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  • Exertional dyspnea and fatigue.

  • Opening snap, diastolic rumble murmur, loud S1, presystolic accentuated murmur.

  • Right ventricular heave and loud P2 if pulmonary hypertension and right-heart failure are present.

  • A2-OS interval ≤ 80 ms in severe mitral stenosis.

  • Sinus rhythm or atrial fibrillation, notched P wave or P mitrale in leads II and III and/or biphasic P wave in V1, right axis deviation, high amplitude of P wave in lead II, and large R wave in V1 on electrocardiography.

  • Flattening of left atrial border and/or double density, elevated left main bronchus, enlarged pulmonary arteries, and Kerley B lines on chest radiography.

  • Thickened and/or calcified mitral leaflets and subvalvular apparatus resulting in “hockey-stick” motion of the anterior leaflet and fusion of commissures resulting in fish-mouth appearance of the rheumatic mitral valve on two- and three-dimensional echocardiography rheumatic valve disease.

  • Calcification of the mitral annulus with extension to the basal mitral leaflets without commissural fusion resulting in tubular narrowing from the annulus to the leaflet tips on two- and three-dimensional echocardiography in degenerative calcific mitral stenosis.

  • Mitral valve area ≤ 1.5 cm2 by planimetry on two- or three-dimensional echocardiography and by pressure half-time, continuity equation, and proximal isovelocity surface area quantification methods on Doppler echocardiography and elevated mean transmitral valve gradient on Doppler echocardiography.


Mitral stenosis is a condition where the mitral valve area is reduced, causing obstruction of blood flow from the left atrium into the left ventricle during left ventricular diastole, which can lead to elevated left atrial pressure resulting in pulmonary hypertension, pulmonary edema, and right-heart failure. This valvular disease becomes clinically evident when the mitral valve area is reduced to approximately 1.5 cm2.

Rheumatic mitral stenosis occurs predominantly in adults and is one of the sequelae of rheumatic fever in about 90% of cases. Approximately two-thirds of cases occur in women. Twenty-five percent of patients have isolated mitral stenosis, and 50% have mixed mitral valve disease or combined mitral and aortic valve involvement. Unlike mitral regurgitation, which can present during the initial acute rheumatic carditis episode, mitral stenosis often develops after recurrent attacks, follows an indolent course, and has a latent period up to 40 years after the index episode of rheumatic fever. Only about 50–70% patients recall having had antecedent group A β-hemolytic streptococcal tonsillopharyngitis.

Rheumatic fever is a major public health problem in low-income countries in Oceania, South Asia, and sub-Saharan Africa. Approximately 60% of these patients will develop rheumatic heart disease. It is estimated that 40.5 million people worldwide have rheumatic heart disease in 2019 with an incidence of 2.8 million per year. The prevalence in high-income countries is 3.4 cases per 100,000 population and increases to more than 1000 case per 100,000 population in low-income countries. The prevalence in Western countries has not decreased substantially because of the ...

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