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Mitral stenosis

Causes

Causes of mitral valve stenosis include rheumatic fever, congenital mitral stenosis, myxoma, prosthetic valves & valve calcificification.

Hemodynamics

  • Low cardiac output
  • Valve: ventricular filling is impaired when the mitral orifice is reduced to 2cm2 and transvalvular pressure gradient developes on exercise. At 1cm2 a gradient of 20mmHg evelopes at rest to maintain normal cardiac output. Calcification may develop in the long run.
  • Left atrium pressure rises, dilatation, thrombosis, fibrillation.
  • Increased pulmonary venous pressure: dyspnoea on exertion, hemoptysis and lung fibrosis. if rapidly above 25mmHg ? pulmonary edema. If gradual this leads to adaptation due to thickening of the walls in the pulmonary vessels.
  • Increased pulmonary capillary wedge pressure.
  • Pulmonary arteriolar constriction leading to disappearance of the murmur.
  • Elevated pulmonary artery pressure.
  • Pulmonary atherosclerosis
  • Pulmonary regurgitation
  • Tricuspid regurge
  • Right sided failure.
  • Peripheral thrombosis with pulmonary  embolism.

Treatment

1. Treatment of grade 1 mitral stenosis 

(mild MS ? by echo + exertional dyspnoea < G2)

Diuretics for congestive symptoms

Prophylaxis against rheumatic fever and infective endocarditis.

Anticoagulants if atrial fibrillation.

Consider digoxin if atrial fibrillation and tachycardia.

2. Treatment of grade 2 mitral stenosis

(tight mitral stenosis + lung congestive symptoms ? dyspnoea > G2)

1st line treatment as above.

If severe symptoms not responding to medical therapy consider surgery with commissurotomy, MVR or balloon valvuloplasty.

3. Treatment of grade 3 mitral stenosis

(tight MS + pulmonary hypertension)

Surgical repair with commissurotomy, MVR or balloon valvuloplasty.

4. Treatment of grade 4 mitral stenosis

(tight mitral stenosis + pulmonary hypertension and Right sides heart failure)

as above followed by antifailure therapy.

* In cases with recurrent embolization that did not respond to anticoagulant therapy and that did not cause serious damage to the patient already are indicated for commissurotomy to remove the atrial appendage.

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