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10-11: Mitral Stenosis

Todd Kiefer; Christopher B. Granger; Kevin P. Jackson

ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • Fatigue, exertional dyspnea, and orthopnea when the stenosis becomes severe.

  • Symptoms often precipitated by onset of atrial fibrillation or pregnancy.

  • Prominent mitral first sound, opening snap (usually), and apical diastolic rumble.

  • Auscultatory A2 to opening snap interval shortens as the mitral stenosis worsens (increased LA pressure).

  • ECG shows LA abnormality and, commonly, atrial fibrillation.

  • Echocardiography/Doppler is diagnostic.

  • Intervention indicated for symptoms, atrial fibrillation, or evidence of pulmonary hypertension. Most symptomatic patients have a mitral valve area of < 1.5 cm2.

GENERAL CONSIDERATIONS

Most patients with native valve mitral stenosis are presumed to have had rheumatic heart disease, although a history of rheumatic fever is noted in only about one-third. (Also see section on Rheumatic Fever.) Rheumatic mitral stenosis results in thickening of the leaflets, fusion of the mitral commissures, retraction, thickening and fusion of the chordae, and calcium deposition in the valve. Mitral stenosis can also occur due to congenital disease with chordal fusion or papillary muscle malposition. The papillary muscles may be abnormally close together, sometimes so close that they merge into a single papillary muscle (the “parachute mitral valve”). In these patients, the chordae or valvular tissue (or both) may also be fused. In older patients and in those undergoing dialysis, mitral annular calcification may stiffen the mitral valve and reduce its motion to the point where a mitral gradient is present. Calcium in the mitral annulus virtually invades the mitral leaflet from the annulus inward as opposed to the calcium buildup in the leaflets and commissures as seen in rheumatic heart disease. Mitral valve obstruction may also develop in patients who have had mitral valve repair with a mitral annular ring that is too small, or in patients who have had a surgical valve replacement (prosthetic valve-patient mismatch or degeneration of the prosthetic valve over time) (eFigures 10–29 and 10–30).

eFigure 10–29.

Combined mitral valve defect with predominant stenosis. PA chest radiograph (A) and left lateral radiograph with an esophagogram (B). Enlargement of the left atrium is manifested by a double contour along the right cardiac border, a prominent atrial appendage, and deep indentation and posterior curving of the opacified esophagus. (Reproduced, with permission, from Thelen M, Erel R, Kreitner KF, Barkhausen J. Cardiac Imaging: A Multimodality Approach. Thieme, 2009.)

Two chest x rays in the front and lateral views, indicate enlargement of the left atrium, which pushes back the esophagus toward the spinal column.
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eFigure 10–30.

The patient had further investigations and was diagnosed with a bicuspid aortic valve. A CTA of the aorta did not reveal aortic dissection. (Reproduced, with permission, from Pouraliakbar H. Chest radiography in cardiovascular disease. In: Maleki M, Alizadehasl A, Haghjoo M. Practical Cardiology. Elsevier, 2018. Copyright © Elsevier.)

A chest x ray with arrows indicating the enlargement of cardiac chamber in a case of bicuspid aortic valve.
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CLINICAL FINDINGS

A. Symptoms and Signs

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