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r. Muhammad Alauddin Sarwar

edical Officer ,
ndh Government Qatar Hospital,
rachi, Pakistan

• Etiology
• Symptoms
• Physical Exam
• Severity
• Natural history
• Timing of
Mitral Stenosis: Etiology

• Primarily a result of rheumatic fever (~ 99%

of MV’s @ surgery show rheumatic
damage )
• Scarring & fusion of valve apparatus
• Rarely congenital
• Pure or predominant MS occurs in
approximately 40% of all patients with
rheumatic heart disease
• Two-thirds of all patients with MS are female.
Normal mitral valve
Chordae Tendinae

Ant papillary muscle

Thickening of cusps

Fusion of chordae

Stenotic mitral valve

Mitral Stenosis:
Mitral Stenosis:
Right Heart ↑ Pulmonary HTN
Failure: Pulmonary
RA Hepatic Congestion LA
Congestion LA Thrombi
Tricuspid Atrial Fib
Regurgitation LA Enlargement
RA Enlargement ↑ LA Pressure
Mitral Stenosis

RV Pressure
RV Overload LV
RVH LV Filling
RV Failure
Mitral Stenosis: Symptoms
• A-fib
• Fatigue • Systemic embolism
• Palpitations • Pulmonary infection
• Cough • Hemoptysis
• Right sided failure
• SOB – Hepatic Congestion
• Left sided – Edema
failure • Worsened by
– Orthopnea conditions that ↑
cardiac output.
– PND – Exertion, fever,
• Palpitation anemia, tachycardia,
A-fib, I/V fluid
Recognizing Mitral
Palpation: Auscultation:
• Small volume pulse • Loud S1- as loud as S2
• Tapping apex- in aortic area
palpable S1 • A2 to OS interval
• +/- palpable inversely proportional
opening snap (OS) to severity
• RV lift • Diastolic rumble: length
• Palpable S2 proportional to
ECG: • In severe MS with
• NSR/AF, LAE, RVH, low flow- S1, OS &
RAD rumble may be
Mitral Stenosis: Natural

Progressive, lifelong disease,
• Usually slow & stable in the early years.
• Progressive acceleration in the later years
• 20-40 year latency from rheumatic fever to
symptom onset.
• Additional 10 years before disabling symptoms
• With physically limiting symptoms
10 yr survival 0-15%
10-20% systemic embolism
30-40% develop AF
• With onset of severe pulmonary hypertension
Mean survival < 3 yrs
Mitral Stenosis: Role of
• Diagnosis of Mitral Stenosis
• Assessment of P
hemodynamic severity S
– mean gradient, mitral A
valve area, pulmonary
artery pressure
• Assessment of right
ventricular size and
• Assessment of valve S
morphology to determine L
suitability for percutaneous A
mitral balloon
valvuloplasty (PMBV)
Mitral Stenosis:
• Complications
Atrial dysrrhythmias
• Systemic embolization (10-
– Risk of embolization is
to, age, presence of atrial
fibrillation, previous
embolic events
• Pulmonary infarcts (result of severe CHF)Animation
• Congestive heart failure
• Hemoptysis
– Massive: secondary to ruptured bronchial veins
(pulm HTN)
– Streaking/pink froth: pulmonary edema, or
• Endocarditis
Mitral Stenosis:Therapy
• Medical
– Diuretics for LHF/RHF
– Digitalis/Beta blockers/CCB for Rate control in A Fib
– Anticoagulation: In A Fib
– Endocarditis prophylaxis

• Balloon valvuloplasty
– Effective long term improvement
Step By Step Balloon valvuloplasty (Commissurotomy )
Inoue balloon technique for
mitral balloon valvotomy.
A. After trans-septal
puncture, the deflated
balloon catheter is
advanced across the
inter-atrial septum,
then across the mitral
valve and into the left
ventricle. B. The
balloon is then inflated
stepwise within the
mitral orifice.
Mitral Stenosis:Therapy
• Surgical
– Mitral commissurotomy
– Mitral Valve Replacement
• Mechanical
• Bioprosthetic
Surgical Commissurotomy

A surgical
procedure to open a
stenotic valve. A
stenotic valve
restricts the flow of
blood. A scalpel
incision widens the
Step by Step Heart Valve
Replacement Animation

( copy the following link and paste it into the address bar of Internet Explorer & hit Enter)