Mitral Stenosis Clinical Presentation
- Author: Claudia Dima, MD, FACC; Chief Editor: Richard A Lange, MD, MBA more...
Symptoms of mitral stenosis usually manifest during the third or fourth decade of life and nearly half of the patients do not recall a history of acute rheumatic fever.
Patients are generally asymptomatic at rest during the early stage of the disease. However, factors that increase heart rate such as fever, severe anemia, thyrotoxicosis, exercise, excitement, pregnancy, and atrial fibrillation may result in dyspnea.
Nearly 15% of patients develop embolic episodes that are usually associated with atrial fibrillation. Rarely, embolic episodes may occur even in the patient with sinus rhythm. Systemic embolization may lead to stroke, renal failure, or myocardial infarction.
Hoarseness can develop from compression of the left recurrent laryngeal nerve against the pulmonary artery by the enlarged left atrium. Also, compression of bronchi by the enlarged left atrium can cause persistent cough.
Hemoptysis may occur and is usually not fatal.
Pregnant women with mild mitral stenosis may become symptomatic during their second trimester because of the increase in blood volume and cardiac output.
The presence of mitral facies (pinkish-purple patches on the cheeks) indicate chronic severe mitral stenosis leading to reduced cardiac output and vasoconstriction.
Jugular vein distension may be seen. In the patient with sinus rhythm, a prominent a wave reflects increased right atrial pressure from pulmonary hypertension and right ventricular failure. A prominent v wave is seen with tricuspid regurgitation.The apical impulse may be laterally displaced or not palpable, especially in cases of severe mitral stenosis. This can be explained by decreased left ventricular filling. Rarely, a diastolic thrill can be felt at the apex with the patient in the left lateral recumbent position. See the videos below.
Often a right ventricular lift is palpable in the left parasternal region in the patient with pulmonary hypertension. A P2 may be palpable in the 2nd left intercostal space.
The auscultatory findings characteristic of mitral stenosis are a loud first heart sound, an opening snap, and a diastolic rumble.
The first heart sound is accentuated because of a wide closing excursion of the mitral leaflets. The degree of loudness of the first heart sound depends on the pliability of the mitral valve. The intensity of the first heart sound diminishes as the valve becomes more fibrotic, calcified, and thickened.
The second heart sound is normally split, and the pulmonic component is accentuated if pulmonary hypertension is present. The opening snap follows the second heart sound. The sudden tensing of the valve leaflets after they have completed their opening excursion causes an opening snap. In patients with elevated left atrial pressure and hence with severe mitral stenosis, the opening snap occurs closer to the second heart sound.
The diastolic murmur of mitral stenosis is of low pitch, rumbling in character, and best heard at the apex with the patient in the left lateral position. It commences after the opening snap of the mitral valve, and the duration of the murmur correlates with the severity of the stenosis. The murmur is accentuated by exercise, whereas it decreases with rest and Valsalva maneuver. In patients with sinus rhythm, the murmur increases in intensity during late diastole (so called, presystolic accentuation) due to increased flow across the stenotic mitral valve caused by atrial contraction.
A high-pitched decrescendo diastolic murmur secondary to pulmonary regurgitation (Graham Steell murmur) may be audible at the upper sternal border.
A pansystolic murmur of TR and an S3 originating from the right ventricle may be audible in the 4th left intercostal space in the patient with right ventricular dilatation.
Iwataki M, Takeuchi M, Otani K, et al. Calcific extension towards the mitral valve causes non-rheumatic mitral stenosis in degenerative aortic stenosis: real-time 3D transoesophageal echocardiography study. Open Heart. 2014. 1(1):e000136. [Medline]. [Full Text].
Marcus RH, Sareli P, Pocock WA, et al. The spectrum of severe rheumatic mitral valve disease in a developing country. Correlations among clinical presentation, surgical pathologic findings, and hemodynamic sequelae. Ann Intern Med. 1994 Feb 1. 120(3):177-83. [Medline].
Henri C, Pierard LA, Lancellotti P, Mongeon FP, Pibarot P, Basmadjian AJ. Exercise Testing and Stress Imaging in Valvular Heart Disease. Can J Cardiol. 2014 Sep. 30(9):1012-1026. [Medline].
Wunderlich NC, Beigel R, Siegel RJ. Management of mitral stenosis using 2D and 3D echo-Doppler imaging. JACC Cardiovasc Imaging. 2013 Nov. 6(11):1191-205. [Medline].
Bruce CJ, Nishimura RA. Newer advances in the diagnosis and treatment of mitral stenosis. Curr Probl Cardiol. 1998 Mar. 23(3):125-92. [Medline].
Schlosshan D, Aggarwal G, Mathur G, Allan R, Cranney G. Real-time 3D transesophageal echocardiography for the evaluation of rheumatic mitral stenosis. JACC Cardiovasc Imaging. 2011 Jun. 4(6):580-8. [Medline].
[Guideline] Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 10. 63(22):e57-185. [Medline]. [Full Text].
[Guideline] Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009 Mar 24. 119(11):1541-51. [Medline].
Antonini-Canterin F, Moura LM, Enache R, Leiballi E, Pavan D, Piazza R. Effect of hydroxymethylglutaryl coenzyme-a reductase inhibitors on the long-term progression of rheumatic mitral valve disease. Circulation. 2010 May 18. 121(19):2130-6. [Medline].
[Guideline] Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 Guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008 Aug 19. 52(8):676-85. [Medline].
[Guideline] Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012 Oct. 33(19):2451-96. [Medline].
Wann LS, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2011 Mar 15. 57(11):1330-7. [Medline].
Feldman T. Rheumatic Mitral Stenosis. Curr Treat Options Cardiovasc Med. 2000 Apr. 2(2):93-104. [Medline].
Rahimtoola SH. Choice of Prosthetic Heart Valve in Adults An Update. J Am Coll Cardiol. 2010 Jun 1. 55(22):2413-2426. [Medline].
Holmes DR Jr, Mack MJ. Transcatheter valve therapy a professional society overview from the american college of cardiology foundation and the society of thoracic surgeons. J Am Coll Cardiol. 2011 Jul 19. 58(4):445-55. [Medline].
Horstkotte D, Niehues R, Strauer BE. Pathomorphological aspects, aetiology and natural history of acquired mitral valve stenosis. Eur Heart J. 1991 Jul. 12 Suppl B:55-60. [Medline].
|Category||Duration After Last Attack||Rating*|
|Rheumatic fever with carditis and residual heart disease (persistent valvular disease† )||10 y or until age 40 y (whichever is longer); sometimes lifelong prophylaxis||IC|
|Rheumatic fever with carditis but no residual heart disease (no valvular disease† )||10 y or until age 21 y (whichever is longer)||IC|
|Rheumatic fever without carditis||5 y or until age 21 y (whichever is longer)||IC|
|*Rating indicates classification of recommendation and level of evidence (eg, IC indicates Class I, level of Evidence C).
†Clinical or echocardiographic evidence.
|Benzathine penicillin G||Children 27 kg (60 lb): 600,000 U
Patients >27 kg: 1,200,000 every 4 wk†
|Penicillin V||250 mg bid||Oral||IB|
|Sulfadiazine||Children 27 kg: 0.5 g qd
Patients >27 kg: 1 g qd
|Macrolide or azalide (for individuals allergic to penicillin and sulfadiazine)||Variable||Oral||IC|
|*Rating indicates classification of recommendation and level of evidence (eg, IA indicates Class I, level of Evidence A).
†In high-risk situations, administration every 3 weeks is justified and recommended.
|Penicillin V (phenoxymethyl penicillin)||Children 27 kg (60 lb): 250 mg bid or tid
Patients >27 kg: 500 mg bid or tid
|Amoxicillin||50 mg/kg qd (maximum 1 g)||Oral||10 d||IB|
|Benzathine penicillin G||Children 27 kg (60 lb): 600,000 U
Patients >27 kg: 1,200,000 U
|For individuals allergic to penicillin|
|Narrow-spectrum cephalosporin (cephalexin, cefadroxil)||Variable||Oral||10 d||IB|
|Clindamycin||20 mg/kg/d divided in 3 doses (maximum 1.8 g/d)||Oral||10 d||IIaB|
|Azithromycin||12 mg/kg qd (maximum 500 mg)||Oral||5 d||IIaB|
|Clarithromycin||15 mg/kg/d divided bid (maximum 250 mg bid)||Oral||10 d||IIaB|
|*Sulfonamides, trimethoprim, tetracyclines, and fluoroquinolones are not acceptable.
† Rating indicates classification of recommendation and level of evidence (eg, IB indicates Class I, level of Evidence B)