Mitral stenosis is commonly caused by rheumatic heart disease which leads to inflammation and fusion of the mitral valve leaflets, reducing the mitral valve orifice area. Severe mitral stenosis, defined as a mitral valve area less than 1.0 cm2, can cause pulmonary hypertension, pulmonary edema, atrial fibrillation, and right heart failure as the heart tries to maintain sufficient cardiac output against the back pressure. Physical exam may reveal signs of pulmonary hypertension like a loud pulmonary component to S2, as well as a tapping apex, opening snap, and mid-diastolic rumble on cardiac auscultation. Echocardiography can determine the severity of mitral stenosis and assess

1. MITRAL STENOSIS
K. Kavindya M. Fernando
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2. Mitral stenosis
• Mitral valve
– Consist of fibrous annulus,
– Anterior & posterior leaflets
– Chordae tendinae,
– Papillary muscle
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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
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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
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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
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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
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7. Symptoms
• Palpitation
• Systemic emboli
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• Dyspnoea
• Pulmonary infections
(Recurrent bronchitis)
• Haemoptysis
• Cough
• R/ heart failure
• Fatigue
• Abdominal and lower
limb swelling
Atrial fibrillation Pulmonary Hypertension

8. Signs
• Face : Mitral fascies
• Pulse : atrial fibrillation
• RV : Heaving, sustained
• Apex: Localized, tapping
• Sounds: Loud S1, Loud P2 (if
pulmonary hypertension),
opening snap
• Murmurs: Mid diastolic rumble at apex
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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
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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
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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
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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
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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
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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)
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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
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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
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18. Investigations
• Chest X-ray
• Electrocardiogram
• Echocardiogram
• Cardiac magnetic resonance
• Cardiac catheterization
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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
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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
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21. Investigations –ECG
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22. Investigations –ECG
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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
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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
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25. Treatment
• Operative therapies
– Trans-septal balloon valvotomy
– Closed valvotomy
– Open valvotomy
– Mitral valve replacement
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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
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27. Treatment: Trans-septal balloon
valvotomy
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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
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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
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30. Treatment: Open valvotomy
• Often preferred to closed valvotomy
• Cusps are carefully dissected apart
under direct vision
• Cardiopulmonary bypass is requied
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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
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