Mitral Stenosis

Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation, which can result in atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation, pulmonary congestion, pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension, and right heart failure. Symptoms include exertional dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, orthopnea, palpitations, fatigue, and hoarseness. Physical examination will demonstrate an opening snap, followed by a rumbling diastolic murmur. An echocardiogram is used for diagnosis. Treatment includes sodium restriction, diuretics, atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation management, possible anticoagulation, and percutaneous commissurotomy or surgery.

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Overview

Definition

Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, which impedes blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure from the left atrium (LA) into the left ventricle (LV) during diastole.

Epidemiology

  • Prevalence has decreased in the developed world. 
  • Incidence:
    • 1 in 100,000 in the United States
    • Higher in developing countries, where rheumatic heart disease is more prevalent
  • Women > men
  • Onset is usually in the 3rd and 4th decade of life.

Etiology

  • Rheumatic heart disease (most common)
  • Congenital 
  • Mitral annular calcification
  • Radiation induced
  • Fabry’s disease
  • Whipple’s disease
  • Systemic lupus erythematosus Systemic lupus erythematosus Systemic lupus erythematosus (SLE) is a chronic autoimmune, inflammatory condition that causes immune-complex deposition in organs, resulting in systemic manifestations. Women, particularly those of African American descent, are more commonly affected. Systemic Lupus Erythematosus
  • Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis
  • Carcinoid disease
  • Conditions that mimic the hemodynamic changes of MS:
    • LA myxoma
    • Large infective endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis
    • Degenerated bioprosthetic MV

Pathophysiology

  • Rheumatic heart disease: molecular mimicry displayed by group A-hemolytic Streptococci after pharyngeal infection → acute pancarditis → chronic valvular inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation → 
    • Fibrosis and thickening of the valve leaflets and fusion of mitral commissures
    • Mitral calcification and stenosis with narrowing of the valve orifice
  • A narrowed MV orifice → restricted LV filling → ↑ LA pressure is required to propel blood →
    • LA dilation → atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation, LA thrombosis 
    • ↑ Pulmonary capillary wedge pressure (PCWP) → pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension → right heart failure
    • ↓ Stroke volume → ↓ cardiac output → left heart failure
Mitral valve stenosis

Obstruction of blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure from the LA to the LV during diastole due to a stenotic MV

Image by Lecturio.

Clinical Presentation

Clinical manifestations

  • Asymptomatic in the early stages
  • Symptoms of heart failure:
    • Progressive exertional dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
    • Fatigue
    • Orthopnea
    • Paroxysmal nocturnal dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
    • Hemoptysis Hemoptysis Hemoptysis is defined as the expectoration of blood originating in the lower respiratory tract. Hemoptysis is a consequence of another disease process and can be classified as either life threatening or non-life threatening. Hemoptysis can result in significant morbidity and mortality due to both drowning (reduced gas exchange as the lungs fill with blood) and hemorrhagic shock. Hemoptysis → from pulmonary edema Pulmonary edema Pulmonary edema is a condition caused by excess fluid within the lung parenchyma and alveoli as a consequence of a disease process. Based on etiology, pulmonary edema is classified as cardiogenic or noncardiogenic. Patients may present with progressive dyspnea, orthopnea, cough, or respiratory failure. Pulmonary Edema and rupture of small pulmonary vessels
  • Symptoms of atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation
    • Palpitations
    • Sequelae from thromboembolism
  • Hoarseness (Ortner’s syndrome) → compression of the left recurrent laryngeal nerve by an enlarged LA
  • Cough → compression of the bronchi by an enlarged LA
  • Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia → compression of the esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus by an enlarged LA

Physical exam

  • Loud S1 → abrupt closure of stenotic MV leaflets (S1 may be absent if the leaflets are heavily calcified.)
  • Normal S2 split with an exaggerated P2 → pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension
  • Early diastolic opening snap after S2, followed by a low-pitched, decrescendo-crescendo rumbling murmur:
    • Heard best at the apex
    • Murmur ↑ with squatting, handgrip (↑ afterload)
    • Murmur ↓ with decreased blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure across the valve (tachycardia, pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension)
    • Opening snap becomes closer to S2 as the stenosis becomes more severe.
    • Snap may be absent if the valve is heavily calcified.
  • Palpable P2 and right ventricle (RV) heave (parasternal lift)
  • The point of maximal impulse is normal or ↓, due to ↓ LV filling.
  • Signs of heart failure (usually right sided):
    • Jugular venous distension
    • Crackles
    • Hepatomegaly 
    • Peripheral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Malar flush (“mitral facies”) → cutaneous vasodilation and hypoxemia → low cardiac output and severe pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension
Mitral stenosis phonocardiogram

Diastolic filling and rumbling murmur of mild and severe mitral stenosis
The mid-diastolic murmur starts after the opening snap (O.S.). The presystolic murmur is due to atrial contraction (and absent in atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation).

Image by Lecturio.

Diagnosis

Echocardiography

  • Transthoracic echocardiography (TTE):
    • Diagnostic modality of choice
    • Findings:
      • Stenotic MV
      • Valve thickening and calcification
      • Commissural fusion
      • LA dilation
      • Evaluation of LV and RV function
    • Doppler is used to evaluate: 
      • Transvalvular gradient
      • Mitral valve area (MVA):
        • Moderate MS: 1.5–2.5 cm2
        • Severe MS: < 1.5 cm2
        • Very severe MS: < 1 cm2
      • Pulmonary artery (PA) pressure
      • Associated valve disease ( mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation (MR))
  • Transesophageal echocardiography (TEE): 
    • Used to exclude LA thrombus before percutaneous balloon valvuloplasty
    • Can also evaluate for LA myxomas or large vegetations that may simulate MS

Other workup

  • Electrocardiography Electrocardiography Recording of the moment-to-moment electromotive forces of the heart as projected onto various sites on the body's surface, delineated as a scalar function of time. The recording is monitored by a tracing on slow moving chart paper or by observing it on a cardioscope, which is a cathode ray tube display. Normal Electrocardiogram (ECG) ( ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG)):
    • Findings are non-specific.
    • Signs of LA enlargement: 
      • “Double-peaked” P waves (P mitrale)
      • Only seen when in sinus rhythm
    • Atrial fibrillation 
    • With severe pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension:
      • Right axis deviation
      • “Tall” P waves 
  • Chest radiograph: 
    • Straightening of the upper left border of the cardiac silhouette → LA enlargement
    • Enlarged PA → pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension
    • Pulmonary vascular congestion:
      • Cephalization
      • Kerley B lines 
  • Cardiac magnetic resonance imaging (cMRI):
    • Used when an echocardiogram is unsatisfactory or there is a discrepancy between findings and the clinical picture
    • Can provide information on valve anatomy
    • Can assess the severity of MS
  • Cardiac catheterization:
    • Part of the preoperative assessment
    • Evaluates for coronary artery disease prior to surgery
    • Can confirm ↑ LA and PA pressures, MVA

Management

  • Periodic monitoring for asymptomatic patients
  • Secondary prevention of rheumatic fever Rheumatic fever Acute rheumatic fever (ARF) is an autoimmune inflammatory process that usually follows Streptococcal pharyngitis. Acute rheumatic fever usually occurs 2-4 weeks after an untreated infection and affects the heart, skin, joints, and nervous system. Rheumatic Fever for patients with rheumatic MS:
    • Penicillin G 
    • Duration of therapy depends on the number of previous attacks and duration since the last episode.
  • Anticoagulation for moderate-to-severe MS:
    • If atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation is present
    • If the patient had a prior embolic event
    • If there is an LA thrombus 
    • Consider anticoagulation for severe LA enlargement.
    • Note: Warfarin is typically used because the novel anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants have not been evaluated in valvular heart disease.
  • Treatment of atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation:
    • Cardioversion in unstable patients
    • Beta blockers and calcium channel blockers Calcium Channel Blockers Calcium channel blockers (CCBs) are a class of medications that inhibit voltage-dependent L-type calcium channels of cardiac and vascular smooth muscle cells. The inhibition of these channels produces vasodilation and myocardial depression. There are 2 major classes of CCBs: dihydropyridines and non-dihydropyridines. Class 4 Antiarrhythmic Drugs (Calcium Channel Blockers) in stable patients
  • Heart failure management:
    • Diuretics
    • Beta blockers are used cautiously (↓ heart rate can ↓ cardiac output).
    • Salt restriction
  • Percutaneous mitral balloon commissurotomy (PMBC): 
    • 1st line
    • Used in severe or symptomatic MS
    • Requires favorable valve morphology with little or no MR and without LA thrombus
    • Can delay valve replacement
  • Surgical MV replacement: 
    • Pursued if PMBC is contraindicated
    • Anticoagulation required:
      • 3–6 months for bioprosthetic valve
      • Lifelong for mechanical valve
Accura balloon mitral stenosis

Percutaneous mitral valvotomy in a case of situs inversus totalis and juvenile rheumatic critical MS. A: Accura balloon entering into the LV; B: distal inflation of the balloon; C: mitral valve dilation

Image: “Accura balloon” by the Department of Cardiology, LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, Uttar Pradesh 208002, India. License: CC BY 2.0.

Differential Diagnosis

  • MR: valve disorder where blood refluxes from the LV to the LA during systole. Mitral valve prolapse (MVP) is the most common etiology. Signs and symptoms are based on severity and can include exertional dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, fatigue, or edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema. The exam will be notable for a systolic murmur at the cardiac apex, and an echocardiogram can establish the diagnosis and differentiate MR from MS. Treatment includes sodium restriction, diuretics, and surgery for severe cases.
  • MVP: the most common cardiac valvular defect, characterized by bulging of the MV leaflets into the LA during systole. Auscultation characteristically reveals a mid-systolic click followed by a possible regurgitant murmur. Patients are generally asymptomatic. However, MVP can progress to MR in some patients. Echocardiography will establish the diagnosis and differentiate MVP from MS. Most patients do not require treatment.
  • Severe aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation: valve disorder allowing blood to reflux back into the ventricle from the aorta during diastole. Patients may present with exertional dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, orthopnea, palpitations, and chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain. An exam will show a blowing, early diastolic decrescendo murmur at the 3rd left intercostal space. Echocardiography will establish the diagnosis and differentiate severe aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation from MS. Treatment involves surgical repair or replacement.
  • Tricuspid stenosis Tricuspid stenosis Tricuspid stenosis (TS) is a valvular defect that obstructs blood flow from the right atrium to the right ventricle during diastole. This condition most commonly results from rheumatic heart disease or a congenital defect, and is usually found in conjunction with other valvular disease. A mid-diastolic murmur is best heard at the lower left sternal border. Tricuspid Stenosis: narrowing of the tricuspid valve, which prevents normal blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure from the RA to the RV. Patients may be asymptomatic or may present with signs and symptoms of systemic venous congestion. A mid-diastolic murmur at the left lower sternal border distinguishes tricuspid stenosis from MS. An echocardiogram will establish the diagnosis. Management includes sodium restriction, diuretics, and surgery for severe cases.
  • Tricuspid regurgitation: valve disorder allowing blood to reflux into the RA from the RV during systole. Patients may be asymptomatic or may present with signs and symptoms of systemic venous congestion. A holosystolic murmur at the left lower sternal border distinguishes tricuspid regurgitation Tricuspid regurgitation Tricuspid regurgitation (TR) is a valvular defect that allows backflow of blood from the right ventricle to the right atrium during systole. Tricuspid regurgitation can develop through a number of cardiac conditions that cause dilation of the right ventricle and tricuspid annulus. A blowing holosystolic murmur is best heard at the left lower sternal border. Tricuspid Regurgitation from MS. An echocardiogram will establish the diagnosis. Management involves treating the underlying cause, sodium restriction, diuretics, and surgery for severe cases.
  • ASD: an opening in the interatrial septum that allows left-to-right shunting of blood. Complications include pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension, heart failure, and atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation. Adults may present with dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, fatigue, and palpitations. A mid-systolic murmur with a fixed and widely split S2 at the left sternal boarder may be heard, which differs from MS. Diagnosis is made with an echocardiogram. Surgical or transcatheter closure is used as treatment.
  • LA myxoma: a benign, primary cardiac tumor that can can cause MV outflow tract obstruction during diastole if located in the LA. Patients present with signs and symptoms of heart failure. The murmur can mimic MS, and a “tumor plop” is also heard as the myxoma drops into the mitral orifice. Diagnosis is made with an echocardiogram and a cMRI, which will differentiate LA myxoma from MS. Treatment includes surgical excision.

References

  1. Armstrong, G.P. (2020). Mitral stenosis. [online] MSD Manual Professional Version. https://www.msdmanuals.com/professional/cardiovascular-disorders/valvular-disorders/mitral-stenosis
  2. Dima, C. (2018). Mitral stenosis. In O’Brien, T.X. (Ed.), Medscape. Retrieved November 23, 2020, from https://emedicine.medscape.com/article/155724-overview
  3. Meyer, T.E., & Gaasch, W.H. (2019). Pathophysiology and natural history of mitral stenosis. In Yeon, S.B. (Ed.), Uptodate. Retrieved November 23, 2020, from https://www.uptodate.com/contents/pathophysiology-and-natural-history-of-mitral-stenosis
  4. Otto, C.M. (2020). Clinical manifestations and diagnosis of rheumatic mitral stenosis. In Yeon, S.B. (Ed.), Uptodate. Retrieved November 23, 2020, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-rheumatic-mitral-stenosis
  5. Gaasch, W.H. (2020). Overview of the management of mitral stenosis. In Yeon, S.B. (Ed.), Uptodate. Retrieved November 23, 2020, from https://www.uptodate.com/contents/overview-of-the-management-of-mitral-stenosis

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