MITRAL STENOSIS (Case based & Evidence based)

Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases(NICVD),
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branch
Honorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi
drtoufiq19711@yahoo.com

Case 1
 A 52-year-old woman presents with gradually increasing
dyspnoea on exertion over the past 2 years.
 Recently she has required 2 pillows at night to alleviate
recumbent dyspnoea.
 On examination, she has an apical diastolic murmur.
2drtoufiq19711@yahoo.com

Case 2
 A 36-year-old prima gravida presents with dyspnoea
on exertion and 2 pillow orthopnoea during her
second trimester.
 Previous physical examinations had disclosed no
cardiac abnormalities.
 On current physical examination, she has a loud S1
and a 2/6 diastolic rumble.

Case 3
 A 35 year old lady complained of progressive exertional
shortness of breath in the past two years.
 Physical examination revealed a loud first heart
sound, an opening snap and a mid diastolic rumbling
murmur with an irregularly irregular pulse.

Case 4
 A 75 year old male with emphysema presents with
increasing dyspnea.
 He is noted to have a II/IV diastolic murmur after an
opening snap at the cardiac apex.
 An echocardiogram shows thickening of the mitral leaflet
tips and a “hockey stick” appearance of the anterior mitral
leaflet.
 The mean pressure gradient across the mitral valve is 7
mmHg and the mitral valve area is 1.2 cm2.
 What is the degree of mitral stenosis present?

Case 5
 A 25-year-old female who is 33 weeks into her
pregnancy is becoming increasingly short of breath
with some lower extremity edema.
 She is afebrile with a heart rate of 110 beats per minute,
respirations 20 per minute and blood pressure 100/60
mm Hg.
 Physical examination reveals a II/IV early diastolic
decrescendo murmur at the cardiac apex.

Case 6
 2. A 32 year old male presents with dyspnea and
hemoptysis.
 He is afebrile, heart rate 100 beats per minute, blood
pressure 120/80, and respirations 22/min.
 His cardiac physical examination reveals a soft, II/IV early
diastolic murmur at the cardiac apex.
 A bronchoscopy is negative for any lesion or malignancy

Case 7
 A 45 year old female presents with dyspnea with a moderate
amount of exertion.
 She can walk up two flights of stairs or two blocks before having to
rest which is new for her (New York Heart Association functional
class II).
 She has no lower extremity edema, paroxysmal nocturnal dyspnea
or orthopnea.
 Physical examination reveals a loud S1 heart sound and an mid-
diastolic decrescendo murmur at the cardiac apex after an opening
snap which has a late-systolic accentuation.
 A treadmill exercise echocardiogram is performed and her
pulmonary artery systolic pressure increases to 70 mmHg. Her
mitral valve is only mildly thickened and calcified with well
preserved leaflet motion.
 The mean pressure gradient across the mitral valve is 4 mmHg.

Mitral stenosis
 Mitral valve
 Consist of fibrous annulus,
 Anterior & posterior leaflets
 Chordae tendinae,
 Papillary muscle

Aetiology
 Almost always rheumatic
in origin
 Older people: can be caused
by heavy calcification of
mitral valve
 Congenital (rare)

Mitral stenosis
 Commonest cause :rheumatic heart disease
 Infections with group A beta hemolytic streptococci
 More common in women
 Inflammation leads to commissural fusion and a
reduction in mitral valve orifice area

Pathophysiology
 Normal valve area: 4-6 cm2
 Mild mitral stenosis:
 MVA 1.5-2.5 cm2
 Minimal symptoms
 Moderate mitral stenosis
 MVA 1.0-1.5 cm2 usually does not produce
symptoms at rest
 Severe mitral stenosis
 MVA < 1.0 cm2

Narrowing of mitral valve
 CO
O2/CO2 exchange
(fatigue, dyspnea,
orthopnea)
Left ventricular
atrophy
pulmonary
congestion
 pulmonary
pressure
 left atrial
pressure
Hypertrophy left
atrium
 blood flow to
left ventricle
Right-sided
failure
Fatigue

To maintain sufficient cardiac
output
1. Left arterial pressure increases
2. Left arterial hypertrophy and dilation
3. Pulmonary veins, pulmonary arterial and R/ heart
pressure increases
4. Increase of pulmonary capillary pressure
5. Followed by development of
 pulmonary oedema
 Atrial fibrillation with tachycardia
 Loss of coordinated atrial contraction

To maintain sufficient cardiac
output
6. This is prevented by (Reactive pulmonary
hypertension)
 Alveolar and capillary thickening
 Pulmonary arterial vasoconstriction
7. Pulmonary hypertension leads to
 R/ ventricular hypertrophy, dilation and failure
with subsequent tricuspid regurgitation

Clinical features
Symptoms
 Breathlessness, cough (pulmonary congestion)
 Chest pain (pulmonary hypertension)
 Hemoptysis (pulmonary congestion or hypertension)
 Fatigue (low cardiac output)
 Oedema, ascites (right heart failure)
 Palpitation (atrial fibrillation)
 Thromboembolic complications

Symptoms
 Palpitation
 Systemic emboli
31
• Dyspnoea
• Pulmonary infections
(Recurrent bronchitis)
• Haemoptysis
• Cough
• R/ heart failure
• Fatigue
• Abdominal and lower
limb swelling
Atrial fibrillation Pulmonary Hypertension

Signs
 Face : Mitral fascies
 Pulse : atrial fibrillation
 RV : Heaving, sustained
 Apex: Localized, tapping
 Sounds: Loud S1, Loud P2 (if
pulmonary hypertension),
opening snap
 Murmurs: Mid diastolic rumble at apex

Mitral Stenosis: Physical
Exam
 First heart sound (S1) is accentuated & snapping
 Opening snap (OS) after aortic valve closure
 Low pitch diastolic rumble at the apex
 Pre-systolic accentuation (esp. if in sinus rhythm)
S1 S2 OS S1

Signs (Face)
 Severe mitral stenosis with pulmonary
hypertension
 Mitral fascies / malar rash
 Bilateral
 Cyanotic or dusky pink
discolouration
 Over the upper cheeks
 Due to atriovenous anastomosis &
 Vascular stasis

Signs (Pulse)
 Small volume pulse
 Usually regular in early stages,
 If the patient is in sinus rhythem
 In severe disease, may develop atrial fibrillation
 Irregularly irregular pulse

Signs (Jugular Veins)
 If R heart failure develops 
 obvious distension of jugular veins
 If pulmonary hypertension or tricuspid stenosis is
present 
 ‘a’ Wave will be prominent

Signs (Palpation)
 Tapping impulse felt parasternally on left side
 Palpable 1st heart sound
 Combined with left ventricular backward displacement
 Produced by an enlarging left ventricle
 Sustained parasternal impulse
 Due to R ventricular hypertrophy

Signs (Auscultation)
 Loud 1st heart sound
 If the mitral valve is pliable
 It will not occur in calcified mitral stenosis
 Opening snap
 Valve suddenly opens with the force of the increased L
arterial pressure
 Low pitched ‘rumbling’ mid diastolic murmur
 Best heard with bell held lightly
 At the apex with the patient lying on the left side

Signs (Auscultation)
 If the patient is in sinus rhythm
 Murmur becomes louder at the end of diastole
 As a result of atrial contraction
 (Pre- systolic accentuation)

How to determine the severity
of mitral stenosis
 Presence of pulmonary hypertension 
 Recognized by R/ ventricular heave & loud
pulmonary component of 2nd heart sound
 And signs with R heart failure : Oedema,
hepatomegaly
 Graham Steell murmur

How to determine the severity
of mitral stenosis
 Closeness of the opening snap to the 2nd heart
sound ∞ severe MS
 Length of mid-diastolic murmur ∞ severity
 As the valve cusps become immobile
 Loud 1st heart sound softens
 Opening snap diasppears
 When pulmonary hypertension occurs : P2 intensity
increase, mid diastolic murmur become quieter

Investigations
 ECG: - right ventricular hypertrophy  tall R waves
 Chest x-ray: - enlarged LA & appendage
- signs of pulmonary venous congestion
 ECHO: - thickened immobile cusps
- reduced valve area
- enlarged LA
- reduced rate of diastolic filling of LV
 Doppler: - pressure gradient across mitral valve
 Cardiac catheterization: - coronary artery disease
- pulmonary artery pressure
- mitral stenosis and regurgitation

Investigations –X-ray
 Small heart with an enlarged L/ atrium
 Pulmonary venous hypertension
 Calcified mitral valve– on penetrated or lateral
view
 Signs of pulmonary oedema or pulmonary
hypertension

Investigations –ECG
 Sinus rhythm in ECG shows a bifid P wave
 Owing to delayed L/atrial activation
 Atrial fibrillation may be present
 ECG features of R/ventricular hypertrophy
 Right axis deviation
 Perhaps tall R wave in lead V1

JMJ 55drtoufiq19711@yahoo.com

Investigations –
Echocardiogram
 Transthoracic echocardiography
 To determine L/ R/ atrial and ventricular size
 The sevirity of MS
 Transoesophageal Echocardiography (TOE)
 To detect the presence of L/ atrial thrombus

Stages of Mitral Stenosis
Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic
Consequences
Symptoms
A At risk of MS  Mild valve doming
during diastole
 Normal transmitral
flow velocity
 None  None
B Progressive
MS
 Rheumatic valve
changes with
commissural fusion
and diastolic
doming of the
mitral valve leaflets
 Planimetered MVA
>1.5 cm2
 Increased transmitral
flow velocities
 MVA >1.5 cm2
 Diastolic pressure
half-time <150 msec
 Mild-to-
moderate LA
enlargement
 Normal
pulmonary
pressure at rest
 None

Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic
Consequences
Symptoms
C Asymptomatic
severe MS
 Rheumatic valve
changes with
commissural
fusion and
diastolic doming
of the mitral valve
leaflets
 Planimetered
MVA ≤1.5 cm2
 (MVA ≤1 cm2 with
very severe MS)
 MVA ≤1.5 cm2
 (MVA ≤1 cm2 with very
severe MS)
half-time ≥150 msec
 (Diastolic pressure
half-time ≥220 msec
with very severe MS)
 Severe LA
enlargement
 Elevated PASP
>30 mm Hg
 None

Stage Definition Valve Anatomy Valve
Hemodynamics
Hemodynamic
Consequences
Symptoms
D Symptomatic
severe MS
 Rheumatic
valve changes
with
commissural
fusion and
diastolic doming
of the mitral
valve leaflets
 Planimetered
MVA ≤1.5 cm2
 MVA≤1.5 cm2
 (MVA ≤1 cm2 with
very severe MS)
half-time ≥150
msec
 (Diastolic pressure
half-time ≥220
msec with very
severe MS)
 Severe LA
enlargement
 Elevated PASP
>30 mm Hg
 Decreased
exercise
tolerance
 Exertional
dyspnea

Mitral Stenosis: Diagnosis and Follow-Up
Recommendations COR LOE
TTE is indicated in patients with signs or
symptoms of MS to establish the diagnosis,
quantify hemodynamic severity (mean pressure
gradient, mitral valve area, and pulmonary artery
pressure), assess concomitant valvular lesions, and
demonstrate valve morphology (to determine
suitability for mitral commissurotomy)
I B
TEE should be performed in patients considered
for percutaneous mitral balloon commissurotomy
to assess the presence or absence of left atrial
thrombus and to further evaluate the severity of
mitral regurgitation
I B

Mitral Stenosis: Diagnosis and
Follow-Up
Exercise testing with Doppler or invasive
hemodynamic assessment is recommended to
evaluate the response of the mean mitral
gradient and pulmonary artery pressure in
patients with MS when there is a discrepancy
between resting Doppler echocardiographic
findings and clinical symptoms or signs
I C

Mitral Stenosis: Medical Therapy
Anticoagulation (vitamin K antagonist [VKA] or
heparin) is indicated in patients with 1) MS and
AF (paroxysmal, persistent, or permanent), or 2)
MS and a prior embolic event, or 3) MS and a left
atrial thrombus
I B
Heart rate control can be beneficial in patients
with MS and AF and fast ventricular response
IIa C
Heart rate control may be considered for patients
with MS in normal sinus rhythm and symptoms
associated with exercise
IIb B

Mitral Stenosis: Intervention
PMBC is recommended for symptomatic patients
with severe MS (MVA <1.5 cm2, stage D) and
favorable valve morphology in the absence of
contraindications
I A
Mitral valve surgery is indicated in severely
symptomatic patients (NYHA class III/IV) with severe
MS (MVA <1.5 cm2, stage D) who are not high risk
for surgery and who are not candidates for or failed
previous PMBC
I B
Concomitant mitral valve surgery is indicated for
patients with severe MS (MVA ≤1.5 cm2, stages C or
D) undergoing other cardiac surgery
I C

Mitral Stenosis: Intervention (cont.)
PMBC is reasonable for asymptomatic patients
with very severe MS (MVA ≤1 cm2, stage C) and
favorable valve morphology in the absence of
contraindications
IIa C
Mitral valve surgery is reasonable for severely
symptomatic patients (NYHA class III/IV) with
severe MS (MVA ≤1.5 cm2, stage D) provided there
are other operative indications
IIa C

PMBC may be considered for asymptomatic
patients with severe MS (MVA ≤1.5 cm2, stage C)
and favorable valve morphology who have new
onset of AF in the absence of contraindications
IIb C
PMBC may be considered for symptomatic patients
with MVA >1.5 cm2 if there is evidence of
hemodynamically significant MS during exercise
IIb C
PMBC may be considered for severely
symptomatic patients (NYHA class III-IV) with
severe MS (MVA ≤1.5 cm2, stage D) who have
suboptimal valve anatomy and are not candidates
for surgery or at high risk for surgery
IIb C

Concomitant mitral valve surgery might be
considered for patients with moderate MS (MVA
1.6–2.0 cm2) undergoing other cardiac surgery
IIb C
Mitral valve surgery and excision of the left atrial
appendage may be considered for patients with
severe MS (MVA ≤1.5 cm2, stages C and D) who
have had recurrent embolic events while receiving
adequate anticoagulation
IIb C

Treatment
 Need no treatment other than prompt therapy of
attacks of bronchitis
 Early symptoms like dyspnea - diuretics
 Onset of atrial fibrillation :digoxin, anticoagulants (to
prevent atrial thrombus and systemic embolism)
 If pulmonary hypertension or symptoms of pulmonary
congestion : surgical therapy

Treatment
 Operative therapies
 Trans-septal balloon valvotomy
 Closed valvotomy
 Open valvotomy
 Mitral valve replacement

Treatment: Trans-septal balloon valvotomy
 Catheter introduced into R atriam via femoral vein
 Under local anasthesia
 Inter atrial septum is punctured
 Catheter enter into left atrium then to mitral
valve
 Balloon is inflated, briefly to split the valve
commissures

Treatment: Trans-septal balloon valvotomy
 Complications
 Regurgitation may result
 Contraindications
 Heavy calcification
 More than mild mitral regurgitation & thrombus in
the L/atrium
 TOE is done before this procedure

Treatment: Closed valvotomy
 For the patients with
 mobile,
 non calcified and
 non regurgitant mitral valves
 Fused cusps  forced apart by a dilator
(introduced through the apex of L/ ventricle)
 Cardiopulmonary bypass is not needed for this
operation

Treatment: Open valvotomy
 Often preferred to closed valvotomy
 Cusps are carefully dissected apart under direct
vision
 Cardiopulmonary bypass is requied
JMJ 81drtoufiq19711@yahoo.com

Treatment: Mitral valve replacement
 It is necessary if
 Mitral regurgitation is present
 Badly diseased or badly calcified stenotic valve,
 Moderate or severe mitral stenosis & thrombus in L
atrium despite anticoagulation
 Artificial valve >20 yrs
 Anticoagulants are necessary

Thank Youdrtoufiq19711@yahoo.com
Asia Pacific Congress of
Hypertension, 2014, February
Cebu city,
Phillipines
Seminar on Management
of Hypertension,
Gulshan, Dhaka

MITRAL STENOSIS (Case based & Evidence based)

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