Mitral Stenosis Workup
- Author: Claudia Dima, MD, FACC; Chief Editor: Richard A Lange, MD, MBA more...
Perform routine baseline tests such as CBC count, electrolyte status, and renal and liver function tests.
Chest radiographic findings suggestive of mitral stenosis include left atrial enlargement (eg, double shadow in the cardiac silhouette, straightening of left cardiac border due to the large left atrial appendage, and upward displacement of the mainstem bronchi), prominent pulmonary vessels, redistribution of pulmonary vasculature to the upper lobes, mitral valve calcification, and interstitial edema (Kerley A and B lines).
Echocardiography is the most specific and sensitive method of diagnosing and quantifying the severity of mitral stenosis.[3, 4] Using a transthoracic 2-dimensional echocardiogram, Doppler study, and color-flow Doppler imaging, the anatomic abnormalities of the stenotic valve (ie, thickening, mobility, motion, calcification), involvement of the subvalvular apparatus and the characteristic fusion of the commissures can be well defined.
With echocardiography, the size of the mitral valve orifice can be precisely quantified. Important information about the ventricular and atrial chamber sizes, the presence of a left atrial thrombus, measurement of transvalvular gradient, and pulmonary arterial pressure can also be obtained.
With the use of Doppler echocardiography, sufficient information can be obtained to develop a therapeutic plan, and, consequently, most patients do not require invasive procedures such as cardiac catheterization.
Transesophageal echocardiography (TEE) provides better quality images than transthoracic echocardiography (TTE) and is more accurate in assessing the anatomic features of the valve and the presence of left atrial appendage thrombus. Recent studies showed that mitral valve area planimetry is feasible in the majority of patients with rheumatic mitral stenosis using 3-dimensional TEE; also, 3-dimensional TEE allows excellent assessment of commissural fusion and commissural opening after catheter-balloon commissurotomy.
See the image and videos below.
In patients with moderate-to-severe mitral stenosis, the ECG can show signs of left atrial enlargement (P wave duration in lead II >0.12 seconds, P wave axis of +45 to -30 marked terminal negative component to the P wave in V1 [1 mm wide and 1 mm deep]) and, commonly, atrial fibrillation. A mean QRS axis in the frontal plane is greater than 80 and an R-to-S ratio of greater than 1 in lead V1 indicates the presence of right ventricular hypertrophy. As the severity of the pulmonary hypertension increases, the mean QRS axis in the frontal plane moves toward the right.
Cardiac catheterization was routine performed in the past. However, the accuracy of echocardiographic findings has resulted in only selective use of catheterization. Cardiac catheterization is now indicated in the following situations:
When a discrepancy exists between clinical and echocardiographic findings
The patient with associated severe lung disease and pulmonary hypertension, in whom mitral stenosis has contributed to their symptoms, needs to be ascertained.
In older patients with severe mitral stenosis, cardiac catheterization is strongly indicated to rule out the presence of concomitant coronary artery disease.
In patients who developed serious symptoms after mitral commissurotomy.
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)