventricle. Rheumatic fever is the most common cause of MS, resulting in chronic inflammation and scarring of the mitral valve leaflets over time. Symptoms of MS range from being asymptomatic to dyspnea, orthopnea, palpitations, and hemoptysis in severe cases. Diagnosis involves auscultation of a mid-diastolic murmur, ECG showing left atrial enlargement, chest X-ray with double cardiac shadows and Kerley lines, and echocardiogram demonstrating thickened immobile valve leaflets.

1. - Dr Rahul Arya
- Assistant Professor
- Department of Medicine

2. ANATOMY OF HEART

3. ANATOMY OF MITRAL VALVE

4. ETIOLOGY
• Rheumatic fever- most common cause
• Other rare causes:-
- Congenital
- Severe mitral annular calcification
- SLE, RA

5. PATHOLOGY
• Chronic inflammation leads to diffuse thickening of the valve leaflets
with formation of fibrous tissue and/or calcific deposits.
• The mitral commissures fuse, the chordae tendineae fuse and
shorten, the valvular cusps become rigid, and these changes, in turn,
lead to narrowing at the apex of the funnel-shaped (“fish-mouth”)
valve.

6. PATHOPHYSIOLOGY
• Normal area of the mitral valve orifice is 4–6 cm2
• 1.5- 2.5 cm2 – mild MS
• 1-1.5 cm2 – mod MS
• < 1 cm2 – severe MS

7. CLINICAL FEATURES- SYMPTOMS
• Asymptomatic
• Dyspnea, orthopnea,PND.
• Palpitations- AF
• Hemoptysis results from rupture of pulmonary-bronchial venous
connections secondary to pulmonary venous hypertension.
• Pulmonary infections, i.e., bronchitis, bronchopneumonia, and lobar
pneumonia.

8. CLINICAL FEATURES-SIGN
• Mitral Facies- malar flush
• Left parasternal heave- RVH
• Tapping apical impulse
• Diastolic thrill over mitral area
• Loud S1

9. •Opening Snap
•Low pitched rumbling mid diastolic murmur with presystolic
accentuation best heard over the apex with the bell of the stethoscope in
left lateral position ,in expiration.

10. SEVERITY OF MS
a) According to A2-OS interval  in severe MS interval becomes shortened.
b) According to gradient across stenotic valve:-
• Normal valve gradient is 0 mmHg
• Mild MS - <5 mmHg
• Moderate MS- 5 to 15 mm Hg
• Severe MS- >15 mm Hg
c) Duration of Diastolic murmur is directly proportional to the severity.

11. Laboratory Examination
1) ECG:-
- P mitrale ( LAE)

12. -Features of atrial fibrillation  absent P wave and varying R-R interval.

13. 2) Chest X-ray:
- Left atrial enlargement 
double heart border
- Straightening of left heart
border (due to prominent
pulmonary artery and LA
appandeges).
- Kerley B and Kerley A lines.

14. 3) Echocardiogram:
- Thickened immobile cusps
- Reduced valve area
- Reduced rate of diastolic filling

15. MEDICAL MANAGEMENT
1. Penicillin prophylaxis of group A β-hemolytic streptococcal infections.
2. Oral diuretics
3. Atrial fibrillation:-
- Beta blockers, nondihydropyridine calcium channel blockers (e.g.,
verapamil or diltiazem), and digitalis glycosides.
- Anticoagulation- Warfarin.

16. SURGICAL MANAGEMENT
• Four modalities of surgery are available:
1. Closed mitral valvotomy/commissurotomy.
2. Open mitral valvotomy/commissurotomy.
3. Percutaneous balloon valvuloplasty.
4. Mitral valve replacement.

17. 1) Closed mitral valvotomy/commissurotomy.
• Preferred in patients with pliable valve and when there is no
associated MR.
2) Open mitral valvotomy/commissurotomy.
• Done for patients with pure MS who have not been operated upon
previously.

18. 3) Percutaneous balloon valvuloplasty.
• It is useful in pregnant women with MS and also for older patients
with severe valvular deformity and other extracardiac disease who
are poor operative candidates.

20. 4) Mitral valve replacement:
• When there is associated MR or when the valve is rigid and calcified,
valve replacement is indicated.
• Valve replacement is done using:
a. Mechanical Prosthesis
b. Bioprosthesis

21. • Life long anticoagulation is indicated in patients receiving mechanical
prosthesis.
• Bioprosthetic valves are not usually used in young patients < 65 years
because of its rapid deterioration.
• However, they are useful in pregnancy, when there is contraindication
to the use of anticoagulants and also in older patients over 65 years
of age.