Mitral stenosis

1.Etiology. Almost
all cases of mitral stenosis in adults are
secondary to rheumatic heart disease.
Most
cases
occur
in
women
Pathophysiologya.Mitral valve stenosis
impedes left ventricular filling, thereby
increasing left atrial pressure as a
pressure gradient develops across the
mitral valve. Elevated left atrial pressure
is referred to the lungs, where it produces
pulmonary congestion. As the stenosis
becomes
more
severe,
it
may
significantly reduce forward cardiac
output.b. Because the right ventricle is
r~sponsible for filling the left ventricle,
the burden of propelling blood across the
stenotic mitral valve is borne by the right
ventricle. The overload on the right
ventricle may be increased further when
secondary pulmonary vasoconstriction
occurs. Thus, the right ventricle must
generate enough force both to overcome
the resistance offered by the stenotic
valve and to propel blood through
constricted
pulmonar~
arteries.
Consequently,
pulmonary
arterial
pressure may increase to three to five
times normaL eventually resulting in right
ventricular iailure .3.Clinical features
a.Symptoms
(1)Left-sided
failure.
Dyspnea on exertion, orthopnea, and
paroxysmal nocturnal dyspnea occur as a
result of reduced left ventricular output
and increased left atrial pressure. In
mitral stenosis, the symptoms of left
ventricular failure usually are not
attributable to left ventricular dysfunction
but, rather, to the mitral stenosis itself. (2)
Right-sided failure. When pulmonary
hypertension occurs, the right ventricle
may fail, producing edema, ascites,
anorexia, and fatigue.(3)Hernoptysis. The
high left atriai pressu re produced in
mitral stenosis may lead to rupture of
small
bronchial
veins,
producing
hemoptysis.
(4)Svstem
embolism.
Stagnation of blood in the enlarged left
atrium and left atrial pressure occurs in
mitral stenosis, particularly if atrial
fibrillation is nresent. under these
circumstances, a thrombus may form in
the left atrium and can become a source
of systemic embolism. (5)Hoarseness
may occur in mitral stenosis as the
enlarged left atrium impinges on the left
recurrent laryngeal nerve tOrtners
syndrome). b.Physical signs (1) Atrial
fibrillation. Frequently, an irregularly
irregular cardiac rhythm indicative of
atrial fibrillation is present. (2)Pulmonary
rales. Bilateral pulmonary rales occur
secondar\ to elevated left atriai and

pulmonary
venous
pressures.
(3)Increased intensity of the S1. The S1,
usually increases In intensity because the
transrnitral gradient limits spontaneous
diastolic mitral \alve closure. Thus, the
mitral valve remains open until ventricular
systole closes it forcibly, resulting in an
increase in S1 intensity. Late in the
course of the disease, the valve may become so stenotic that it no longer opens
or closes, reducing the intensity of S1
(4)Increased
intensity of the P2
component of the 5. The P2 component of
the ~2 is usually increased in intensity if
pulmonary hypertension has developed.
(5)Opening snap. An opening snap is
heard following the ~2 as the stenotic
valve is forced open in diastole by the
high left atrial filling pressure. The higher
the pressure, the sooner the mitral valve
opens. Thus, a short interval (<0.10
second induration) indicates relatively
high left atrial pressure and severe
stenosis.(6)Diastolic rumble. The murmur
of mitral stenosis is a low-pitched apical
rumble, which begins after the opening
snap. If the patient is in sinus rhythm,
atrial systole produces a presystolic
accentuation of this murmur (7) Sternal
lift. Enlargement of the right ventricle as a
result of pulmonary hyperten produces a
systolic lift of the sternum.(8) Other
symptoms. Neck vein distention, edema,
hepatic enlargement, and ascites may he
present if right ventricular failure occurs.
4.Laboratory diagnosis a.ECG: The ECG
may show atrial fibrillation as well as
signs of left atrial enlargement and right
ventricular hypertrophy. b.Chest
radiography (1)Straightening of the left
heart border and a double density along
the right heart border (formed by the right
and left atria) occur as a result of left
atrial enlargement.(2)Signs of pulmonary
venous hypertension, including an
increase in pulmonary vascular markings
and Kerleys lines, are likely to be
present.(3)When pulmonary hypertension
leads to right ventricular enlargement, the
lateral view shows a loss of the
retrosternal airspace. C.Echocardiograph
usually provides excellent images of the
mitral valve. (1)The echocardiogram
shows reduction in the excursion of the
valve leaflets and thickening of the valve.
Two-dimensional echocardiography can
be used to visualize and measure the
residual mitral valve orifice, invariably, left
atrial enlargement is present. (2)Doppler
examination of the mitral valve may also
help to quantify the severity of the
stenosis 5.Therapy: a.Medical therapy is

reserved for patients with mild-tomoderate symptoms of left-sided failure.

(1)Diuretics. The mainsta\ of treatment,
these agents are used to control
pulmonary congestion and to limit
dyspnea and orthopnea. (2)Digitalis.
Because left ventricular muscle function
usually is normal in mitral stenosis, the
use of digitalis is of little benefit to
patients in sinus rhythm. In patients in
atrial fibrillation, however, digitalis is used
to slow ventricular rate. A rapid
ventricular rate in mitral stenosis shortens
diastole, thereby reducing left ventricular
filling, which, in turn, further increases left
atrial pressure and reduces cardiac
output. Il-Blockers and diltiazem or
verapamil may be added to digoxin if
further heart rate control is necessary.
(3)Anticoagulants. Patients with mitral
stenosis and coexistent atrial fibrillation
have a high incidence of systemic
embolism.
In
such
patients,
anticoagulation therapy. Balloon
valvuloplasty.Unlike balloon valvuloplasty
for aortic stenosis, balloon valvuloplastv
for mitral stenosis can offer effective longterm improvement. The best candidates
for balloon mitral valvuloplasty are those
in sinus rhythm with relatively mild mitral
regurgitation
and
mild-to-moderate
thickening of the mitral valve leaflets.
c.Surgical therapy is effective in relieving
the symptoms of mitral, stenosis and in
prolonging life in symptomatic patients.
Surgery should be performed prior to the
development of pulmonary hypertension,
which increases surgical risk. However, if
pulmonary hypertension is present and
surgery
is
successful,
pulmonary
hypertension
usually
regresses
postoperatively.
(1
Mitral
commissurotomy. In young patients
without significant ,alvular calcification or
mitral regurgitation, commissurotomy
allows relief of the stenosis without valve
replacement. (2)Mitral valve replacement.
If commissurotomy cannot be performed,
valve replacement relieves the stenosis
and the symptoms.