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Mitral Stenosis

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Mitral Valve disease secondary to rheumatic fever treatable with surgery

Aetiology

The normal cross-sectional area - 5 cm² and symptoms begin when the valve area is 1-2 cm².
Pre-existing RHD causes scarring and contracture of the valve orifice into the classic fish-mouth appearance.
Anticoagulation if AF/PAF or previous cardiac embolus
Scarring, contraction and narrowing of the mitral valve cross-sectional area due to previous rheumatic fever.

Causes

Common Causes	Details
Rheumatic Heart Disease	Rheumatic heart disease is the most common cause of mitral stenosis. It results from an immune response to a streptococcal infection, which causes inflammation and scarring of the mitral valve, leading to narrowing. This process typically occurs over many years following an episode of rheumatic fever.
Congenital Mitral Stenosis	Some individuals are born with a malformed mitral valve that is abnormally narrow. This congenital defect can lead to mitral stenosis at a younger age. It is often associated with other congenital heart defects.
Mitral Annular Calcification	Mitral annular calcification is a degenerative process where calcium deposits build up in the mitral valve annulus, leading to narrowing of the valve opening. This condition is more common in elderly patients and those with chronic kidney disease or hypercalcemia.
Rare Causes	Details
Radiation-Induced Mitral Stenosis	Radiation therapy to the chest, often used in the treatment of cancers such as lymphoma or breast cancer, can lead to late-onset mitral stenosis. The radiation causes fibrosis and thickening of the mitral valve and surrounding tissues, leading to stenosis.
Infective Endocarditis	Infective endocarditis can cause mitral stenosis if the infection leads to the formation of large vegetations on the mitral valve leaflets or if the healing process results in scarring and fibrosis. This is a less common cause of mitral stenosis.
Lupus and Other Autoimmune Diseases	Systemic lupus erythematosus (SLE) and other autoimmune diseases can cause mitral stenosis through chronic inflammation and fibrosis of the mitral valve. Libman-Sacks endocarditis, a type of non-bacterial endocarditis seen in lupus, can contribute to valve dysfunction.
Carcinoid Syndrome	Carcinoid syndrome, caused by a carcinoid tumour that secretes serotonin and other vasoactive substances, can lead to fibrotic changes in the heart valves, including the mitral valve. Although more commonly affecting the right side of the heart, the mitral valve can also be involved.

Clinical

Pulse - Atrial fibrillation low volume + systemic emboli
Pulmonary oedema (NOT LVF)
Opening snap + Mid diastolic murmur + Presystolic accentuation if in SR
Murmur is a low pitched diastolic rumble
Loud S1 - tapping apex beat as systole occurs with valve cusps wide apart
RV Lift and Loud P2 if pulmonary hypertension
Early diastolic murmur of pulmonary regurgitation - Graham Stell murmur
Hoarseness is due to the pressure of an enlarged Left atrium or pulmonary artery on the left recurrent laryngeal nerve and is called Ortner's syndrome
Dysphagia due to large LA pressing on the oesophagus
Left atrial enlargement can cause pressure on left main bronchus - Left bronchiectasis

Decompensation

Exercise, emotional stress, pregnancy 2nd trimester
Infection, or with uncontrolled atrial fibrillation

Differential

A left atrial myxoma can be mistaken for Mitral stenosis. The myxoma can prolapse across the mitral valve during diastole and cause obstruction to flow. There may be a tumour "plop"

Investigations

Bloods: U&E, LFTs, FBC - anaemia, raised ESR or CRP may suggest Endocarditis
ECG: P mitrale, AF, RBBB, Right ventricular hypertrophy
CXR: large LA on lateral, straight left heart border, pulmonary oedema, Enlarged PA, Right ventricle, Pulmonary haemosiderosis
Echocardiogram:poor leaflet separation in diastole, calcification and fusion of valve leaflets. Trans oesophageal view is best
Cardiac Catheterisation : gradient between LA (PA wedge) and LVEDP > 15 mmHg

Severity by valve area

Normal 4-6 cm²
Mild 1.5-2.5 cm²
Moderate 1-1.5 cm²
Severe < 1 cm²

Management

Management Strategy	Details
Medical Management	Diuretics: to manage pulmonary congestion by reducing fluid overload. Beta-blockers/Calcium Channel Blockers/Digoxin: Slows heart rate to improve LV filling, especially with fast AF. Anticoagulation: Essential in patients with atrial fibrillation or those at high risk of thromboembolism to prevent stroke. Must use Warfarin or Heparin. DOACs are contraindicated Antiarrhythmic Drugs: Used to control the heart rate or convert atrial fibrillation to sinus rhythm.
Percutaneous Mitral Balloon Valvotomy (PMBV)	Preferred treatment for symptomatic patients with favorable valve anatomy. Uses a balloon catheter to dilate the stenotic mitral valve, improving blood flow. Balloon reaches the LA by a trans atrial septal puncture and inflated This results in commissural splitting and enlargement of the valve orifice. Best in younger patients without severe valvular thickening or calcification. Suitability is determined with a scoring system
Surgical Mitral Valve Repair or Replacement	Mitral Valve Repair: for certain patients with MS due to less severe valve damage. Mitral Valve Replacement: for patients with severe MS, especially if they are not candidates for PMBV. Replace with a mechanical or bioprosthetic valve. Tissue or metal valves used.
Management of Atrial Fibrillation	AF is common in mitral stenosis. Rate control with beta-blockers/CCBs or Digoxin Rhythm control with antiarrhythmic drugs. Warfarin/Heparin (NOT DOAC) anticoagulation to prevent thromboembolic events.
Lifestyle Modifications	Salt Restriction: Reduces fluid retention and reduce the workload on the heart. Exercise: Mild exercise but strenuous activities should be avoided Regular Monitoring: Follow-up with echocardiography to assess the progression of mitral stenosis and adjust treatment as necessary.

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