History

Fact Explanation
Progressive worsening Shortness of breath with or without Orthopnea/ Paroxysmal nocturnal dyspnea Due to Pulmonary venous congestion and bronchitis [1]
Cough - Productive with blood tinged, frothy sputum to frank haemoptysis Due to rupture of pulmonary-bronchial venous connections secondary to pulmonary venous hypertension [2]
Weakness and Fatigue Due to development of Right heart failure following Pulmonary hypertension [1]
Lower limb swelling Due to development of Right heart failure following Pulmonary hypertension [1]
Abdominal swelling Due to development of Right heart failure following Pulmonary hypertension [1]
Palpitations Due to risk of developing palpitation because of enlarged Left Atrium [1]
Symptoms of Chest infection such as: Fever, Cough, Pleuritc chest pain, Shortness of breath Pulmonary infection commonly complicate untreated Mitral stenosis [1]
Acute Neurological weakness Systemic emboli causing end organ ischaemia following Atrial Fibrillation [1]
Childhood history of Rheumatic fever The most common cause of Mitral stenosis is Rheumatic heart disease secondary to group A beta Haemolytic streptococcus infection [1]
Hoarseness of Voice Ortner’s syndrome. The enlarged left atrium may impinge on the left recurrent laryngeal nerve, causing hoarseness [3]
References
  1. Kumar P, Clark M. Kumar and Clark's Clinical Medicine. 8th edition. Edinburgh. Saunders-Elsevier.
  2. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison's Principle's of Internal Medicine. 18th edition. McGrawHill- Medical. New York.
  3. Carabello BA. Modern Management of Mitral Stenosis. Circulation 2005; 112: 432-437 doi: 10.1161/​CIRCULATIONAHA.104.532498

Examination

Fact Explanation
Face - Malar Flush [1] Due to severe Mitral stenosis with pulmonary hypertension that causes development of arteriovenous anastomoses and vascular stasis [1]
Pulse - Small volume pulse [1] Mitral stenosis causes reduced blood flow across mitral valve there reduced stroke volume [2]
Pulse - Regular early in the disease, but may become Irregularly irregular [1] Patients develop atrial fibrillation [1]
Jugular veins - Elevated JVP [1] Due to development of Right heart failure. If pulmonary Hypertension develops/ Tricuspid regurgitation develops the 'a' wave will be prominent [1]
Blood pressure : Pulse pressure may be reduced [2] Mitral stenosis causes reduced blood flow across mitral valve there reduced stroke volume [2]
Chest - Palpation : Tapping apex beat [1] Due to palpable first heart sound combined with left ventricular backward displacement produced by an enlarging right ventricle [1]
Cardiac Auscultation :1st heart sound - Loud [3] Valve cusps are widely apart at the onset of systole [3] But will not occur in calcific mitral stenosis [1]
Cardiac Auscultation : Opening snap [1] Due to sudden opening of mitral valve with the force of increased left atrial pressure. Closeness of opening snap to second heart sound is proportional to severity of mitral stenosis [1]
Cardiac Auscultation : Murmur - Low pitched, Mid diastolic, rumbling murmur best heard with Bell of stethoscope at the apex with the patient lying onto the left side. [1] Due to turbulent flow across stenotic mitral valve. Length of the mid diastolic murmur is proportional to the severity [1]
Cardiac auscultation : Early diastolic murmur of Pulmonary area [1] Graham Steell murmur resulting due to pulmonary valve regurgitation caused by pulmonary hypertension [1]
Right Ventricular Heave, Loud pulmonary component of second heart sound [1] Signs of Pulmonary hypertension [1]
Lower limb oedema, Ascites, Liver enlargement [1] Signs of Right heart failure [1]
References
  1. Kumar P, Clark M. Kumar and Clark's Clinical Medicine. 8th edition. Edinburgh. Saunders-Elsevier.
  2. Carabello BA. Modern Management of Mitral Stenosis. Circulation 2005; 112: 432-437 doi: 10.1161/​CIRCULATIONAHA.104.532498
  3. Talley NJ, O'Connor S. Clinical Examination A Sytematic guide to physical diagnosis. 7th Edition. Sydney. Churchill-Livingstone-Elsevier.

Differential Diagnoses

Fact Explanation
Aortic regurgitation Auscultation reveals high pitched, early diastolic murmur, best heard at left sternal edge. Pulse is bounding, collapsing of pulse present. Other signs of Hyperdynamic circulation present [1]
Chronic Obstructive pulmonary disease (COPD) Progressive worsening shortness of breath, Atrial fibrillation, signs of Pulmonary hypertension may be present. However Poor chest expansion, hisotry of heavy smoking more in favor of COPD [1]
Atrial myxoma Loud 3rd heart sound - "Tumor plop", Fever, high ESR would be seen [1]
References
  1. Kumar P, Clark M. Kumar and Clark's Clinical Medicine. 8th edition. Edinburgh. Saunders-Elsevier.

Investigations - for Diagnosis

Fact Explanation
Echocardiogram - Transthoracic echo [1], [2], [3] To diagnose valve lesion. To determine severity of valve lesion. Echocardiography also evaluates pulmonary artery pressures, associated MR, concomitant valve disease, and LA size. Advantage of Trans thoracic route is non invasive. Disadvantage it is less sensitive than TOE. [4]
Echocardiogram - Transoesophageal echo (TOE) [1], [2] Advantages of TOE include better spatial resolution and superior performance over Trans Thoracic route. Better accuracy of detecting Thrombosis, prosthetic dysfunction, Endocarditis. [4] TOE should be performed to exclude LA thrombus before PMC or after an embolic episode. [4]. It is used not only as a diagnostic tool but also as a monitoring adjunct for operative and per cutaneous cardiac procedures [5]. Disadvantages include oral, esophageal, or pharyngeal trauma, arrhythmias, complications of conscious sedation [5]
3D Echocardiogram [4] Improves the accuracy of evaluation of valve morphology (especially visualization of the commissures) [4]
Cardiac MRI [1] Can accurately show Mitral valve anatomy. But rarely used. [1]
References
  1. Kumar P, Clark M. Kumar and Clark's Clinical Medicine. 8th edition. Edinburgh. Saunders-Elsevier.
  2. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison's Principle's of Internal Medicine. 18th edition. McGrawHill- Medical. New York.
  3. Bach DS. The New England Journal of Medicine 1997; 337:31July 3, 1997. DOI: 10.1056/NEJM199707033370106
  4. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). European Heart Journal (2012) 33, 2451–2496 doi:10.1093/eurheartj/ehs109
  5. Peterson GE, Brickner ME, Reimold SC. Transesophageal Echocardiography Clinical Indications and Application. Circulation. 2003; 107: 2398-2402 doi: 10.1161/​01.CIR.0000071540.97144.89

Investigations - Fitness for Management

Fact Explanation
Cardiac Catheterization If co-existing abnormalities such as Mitral regurgitation, Aortic valvular disease or coronary artery disease is suspected, In patients who have undergone PMBV or previous mitral valve surgery and who have redeveloped serious symptoms [1]
Stress testing Indicated in patients with or without symptoms equal to or discordant with the severity of MS. Exercise echocardiography is the preferred option. Assessment of changes in mitral gradient and pulmonary pressures can be done in response to stress. [2]
References
  1. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison's Principle's of Internal Medicine. 18th edition. McGrawHill- Medical. New York.
  2. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). European Heart Journal (2012) 33, 2451–2496 doi:10.1093/eurheartj/ehs109

Investigations - Followup

Fact Explanation
2D Echocardiogram Asymptomatic patients with clinically significant MS, who have not undergone intervention, should be followed up Annually. Longer intervals (2 to 3 years) may be done in case of less severe stenosis. Follow up of patients after successful PMC is similar to that of asymptomatic patients. It should be more stringent if asymptomatic restenosis occurs. [1]
References
  1. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). European Heart Journal (2012) 33, 2451–2496 doi:10.1093/eurheartj/ehs109

Investigations - Screening/Staging

Fact Explanation
Chest X-ray Small heart with enlarged left atrium. Pulmonary venous congestion could be seen. In sever disease pulmonary edema can be seen [1]
Electrocardiogram In sinus rhythm P wave is bifid can be seen - due to delayed atrial activation. Atrial fibrillation can be frequently seen. Features of Right ventricular hypertrophy can be seen [1]
References
  1. Kumar P, Clark M. Kumar and Clark's Clinical Medicine. 8th edition. Edinburgh. Saunders-Elsevier.

Management - General Measures

Fact Explanation
Protussive or Antitussive medication For management episodes of bronchitis [1], [2]
Low dose diuretics For management of early symptoms of mitral stenosis such as mild dyspnoea [1]
Long acting nitrates Transiently ameliorate dyspnoea [3]
Beta blockers Improve exercise tolerance [3]
Calcium channel blockers Improve exercise tolerance [3]
Anticoagulant therapy A target INR between 2 to 3 is to be maintained in patients with either permanent or paroxysmal AF [3]
Pregnancy Mild symptoms - diuretics, For advanced disease relief of Mitral stenosis by Balloon Mitral Valvotomy [4]
References
  1. Kumar P, Clark M. Kumar and Clark's Clinical Medicine. 8th edition. Edinburgh. Saunders-Elsevier.
  2. Aber CP. `Bronchitis' in Patients with Mitral Stenosis. Thorax. Mar 1963; 18(1): 50–53. NCBI.
  3. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). European Heart Journal (2012) 33, 2451–2496 doi:10.1093/eurheartj/ehs109
  4. Carabello BA. Modern Management of Mitral Stenosis. Circulation 2005; 112: 432-437 doi: 10.1161/​CIRCULATIONAHA.104.532498

Management - Specific Treatments

Fact Explanation
Percutaneous mitral commissurotomy (PMC) [1] Intervention should only be performed in patients with clinically significant MS (valve area ≤1.5 cm). Contraindications for PMC include, Mitral valve area >1.5 cm², Thrombus in left atrium, mitral regurgitation which is moderate or more, Severe or bicommissural calcification, Severe concomitant aortic valve disease, Absence of commissural fusion, or severe combined tricuspid stenosis and regurgitation, Concomitant coronary artery disease requiring bypass surgery. Surgery is preferable in patients who are unsuitable for PMC [3]
Open Commissurotomy [2] Done under direct vision. The valve can be conserved, it avoids the risks inherent to prosthetic valves and also avoids the need for anticoagulation in patients in sinus rhythm [2]
Mitral Valve Replacement [2] If unfavorable valve characteristics preventing repair of damaged valve. Elderly presentation of Mitral stenosis. Needs anticoagulation if Mechanical valves are chosen. [3]
References
  1. Kang DH, Lee CH, Kim DH, et al. Early percutaneous mitral commissurotomy vs. conventional management in asymptomatic moderate mitral stenosis. European Heart Journal (2012) 33, 1511–1517 doi:10.1093/eurheartj/ehr495
  2. Carabello BA. Modern Management of Mitral Stenosis. Circulation 2005; 112: 432-437 doi: 10.1161/​CIRCULATIONAHA.104.532498
  3. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). European Heart Journal (2012) 33, 2451–2496 doi:10.1093/eurheartj/ehs109