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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

DIFFERENTIAL DIAGNOSIS

  • Tricuspid stenosis

  • Aortic regurgitation with prominent Austin Flint murmur

  • Other ...

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