Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 10-11: Mitral Stenosis + Key Features Download Section PDF Listen +++ ++ Underlying rheumatic heart disease in almost all patients (although history of rheumatic fever is often absent) + Clinical Findings Download Section PDF Listen +++ ++ An opening snap following A2 due to stiff mitral valve Interval between opening snap and aortic closure sound is long when the left atrial pressure is low but shortens as left atrial pressure rises and approaches the aortic diastolic pressure Low-pitched rumble at apex with patient in left lateral position, increased by brief exercise Moderate stenosis (valve area 1.5–1.0 cm2): exertional dyspnea and fatigue common, especially with tachycardia Severe stenosis (valve area < 1.0 cm2): severe pulmonary hypertension develops due to a "secondary stenosis" of the pulmonary vascular bed Sudden increase in heart rate may precipitate pulmonary edema Paroxysmal or chronic atrial fibrillation develops in ~50–80%, may precipitate dyspnea or pulmonary edema + Diagnosis Download Section PDF Listen +++ ++ ECG typically shows left atrial abnormality and, often, atrial fibrillation Doppler echocardiography confirms diagnosis and quantifies severity by assigning 1–4 points to each of four observed parameters, with 1 being the least involvement and 4 the greatest Mitral leaflet thickening Mitral leaflet mobility Submitral scarring Commissural calcium Cardiac catheterization to detect valve, coronary, or myocardial disease, usually done only after a decision to intervene has been made + Treatment Download Section PDF Listen +++ ++ Control heart rate Attempt conversion of atrial fibrillation Once atrial fibrillation occurs, provide lifelong anticoagulation with warfarin, even if sinus rhythm is restored Intervention to relieve stenosis indicated for symptoms (eg, pulmonary edema, decline in exercise capacity) or evidence of pulmonary hypertension Percutaneous balloon valvuloplasty Low mortality rate (< 0.5%) Low morbidity rate (3–5%) Can be repeated if the morphology of the valve remains suitable Not effective when bioprosthetic valve stenosis occurs Surgical valve replacement is done in combined stenosis and regurgitation or when the mitral valve is significantly distorted and calcified Operative mortality rate is ~1–3%