Mitral stenosis
Mitral stenosis is obstruction of left atrial emptying from a narrowed mitral valve, overwhelmingly rheumatic in origin. It causes left atrial hypertension, atrial fibrillation, and pulmonary congestion, with a diastolic rumble and opening snap; severe symptomatic disease is treated with percutaneous balloon valvuloplasty or valve surgery.
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What this article covers
- Overview
Definition: mitral stenosis is obstruction to left atrial emptying caused by narrowing of the mitral valve orifice, raising left atrial pressure.
- Epidemiology
Overwhelmingly rheumatic in origin, and common where rheumatic fever persists.
- Risk factors
Prior rheumatic fever (the dominant cause).
- Pathophysiology
Fixed obstruction: commissural fusion and leaflet thickening narrow the orifice, requiring a raised left atrial pressure to fill the ventricle.
- Clinical features
Exertional dyspnea, orthopnea, and fatigue.
- Differential diagnosis
Mitral regurgitation: an apical holosystolic (not diastolic) murmur with volume overload rather than obstruction (Mitral regurgitation).
- Diagnosis
Establish and grade with echocardiography measuring the mitral valve area and gradient: the diagnostic basis is echocardiography demonstrating rheumatic leaflet thickening and commissural fusion with…
- Management
First-line, relieve severe symptomatic obstruction with percutaneous balloon mitral valvuloplasty: in suitable pliable, non-calcified valves without significant regurgitation or left atrial thrombus…
- Complications
Atrial fibrillation and cardioembolic stroke.
- Prognosis
Good with timely valvuloplasty in suitable anatomy.
- Prevention
Secondary rheumatic fever prophylaxis with long-term penicillin to prevent recurrent carditis.
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Related articles
- Mitral regurgitation
Mitral regurgitation is systolic backflow from the left ventricle into the left atrium, classified as primary (valve disease) or secondary (ventricular or annular disease). Chronic disease causes volume overload with an apical holosystolic murmur, while acute severe regurgitation causes pulmonary edema; severe primary disease is treated with valve repair or replacement.
- Rheumatic heart disease
Rheumatic heart disease is chronic valvular damage following acute rheumatic fever, an autoimmune sequela of group A streptococcal pharyngitis. It predominantly scars the mitral and aortic valves, causing stenosis and regurgitation years later; management is secondary antibiotic prophylaxis, treatment of valve lesions, and prevention of recurrent rheumatic fever.
- Atrial fibrillation
Atrial fibrillation is a supraventricular tachyarrhythmia with disorganized atrial activation and an irregularly irregular ventricular response, the most common sustained arrhythmia and a major cause of stroke. Diagnosis is by ECG showing no discrete P waves with irregular RR intervals, and management addresses rate or rhythm control, stroke prevention by CHA2DS2-VASc-guided anticoagulation, and the underlying cause.
- Tricuspid stenosis
Tricuspid stenosis is obstruction of right atrial emptying from a narrowed tricuspid valve, almost always rheumatic and usually accompanying mitral stenosis. It causes right-sided congestion with a prominent jugular a wave and a diastolic murmur that increases with inspiration; severe symptomatic disease is treated with valve repair or replacement.
- Aortic regurgitation
Aortic regurgitation is diastolic backflow of blood from the aorta into the left ventricle from valve or aortic root disease. Chronic disease causes volume overload with a wide pulse pressure and a decrescendo diastolic murmur, while acute severe regurgitation is a surgical emergency; severe symptomatic or decompensating disease is treated with valve replacement.
- Constrictive pericarditis
Constrictive pericarditis is a rigid, often calcified pericardium that impairs diastolic filling, causing predominantly right-sided heart failure. It follows pericardial injury (post-surgical, tuberculous, radiation, or idiopathic), is distinguished from restrictive cardiomyopathy by hemodynamic and imaging features, and definitive treatment is pericardiectomy.