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Mitral valve stenosis

Last updated: August 12, 2021

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Mitral stenosis (MS) is a structural anomaly of the mitral valve resulting in a decreased cross-sectional area of the valve. The stenosis impairs blood flow from the left atrium to the left ventricle, progressively causing left atrial distension, pulmonary venous congestion, pulmonary hypertension, and congestive heart failure. MS is most commonly a complication of rheumatic fever and is slowly progressive. Patients typically remain asymptomatic for years until the mitral valve area becomes critically reduced. Patients with severe stenosis often present with atrial fibrillation and symptoms of heart failure (dyspnea, fatigue, orthopnea). Asymptomatic patients are initially managed conservatively and the mitral valve is regularly monitored with transthoracic echocardiography. Once symptoms develop or the valve area decreases to 1.5 cm2, percutaneous valvuloplasty or surgical intervention may be considered. Occasionally, patients with MS have heart failure secondary to tachycardia or increased cardiac demand and require urgent medical management.

American College of Cardiology/American Heart Association stages of mitral stenosis [1]
Stage Definition Symptoms Mitral valve area (cm2) Associated findings
A
  • At risk for MS
  • None
  • Normal
  • None
B
  • Progressive MS
  • > 1.5
  • Mild to moderate left atrial enlargement
  • Normal PASP
C
  • Asymptomatic severe MS
  • ≤ 1.5
  • Severe left atrial enlargement
  • PASP > 50 mm Hg
D
  • Symptomatic severe MS
  • ≤ 1.5
  • Severe left atrial enlargement
  • PASP > 50 mm Hg

Symptoms [2]

Patients with MS typically progress over many years from being asymptomatic to having symptoms of profound heart failure. Acute symptoms may occur in patients with tachyarrhythmias or an increased cardiac output secondary to pregnancy, sepsis, or exercise.

Examination findings [2]

Approach [1]

Initial evaluation

Transthoracic echocardiography (TTE) [3][4]

  • TTE is the most important test for diagnosing and guiding the treatment of mitral stenosis.
  • Characteristic findings include:
    • Reduced mitral valve area (MVA): ≤ 1.5 cm2 is considered to be severe MS
    • Thickened, calcified leaflets with commissural fusion
    • Increased mean diastolic pressure gradient across the mitral valve
    • Secondary cardiac changes, including:
  • MVA, valve pressure gradient, and presence or absence of symptoms and pulmonary artery hypertension are used to grade the severity of disease.

ECG [5]

Chest x-ray (PA and lateral views) [6]

Laboratory tests

Additional evaluation [1]

Further studies are indicated in select patients when TTE findings are unclear or do not correlate with symptoms, or when an intervention is planned.

Transesophageal echocardiography (TEE)

  • Indicated to confirm the diagnosis if TTE examination is technically suboptimal
  • Used prior to intervention to identify:

Stress testing [11]

Cardiac catheterization

Approach [1]

The following recommendations are for rheumatic MS. For all other causes of MS, early consultation with cardiology is recommended as treatment can vary significantly.

  • Initial management
    • General cardiac care and serial TTEs until signs or symptoms of disease progression occur [12]
    • In case of acute heart failure: immediate medical stabilizations and treatment of the precipitating cause
  • Indications for interventional management include:

Acute stabilization

Patients with mitral stenosis often develop acute heart failure following the onset of atrial fibrillation. Rapid and progressive treatment of atrial fibrillation is necessary in patients with severe mitral stenosis.

Conservative management

Many patients with mild to moderate disease can be managed conservatively for years. Patients should remain under the care of cardiology with regular monitoring of valve function.

Serial TTE examinations [1]

  • Serial TTEs are performed to monitor the progression of MS and guide the timing of interventions.
    • Patients typically do not develop symptoms until they have severe disease.
    • Early detection prevents irreversible cardiac changes.
  • Asymptomatic patients
    • Every 3–5 years if MVA is > 1.5 cm2
    • Every 1–2 years if MVA is 1–1.5 cm2
    • Annually if MVA is < 1 cm2
  • TTE should be repeated earlier if symptoms develop or change.

Optimizing medical therapy [1]

Decreased heart rate may also limit cardiac output and cause hypotension; monitor patients carefully.

Anticoagulation

Additional measures

Interventional management

Patients with severe or symptomatic MS should be considered for intervention.

Indications

Procedures

  • Percutaneous mitral valve balloon commissurotomy (PMBC) [15]
    • PMBC is the preferred intervention in most patients with severe MS.
    • A balloon catheter is advanced percutaneously through the mitral valve and inflated to break open commissural stenosis and increase the mitral valve area. [15][16]
    • The Wilkins score is used to determine eligibility.
  • Surgery
    • Surgical interventions include open commissurotomy and mitral valve (mechanical or bioprosthetic) replacement.
    • Indications
      • Unfavorable anatomy for PMBC
      • Presence of thrombus in the left atrium
      • Mixed valvular disease (e.g., severe MR, tricuspid disease)
    • Contraindicated if there is a prohibitively high surgical risk

We list the most important complications. The selection is not exhaustive.

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  2. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
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  9. Marwick TH, Amann K, Bangalore S, et al. Chronic kidney disease and valvular heart disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2019; 96 (4): p.836-849. doi: 10.1016/j.kint.2019.06.025 . | Open in Read by QxMD
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