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Mitral Stenosis Workup

  • Author: Claudia Dima, MD, FACC; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Nov 06, 2014
 

Laboratory Studies

Perform routine baseline tests such as CBC count, electrolyte status, and renal and liver function tests.

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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.[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.[5]

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[6] and commissural opening after catheter-balloon commissurotomy.

See the image and videos below.

Transesophageal echocardiogram with continuous wav 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.
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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.

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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 commissurotomy.
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Contributor Information and Disclosures
Author

Claudia Dima, MD, FACC Interventional Cardiology

Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth B Desser, MD † Former Clinical Professor, Director of Cardiology Fellowship, Banner Good Samaritan Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven J Compton, MD, FACC, FACP, FHRS Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Physicians, American Heart Association, American Medical Association, Heart Rhythm Society, Alaska State Medical Association, American College of Cardiology

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Additional Contributors

L Michael Prisant, MD, FACC, FAHA Cardiologist, Emeritus Professor of Medicine, Medical College of Georgia, Georgia Regents University

L Michael Prisant, MD, FACC, FAHA is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Clinical Pharmacology, American College of Forensic Examiners Institute, American College of Physicians, American Heart Association, American Medical Association

Disclosure: Received honoraria from Boehringer-Ingelheim for speaking and teaching.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Holger P Salazar, MD, Senthil Nachimuthu, MD, FACP, and Kiruthika Balasundaram, MBBS, to the development and writing of this article.

References
  1. 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].

  2. 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].

  3. 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].

  4. 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].

  5. Bruce CJ, Nishimura RA. Newer advances in the diagnosis and treatment of mitral stenosis. Curr Probl Cardiol. 1998 Mar. 23(3):125-92. [Medline].

  6. 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].

  7. [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].

  8. [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].

  9. 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].

  10. [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].

  11. [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].

  12. 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].

  13. Feldman T. Rheumatic Mitral Stenosis. Curr Treat Options Cardiovasc Med. 2000 Apr. 2(2):93-104. [Medline].

  14. Rahimtoola SH. Choice of Prosthetic Heart Valve in Adults An Update. J Am Coll Cardiol. 2010 Jun 1. 55(22):2413-2426. [Medline].

  15. 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].

  16. 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].

 
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M-mode across the mitral valve showing a flat E-F slope resulting from elevated left atrial pressure throughout diastole due to a significant gradient across the mitral valve. Increased thickness and calcification of anterior leaflet of the mitral valve and decreased opening of the anterior and posterior leaflets in diastole are also shown.
Parasternal long-axis view demonstrating calcification and doming in diastole of the anterior valve leaflet and mild restriction in the opening of posterior mitral valve leaflet.
Apical 4-chamber view demonstrating restricted opening of the anterior and posterior mitral valve leaflet with diastolic doming of anterior leaflet with left atrial enlargement.
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.
Apical 4-chamber view with color Doppler demonstrating aliasing in the atrial side of the mitral valve consistent with increased gradient across the valve. This figure also shows mitral regurgitation and left atrial enlargement.
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.
Table 1. Duration of Secondary Rheumatic Fever Prophylaxis
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.



Table 2. Secondary Prevention of Rheumatic Fever (Prevention of Recurrent Attacks)
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.



Table 3. Primary Prevention of Rheumatic Fever (Treatment of Streptococcal Tonsillopharyngitis*)
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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