Laboratory Studies
Perform routine baseline tests such as CBC count, electrolyte status, and renal and liver function tests.
Imaging Studies
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. 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.[2]
- 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.
See the image and videos below.
Transesophageal echocardiogram with continuous wave Doppler interrogation across the mitral valve demonstrating an increased mean gradient of 16 mm Hg consistent with severe mitral stenosis. Magnified view of the mitral valve in apical 4-chamber view revealing restricted opening of both leaflets. Transesophageal echocardiogram in an apical 3-chamber view showing calcification and doming of the anterior mitral leaflet and restricted opening of both leaflets. Transesophageal echocardiogram in an apical 3-chamber view with color Doppler interrogation of the mitral valve revealing aliasing, which is consistent with increased gradient across the mitral valve secondary to stenosis. Also shown in this image, a posteriorly directed jet of severe mitral regurgitation. Other Tests
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.
Procedures
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 valvotomy.
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. Feb 1 1994;120(3):177-83. [Medline].
Bruce CJ, Nishimura RA. Newer advances in the diagnosis and treatment of mitral stenosis. Curr Probl Cardiol. Mar 1998;23(3):125-92. [Medline].
[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. Mar 24 2009;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. May 18 2010;121(19):2130-6. [Medline].
[Guideline] Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT. 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. Aug 19 2008;52(8):676-85. [Medline].
Feldman T. Rheumatic Mitral Stenosis. Curr Treat Options Cardiovasc Med. Apr 2000;2(2):93-104. [Medline].
Rahimtoola SH. Choice of Prosthetic Heart Valve in Adults An Update. J Am Coll Cardiol. Jun 1 2010;55(22):2413-2426. [Medline].
Horstkotte D, Niehues R, Strauer BE. Pathomorphological aspects, aetiology and natural history of acquired mitral valve stenosis. Eur Heart J. Jul 1991;12 Suppl B:55-60. [Medline].
[Guideline] Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. Sep 23 2008;52(13):e1-142. [Medline].
Bonow RO, Otto CM. Valvular heart disease. In: Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 2. 8th ed. Philadelphia, PA: WB Saunders; 2008:1646-1657.
Carabello BA. Modern management of mitral stenosis. Circulation. Jul 19 2005;112(3):432-7. [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. | |||
| Agent | Dose | Mode | Rating* |
| Benzathine penicillin G | Children 27 kg (60 lb): 600,000 U Patients >27 kg: 1,200,000 every 4 wk† | Intramuscular | IA |
| Penicillin V | 250 mg bid | Oral | IB |
| Sulfadiazine | Children 27 kg: 0.5 g qd Patients >27 kg: 1 g qd | Oral | IB |
| 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. | |||
| Agent | Dose | Mode | Duration | Rating † |
| Penicillins | ||||
| Penicillin V (phenoxymethyl penicillin) | Children 27 kg (60 lb): 250 mg bid or tid Patients >27 kg: 500 mg bid or tid | Oral | 10 d | IB |
| 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 | Intramuscular | Once | IB |
| 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) | ||||
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