MITRAL STENOSIS Sagar Naik, PT

MITRAL STENOSIS
Sagar Naik, PT

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The mitral valve is most frequently damaged by rheumatic carditis. The
pathologic changes of mitral valve, resulting in obstruction to blood flow is called

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mitral stenosis.

g Etiology:
Two-thirds of all patients with mitral stenosis (MS) are females.
Mitral stenosis is generally rheumatic in origin; very rarely, it is congenital.
Pure or predominant mitral stenosis occurs in approximately 40% of all
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patients with rheumatic heart disease.
In others, lesser degrees of mitral stenosis may accompany mitral regurgitation
(MR) and aortic valve lesions.

g Pathology:
In rheumatic stenosis the valve fibrous tissue and/or calcific deposits diffusely
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thicken leaflets.
The mitral commissures fuse, the chordae tendinae fuse and shorten, the
valvular cusps become rigid, and these changes, in turn, lead to narrowing at
the apex of the funnel-shaped (fish-mouth) valve.
Although the initial insult to the mitral valve is rheumatic, the later changes
may be a nonspecific process resulting from trauma to the valve caused by
altered flow patterns due to the initial deformity.
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Calcification of the stenotic mitral valve immobilizes the leaflets and narrows
the orifice further.
Thrombus formation and arterial embolization may arise from the calcific
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valve itself, but more frequently arise from the dilated left atrium (LA) in
patients with atrial fibrillation (AF).

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 MITRAL STENOSIS Sagar Naik, PT

g Pathophysiology:
The cross-sectional area of the normal mitral valve area is 4-6 cm2.
Narrowing of the valve area to less than 2.5 cm2 must occur before
development of symptoms.

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A mitral valve area more than 1.5 cm2 usually does not produce symptoms at
rest.

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Mitral stenosis slows ventricular filling during diastole
(By preventing the free flow of blood from the left atrium to the left ventricle)

The pressure in the left atrium rises to maintain cardiac output

4a Causes atrial hypertrophy & dilatation

Pulmonary congestion results due to rise in left atrial pressure

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This results in pulmonary hypertension

Causes right heart failure & tricuspid regurgitation

(Due to increased demand on right ventricle)

g Clinical Features:
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Patient may remain asymptomatic for years and then present with
symptoms when the heart is stressed by an event such as pregnancy, fever or a
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chest infection, or with the onset of atrial fibrillation.

B Symptoms:
Dyspnoea on exertion
Orthopnoea
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 MITRAL STENOSIS Sagar Naik, PT

Paroxysmal nocturnal dyspnoea

Haemoptysis or frank pulmonary oedema
Fatigue
Palpitation (Atrial fibrillation)
Cough

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Chest pain
Symptoms of thromboembolic complications

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Hoarseness of voice

B Physical Signs:
Small volume pulse
Atrial fibrillation
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Mitral facies
Auscultation
h Loud first heart sound, opening snap
h Mid-diastolic murmur
Signs of raised pulmonary capillary pressure
h Crepitations
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h Pulmonary oedema
h Effusions
Signs of pulmonary hypertension
h RV heave
h Loud P2

g Investigations:
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ECG
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h Left atrial hypertrophy

h Right ventricular hypertrophy
Chest radiograph
h Enlarged left atrium
h Signs of pulmonary venous congestion
Echocardiogram
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 MITRAL STENOSIS Sagar Naik, PT

h Thickened immobile cusps

h Reduced valve area
h Reduced rate of diastolic filling of left ventricle
Doppler Echocardiogram
h Pressure gradient across mitral valve

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h Pulmonary artery pressure
Cardiac Catheterization

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h Pressure gradient between left atrium and left ventricle

g Differential Diagnosis:
Left atrial myxoma
Cor triatriatum
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Congenital mitral stenosis

g Treatment:
B Medical Management:
Medical therapy for mitral stenosis consists of treatment of congestive
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heart failure and atrial fibrillation when these develop, and prevention of
systemic embolism and infective endocarditis.
Secondary prophylaxis against recurrence o rheumatic fever.
Diuretics as needed for pulmonary congestion
Digoxin to increase inotropy and as a rate-controlling agent in
atrial fibrillation
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-blockers, calcium channel blockers to alleviate high heart rates

Anticoagulants drug therapy in patients with previous embolic
event
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Antibiotics prophylaxis against infective endocarditis

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 MITRAL STENOSIS Sagar Naik, PT

B Surgical Management:
Percutaneous Mitral Valvuloplasty by using balloon dilatation
Open Mitral Commisurotomy (Mitral valve repair)
Mitral Valve Replacement (MVR) with prosthetic valves

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