Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ Exertional dyspnea or fatigue Opening snap (OS), loud S1 (closing snap), diastolic rumbling murmur with presystolic accentuation in sinus rhythm. An A2–OS interval < 80 ms if severe stenosis present A parasternal lift with a loud pulmonic component of the S2 if pulmonary hypertension present Electrocardiography: 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 Chest x-ray: flattening of left atrial border and/or double density, elevated left main bronchus, enlarged pulmonary arteries, and Kerley B lines 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 2- and 3-dimensional echocardiography Reduced mitral valve area by planimetry on 2- or 3-dimensional echocardiography and by pressure half-time, continuity equation, and proximal isovelocity surface area quantification methods on Doppler echocardiography and increased mean transmitral valve gradient on Doppler echocardiography Elevated transmitral pressure gradient and prolonged pressure half-time by Doppler echocardiography +++ GENERAL CONSIDERATIONS ++ In adults, mitral stenosis is almost always rheumatic in origin, but 50% have no history of rheumatic fever Affected women outnumber affected men by 2:1 Pathology shows thickened leaflet edges with commissural fusion; thickened chordae with fusion The normal mitral orifice is 4–6 cm2; an elevated transmitral pressure gradient develops at < 2.0 cm2 The elevated transmitral pressure raises left atrial pressure, which is transmitted to the lungs Mitral valve flow is related to heart rate and diastolic filling time; as heart rate increases with exercise, filling time decreases, which greatly compromises mitral valve flow in mitral stenosis +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Early patients may be asymptomatic unless they experience increases in heart rate or cardiac output such as with exercise, pregnancy, or atrial fibrillation Dyspnea, orthopnea, and fatigue Palpitation, often due to atrial fibrillation Stroke, usually due to atrial fibrillation Hoarseness due to left atrial compression of the recurrent laryngeal nerve Hemoptysis due to elevated bronchial venous pressure +++ PHYSICAL EXAM FINDINGS ++ Elevated jugular venous pulse with a prominent a wave in sinus rhythm Normal left ventricular apical impulse, but palpable right ventricular lift if pulmonary pressures elevated S1, P2, and an OS may be palpable Auscultation: loud S1; OS; apical diastolic rumble; murmur of mitral, pulmonic, and tricuspid regurgitation may occur; loud P2 if pulmonary hypertension present As the severity of mitral stenosis increases, the A2–OS interval shortens and the diastolic rumble lengthens Signs of pulmonary congestion and right heart failure may be present ++... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.