MRCP PACES Mitral Stenosis

Relevant physical signs

  • Hands and wrists
    • Stigmata of infective endocarditis
      • Janeway lesions (painless)
      • Osler nodes (painful)
      • Splinter haemorrhage
      • Clubbing
    • Pulse
      • Usually in atrial fibrillation
      • May be of low-volume in severe mitral stenosis, often volume variable
  • Face and neck
    • Malar flush (low cardiac output state with pulmonary hypertension)
    • Jugular venous pulsation
      • Raised (congestive cardiac failure)
      • Giant v waves (tricuspid regurgitation secondary to pulmonary hypertension)
    • Hoarse voice (Ortner’s syndrome – compression of recurrent laryngeal nerve by LA enlargement)
  • Chest
    • Inspection
      • Left lateral thoracotomy (mitral valvotomy)
      • Small scar in anterior axillary line (mitral valvotomy)
      • Implantable cardiac device
    • Palpation
      • Apex beat usually not displaced
        • Tapping quality due to loud S1
      • Right ventricular heave (pulmonary hypertension in moderate MS)
      • Palpable P2 (pulmonary hypertension)
    • Auscultation
      • S1 – usually loud due to mobile, pliable leaflets (may be soft if calcified)
      • S2 – loud if there is consequent pulmonary hypertension
      • Opening snap – shortly after S2, may disappear with progressively severe lesions
      • Mid-diastolic rumbling murmur – length of murmur correlates with severity
        • Accentuated in expiration in the left-lateral position
      • Pan-systolic murmur
        • Co-existent mitral regurgitation – will radiate to the axilla
        • Functional tricuspid regurgitation secondary to pulmonary hypertension
          • Loudest over the lower left sternal edge in inspiration
          • Giant v waves
      • Early-diastolic murmur over pulmonary area (Graham-Steele murmur of pulmonary regurgitation secondary to pulmonary hypertension)
  • Lung bases for crepitations of pulmonary oedema
  • Peripheral oedema
  • Signs of anticoagulation (bruising, pronator drift with previous ICH / thromboembolic CVA)
  • Complete examination by:
    • Looking at vitals chart, particularly temperature and blood pressure
    • Urine dipstick for evidence of microscopic haematuria (rheumatic heart disease)
    • Examine the abdomen for pulsatile hepatomegaly

Differential diagnosis of a diastolic murmur

  • Mitral stenosis
  • Left atrial mass (thrombus or myxoma)
  • Austin-Flint murmur secondary to severe aortic regurgitation
  • Aortic regurgitation

Causes of mitral stenosis

  • Rheumatic heart disease (by far the most common)
  • Congenital mitral stenosis
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
  • Carcinoid syndrome

Clinical markers of severity

  • Early opening snap
  • Increased length of the murmur
  • Signs of pulmonary hypertension
  • Signs of congestive cardiac failure
  • Graham-Steell murmur of pulmonary regurgitation
  • Low pulse pressure

Investigations

  • Confirm diagnosis and assess severity : transthoracic echocardiogram
    • Mitral valve area
      • Normal 3 – 4 cm2
      • Mild: >1.5cm2
      • Moderate: 1 – 1.5cm2
      • Severe: <1cm2
    • Mean gradient across the valve
      • Mild <5mmHg
      • Moderate 5 – 10mmHg
      • Severe >10mmHg
    • Estimated pulmonary artery systolic pressure
      • Mild: <30mmHg
      • Moderate: 30 – 50mmHg
      • Severe: >50mmHg
  • Electrocardiogram
    • Atrial fibrillation
    • p mitrale
  • Chest radiograph
    • Left atrial enlargement
    • Cardiomegaly
    • Pulmonary oedema
  • Consider coronary angiogram to see if concomitant coronary artery bypass graft is required

Management

  • Multidisciplinary team approach
  • Patient education
    • Disease process, awareness of exacerbations in recurrent Streptococcal infections
    • Symptoms of cardiac failure / pulmonary hypertension
  • Medical management
    • Atrial fibrillation
      • Rate control with beta blocker, digoxin, calcium channel blocker or amiodarone
      • Anti-coagulation with warfarin (NOACs are not licensed for valvular AF)
    • Congestive cardiac failure: diuretics for acute episodes
    • In patients with definite evidence of rheumatic heart disease
      • Consider prophylaxis against Group A Streptococcus with penicillin
      • Duration of prophylaxis unclear, possibly 10 years from last attack
    • No indication for infective endocarditis prophylaxis in native valve MS
  • Definitive percutaneous / surgical management
    • Indications
      • Symptomatic mitral stenosis
      • Pulmonary hypertension
      • Pulmonary oedema
      • Haemoptysis
      • Recurrent thromboembolic events despite therapeutic anticoagulation
      • Moderate-severe MS in patients undergoing other cardiac surgery
    • Percutaneous mitral balloon commissurotomy
      • Favourable anatomy
      • No left atrial thrombus (requires trans-oesophageal echocardiogram)
      • No mitral regurgitation
    • Open commissurotomy and valve repair
      • Favourable anatomy (pliable, non-calcified valves)
      • No mitral regurgitation
      • Requires open heart surgery
      • Suitable if patients cannot undergo percutaneous procedure due to LA thrombus
    • Mitral valve replacement (last resort due to peri-operative mortality and morbidity)
      • Valve anatomy not suitable to commissurotomy
      • Mitral valve replacements are usually metallic

Summary

Sir, this patient has mitral stenosis which is at least moderate in severity. On examination, there is a mid-diastolic murmur which is grade 2/6 and heard loudest over the apex in the left lateral position and in expiration. The mitral stenosis is complicated by atrial fibrillation, which is currently rate-controlled. I would expect this patient to be on anticoagulation, but I do not see any bruising to suggest this. The mitral stenosis is also complicated by pulmonary hypertension, as evidenced by a right ventricular heave and a loud pulmonary component of the second heart sound. There is no murmur of functional tricuspid regurgitation or pulmonary regurgitation. The lung bases are clear to auscultation, the jugular venous pulsation is not elevated and there is no peripheral oedema. There are no peripheral stigmata of infective endocarditis. Other differentials for a diastolic murmur include an atrial myxoma or left atrial thrombus, and an Austin-Flint murmur associated with severe aortic regurgitation. The most common cause for mitral stenosis is rheumatic heart disease.

In summary, this patient has at least moderate mitral stenosis.

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