Mitral Stenosis made Easy

Introduction
Hi! My name is Tuan Ahamed Cassim – The founder of MedWiz.net and
the author of “Mitral Stenosis made Easy”. First and foremost I would
like to welcome you to my small hand book and I am so glad that you
are here to read my book.
Before I proceed I would like to share with you a few words on why I
decided to write this book. Let me tell you a story on how I landed on
this idea to write this. When I was trying to get started to study for my
exam, I was overwhelmed with a lot of information and I got so
confused on where I should start. Over a period of time I felt so
intimidating and I could not really figure out where I should get started.
Anyhow I started studying about Mitral Stenosis from fresh start. It was
my beginning. This led me to study other topics as well. The main
lesson I learnt from here is that you should get started somewhere and
not procrastinate. I learnt this in the hard way. But I don’t want you to
learn the hard way. I want to help you to get started as soon as
possible.  So I decided to write this book in a way that is easy to
understand by any student who is looking to get started. My main goal
is to build the incentive for the people to study more. It is just to make
you get started. In this book I have tried my best to make some hard
concepts into simple ones in a way that is easy to understand, using my
previous experiences of study. 
Mitral Stenosis
So before we get deep into the disease of Mitral Stenosis, let us be
clear of the meaning of Mitral Stenosis. Mitral Stenosis is a valvular
heart disease which is caused by the stenosing (or narrowing) of the
orifice or the opening of Mitral Valve.
Pathophysiology

So as you can see above, a schematic diagram of the human heart. I

want you to focus on the flow of blood from left Atrium to Left
ventricle. In Mitral Stenosis the blood will have some hard time to pass
from left atrium to left ventricle. It is because of the narrowing of the
orifice of mitral valve. Therefore during diastole, the left atrium has to
do extra work in order for the blood to pass normally from left atrium
to left ventricle. Therefore the left atrium will get hypertrophied over
time.

Now I want you to look at the diagram above. As I said before, there is
high resistance or high difficulty for the blood to pass from left atrium
to left ventricle. So gradually, there will be a tension built up at the
pulmonary vein and then Lungs and finally the tension gets built up at
the Pulmonary artery. As a result, the Right ventricle has to do more
work in order to pump blood from right ventricle to pulmonary artery.
Therefore as the time passes with this condition, the Right ventricle
gets hypertrophied.
So according to my previous explanation, the heart should look like the
diagram below, schematically. The red color represents hypertrophy.

Etiology
So now I hope that you have got some basic understanding of ‘what’
really happens in mitral stenosis and ‘how’ it occurs. Next we will look
into ‘why’ it happens or in other words what are the causes of mitral
stenosis.
1) Rheumatic heart disease – Secondary to previous rheumatic fever
due to infection with group a beta-hemolytic streptococcus.
2) Congenital (Rare form)
3) Due to tumor
4) Calcification and fibrosis of the mitral valve, the valve ring and
subvalvular apparatus (Chordae tendinae)
Symptoms
Now I want you to recall what you learnt previously in pathphysiology
of mitral stenosis in this book.
1) The first thing what I need to you to understand is that there will
be severe progressive dyspnoea (Difficulty in breathing) due to
Mitral Stenosis. How this happens? Well, do you remember that I
said that there will be high resistance for the blood to flow from
left atrium to left ventricle? Yes. As a result, there will
hypertension at the level of pulmonary vein due to the high
resistance. So what is it that comes before pulmonary vein? Yes, it
is the Lung! Then this tension will also affect the Lung! So
therefore there will be developed a severe dyspnoea. And this
dyspnoea is also caused due to recurrent bronchitis.
2) The second is there will be cough with hemoptysis (Blood in
sputum). I hope this thing is self explanatory since this is also
linked with Lung. Due to hypertension in Lung and the vessels in
lung, the blood gets expectorated in sputum (Hemoptysis).
3) Right Heart failure. Guess why? It is due to hypertension in
pulmonary Artery! If you guessed that right, my congradulations!
 Since the right ventricle has to work more and more extra, the
right ventricle compensates this by becoming hypertrophied as
shown in a previous diagram in this book. But will the right
ventricle continue this way for long time? Of course Not! So there
will be a gradual development of right heart failure!
4) Since the left atrium is hypertrophied and is large, this favours
atrial fibrilation. This results in palpitation of the heart.
5) And also since the atrial fibrillation does not do its work to pump
blood properly, there will be a development of systemic emboli
(Blood coagulation) most commonly to the cerebral vessels. The
 emboli could also occur in messenteric, renal or peripheral vessels
as well.
Signs
1) Mitral Face (Malar flush) – It occurs due to vascular stasis at the
atriovenous anastomoses.

2) Small volume pulse

3) When Right heart failure develops in this disease, the blood that
comes from vena cava to right atrium and then to right ventricle
will have some hard time to get pumped from right ventricle
onwards right? Yes. So there will be some pressure developed in
vena cava level due to high resistance of blood at that level. This is
manifested with distension of jugular veins.
Auscultation

This section should be the most interesting section of this whole

book! I don’t want you to leave without getting you to understand
this section. It is because I honestly believe that this has to be learnt
in a very interesting way. Otherwise things will get boring! Hopefully
you will find this section more interesting to help you get the main
concept on this section very fast! 
What is S1 and S2?
It is simple. They both are heart sounds that you hear! Lub dub Lub
dub! S1 is the first sound you hear (Lub) and S2 is the second heart
sound you hear (Dub).
It is important that you understand how this sound occurs. Don’t
panic. It is easy to understand.
- S1 simply occurs due to closure of the atrioventricular valves (i.e.
closure of mitral and tricuspid valves). This happens during systole
only. It is because AV valves can only cause when the ventricles
contract. Just like your door gets shut when there is a strong wind
inside. You get the point!
- S2 simply occurs due to closure of Aortic and Pulmonary valves. It
happens during diastole. And during systole these valves (semi
lunar valves) get opened. And during diastole they get closed,
giving S2 sound!
Now I want you to visualize the heart with Mitral stenosis. I want you
to recall everything that you read and learnt from this book in
previous pages.
First let us focus on the left atrium. So when the hypertrophied
atrium contracts, the leaflets open suddenly. As a result we hear the
opening of the leaflets of the valve as well. This is called ‘Opening
Snap’.
Secondly let us focus around the mitral valve itself. Since the mitral
valve is narrowed, the blood flow from Left atrium to left ventricle
gets less. So the leaflets of the mitral valve (Or I would like to call
them as wings!) will have more space to move freely. Just like the
door is wide open. Now don’t get confused with mitral valve and
leaflets. Just because leaflets are like doors that are wide open does
not mean the Orifice or the opening of the valve is wide open. No! It
is not. The opening is narrowed. But now I am speaking about the
leaflets. So since the leaflets are freely on the space due to less
blood in the left ventricle, then as the systole occurs the leaflets get
closed very very loudly! This causes the S1 to be abnormally loud!
Now I want you to focus on the occurrence of blood flow from left
atrium to left ventricle. Just focus on that for now.
You see that there is 2 phases of filling of ventricles during diastole.
They are passive filling and then active filling. First the blood from
left atrium gets filled passively (i.e. without using any contraction or
energy). I repeat that passive filling makes the blood to just flow
from left atrium to left ventricle just calmly. And during active filling,
the left atrium contracts with energy and then pumps the rest of the
remaining blood in left atrium towards the left ventricle. This is the
whole picture of diastole. Now, during this process where the blood
flows from the left atrium to left ventricle, there will also be a sound
generated due to the turbulent flow of blood from left atrium to left
ventricle.

So now you should understand this turbulent flow results in a sound

being generated. This sound is called as a “Murmur” in the medical
space.  This murmur that is generated at the mitral valve occurs
during diastole. Why? It is because it is only during diastole the
blood flows across the mitral valve even in Mitral Stenosis. One of
the reasons we hear the murmur in mitral stenosis is because of the
narrowing of the valve. Just imagine the room is full of people. And
the door opening is very close. When the people goes out of the
room, they make noise right? It is just same as a murmur. A
turbulent noise!

Now I want you to focus on the stage of Diastole. During passive

filling the blood flows from left atrium to left ventricle. So gradually
the volume of blood in the left atrium reduces over time. Keeping
this in mind I want you to imagine a small room with a huge number
of people inside and there is a door for exit. When everybody is
asked exit the room, they would exit with huge noise due to
turbulence. But gradually the number of people inside the room will
reduce over time because the people are gradually going out from
the exit door. Now since the number of people gets reduced over
time, what do you think would happen to the noise? Will it increase
or decrease? It would decrease of course. It is because the amount
of people to make noise will reduce.
Likewise when the blood flows from left atrium to left ventricle, the
amount of blood in left atrium will decrease over time. Hence, the
noise reduces. In other words, the murmur reduces. This is shown by
the murmur on the picture shown as ‘during passive filling’. Notice
the reduction of the murmur.
Now passive filling is over. Next is active filling. Here, the atrium
contracts in order to force and push the remaining blood from the
left atrium to left ventricle, actively and energetically. During this
process we hear the ‘Presystolic Accentuation’. That is shown as
‘during active filling’ in the diagram above.
Ok, now that you have read my book and I hope you would have
benefitted from this book and I hope that I would have made certain
concepts easier than you thought before. I don’t want to overwhelm
you with a lot of information. I just need you to get started and
understand the basics first. I strongly believe that if you get started
with little steps you can get ahead easily. My main goal from this
book is to build a student friendly foundation to get started for
students who are finding it intimidating to study Internal Medicine
related topics. Sometimes you just need to know some small points
here and there in order to grasp the whole idea, which will make an
incentive for you to learn more and more.
If you find this book worth your time reading and if you benefit from
this book which I hope you did, sincerely!  Please send me your
feedbacks about this book.
And at last but not the least, I would like to thank you very much for
taking your valuable time for reading this book and please click the
link below to join my MedWiz Mastermind group. I hope this
mastermind group be an amazing group for all medical students
around the globe. It is a group where all like-minded A-Players who
are in medical field get together in one single group. I hope to
provide more value for this group in future. So I see you in the group,
so click the link below to join now! 
‘MedWiz Club’ Facebook Group
Or go to the following link: -
https://www.facebook.com/groups/1487072661595588/

At the end I would like to share with you a quote which I want you to
reflect upon in your medical career.
“The secret to getting ahead is… Getting started!”

Thank you very much for your time! And See you inside the group! 
- Tuan Ahamed Cassim > Founder of MedWiz.net
References
Malar Flush: -
https://myhow.files.wordpress.com/2010/07/malar.jpg

Auscultation: -
http://www.stethographics.com/heart/images/sites.jpg