Mitral stenosis

Alternative names

Mitral valve obstruction

Definition

Mitral stenosis is a narrowing or blockage of the opening of the mitral valve, which separates the
upper and lower chambers on the left side of the heart. This prevents proper blood flow from
moving between the left atrium (upper chamber of the heart) and ventricle (lower chamber of the
heart).

Causes, incidence, and risk factors

Mitral stenosis is a heart valve disorder. Symptoms usually develop between the ages of 20 and
50. It most commonly occurs in people who have had rheumatic fever. Since rheumatic fever
rates are declining in the United States, the incidence of mitral stenosis is also decreasing. Only
rarely do other disorders cause mitral stenosis.

The condition may be present from birth (congenital), but it seldom occurs as a single defect.
Congenital mitral stenosis is more often part of a complex heart deformity.

Mitral stenosis prevents the valve from opening properly and blocks the blood flow from the left
atrium to the left ventricle. As the valve area becomes smaller, less blood flows forward to the
body. The atrium swells as pressure builds up and blood may flow back into the lungs, resulting in
pulmonary edema (fluid in the lung tissue).

The main risk factor for mitral stenosis is a history of rheumatic fever. Symptoms may begin with
an episode of atrial fibrillation or may be triggered by pregnancy or other stress on the body such
as infection (in the heart, lungs, etc.) or other cardiac disorders.

Symptoms

• Difficulty breathing
o During or after exercise
o When lying flat (orthopnea)
o Awakening at night with difficulty breathing
• Cough
o May have blood in the sputum (hemoptysis)
• Fatigue, tired easily
• Frequent respiratory infections (such as bronchitis)
• Chest discomfort (rare)
o Tight, crushing, pressure, squeezing, constricting
o Radiates to the arm, neck, jaw, or other areas
o Increases with activity, decreases with rest
• Sensation of feeling the heart beat (palpitations)
• Swelling of feet or ankles
Note: There are often no symptoms. However, symptoms may appear or get worse with exercise
or any activity that raises the heart rate.

Signs and tests

The health care provider will listen to the heart and lungs with a stethoscope. A distinctive
murmur, snap, or other abnormal heart sound may be heard. The typical murmur is a "rumbling
apical diastolic murmur with pre-systolic accentuation." This means a rumbling sound is heard
over the heart during the resting phase of the heart beat. The sound gets louder just before the
heart begins to contract.

The exam may also reveal an irregular heartbeat or lung congestion. Blood pressure is usually
normal.

Mitral stenosis may be difficult to distinguish from left atrial myxoma (a tumor of the heart).

Narrowing or obstruction of the valve or enlargement of the atrium may show on:

• Echocardiogram
• Transesophageal echocardiogram (TEE)
• Doppler ultrasound
• Chest x-ray
• ECG (electrocardiogram)
• Cardiac catheterization
• MRI

This disease may also alter the results of the following tests:

• Swan-Ganz (right heart catheterization)

• Nuclear ventriculography (MUGA or RNV)

Treatment

Treatment depends on the symptoms and condition of the heart and lungs. Persons with mild
symptoms or none at all may not need treatment. Hospitalization may be required for diagnosis
and for treatment of severe symptoms.

There are a number of different treatment options.

Medications include diuretics (water pills), nitrates, or beta-blockers. Digoxin may be used to treat
atrial fibrillation. Anti-coagulants (blood thinners) are used to prevent blood clots from forming and
traveling to other parts of the body.

Some patients may need heart surgery to repair or replace the valve. Replacement valves can be
made from different materials, some of which may last for decades and others which can wear
out and require replacement.

Percutaneous mitral balloon valvotomy (also called valvuloplasty) may be considered instead of
surgery. During this procedure, a catheter (tube) is inserted into a vein, usually in the leg, and up
into the heart. A balloon on the tip of the catheter is inflated, widening the mitral valve and
improving blood flow. This procedure is less likely to work in patients with severely damaged
mitral valves.

Expectations (prognosis)

The outcome varies. The disorder may be mild, without symptoms, or may be more severe and
eventually disabling. Complications may be severe or life threatening. Mitral stenosis is usually
controllable with treatment and improved with valvuloplasty or surgery.

Complications

• Pulmonary edema
• Atrial fibrillation
• Pulmonary hypertension
• Right-sided heart failure
• Stroke
• Emboli (migration of clot) to the intestines, kidneys, or other areas

Calling your health care provider

Call your health care provider if symptoms suggest mitral stenosis.

Call your health care provider if you have mitral stenosis and symptoms do not improve with
treatment, or if new symptoms appear.

Prevention

Follow treatment recommended for conditions that may cause valve disease. Treat strep
infections promptly to prevent rheumatic fever. Tell your health care provider if you have a family
history of congenital heart diseases.

Mitral stenosis itself often cannot be prevented, but complications can be prevented. Inform your
health care provider of any history of heart valve disease before medical treatment.

For example, any dental work, including cleaning, and any invasive procedure, can introduce
bacteria into the bloodstream. These bacteria can infect a damaged mitral valve. Preventive
antibiotics before these procedures will help to decrease the risk for endocarditis.

Taking anticoagulation medication as prescribed is very important because mitral stenosis tends
to produce both cerebral and peripheral emboli (blood clots in the brain and extremities), which
can cause severely disabling and/or life-threatening complications like stroke.

— MAHMUD CD9