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Mitral Stenosis in Emergency Medicine Follow-up

  • Author: Ethan S Brandler, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Dec 28, 2015
 

Further Inpatient Care

Percutaneous balloon valvotomy is, in general, the initial procedure of choice for symptomatic patients with moderate-to-severe mitral stenosis. It can double the mean valve area with a 50-60% decrease in the transmitral pressure gradient, producing a prominent and sustained symptomatic improvement.[11]

The 2006 ACC/AHA Practice Guidelines recommend percutaneous mitral balloon valvotomy for symptomatic patients (New York Heart Association [NYHA] Functional Class [FC] II, III, or IV) with moderate or severe mitral stenosis and favorable valve morphology in the absence of left atrial thrombus or significant mitral regurgitation.[2, 11]

In patients with indications for intervention, percutaneous valvotomy has proven superior to closed commissurotomy in some long-term studies. The overall event-free (no death, repeat valvotomy, or valve replacement) survival rate is 80-90% in patients with favorable valve morphology. More than 90% of patients free of events remain in NYHA FC I or II.[11]

Surgical commissurotomy is required when the conditions for percutaneous valvotomy are not met. In the United States, open commissurotomy is considered preferable to close commissurotomy.

The 2006 ACC/AHA Practice Guidelines gave a class I recommendation for surgical intervention in patients with NYHA FC III-IV symptoms, moderate or severe mitral stenosis, and valve morphology favorable for repair or replacement if one of the following is noted:[2, 11]

  • Percutaneous mitral balloon valvotomy is not available.
  • A left atrial thrombus is present despite anticoagulation.
  • A nonpliable or calcified valve is present, with the decision to proceed with either repair or replacement made at the time of the operation.

Patients with moderate or severe mitral regurgitation should undergo valve replacement.

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Inpatient & Outpatient Medications

Medications cannot correct mitral stenosis, but therapy can reduce the incidence and severity of symptoms and complications.

Drugs that increase diastolic filling time and decrease the heart rate are typically used. Beta-blockers are frequently used in this situation. Calcium channel blockers, such as diltiazem, and digoxin may also be used. Beta-blockers are preferred over digoxin because they control exercise-induced increases in heart rate.

Rhythm control is of questionable clinical significance. Amiodarone may be used to maintain sinus rhythm, but its use may cause complications.

Anticoagulation is used in patients with atrial thrombi, in patients with atrial fibrillation, or in patients with a prior thromboembolic event.

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Deterrence/Prevention

Some European guidelines for the treatment of group A Streptococcus (GAS) pharyngitis are remarkably different than those in the United States.[28] Indeed, some European guidelines consider acute pharyngitis a self-limiting disease and do not recommend testing for GAS or prescription of antibiotics for GAS pharyngitis. The following discussion is based on guidelines and policy statements published by the American Heart Association and the American College of Cardiology and expert opinion.[29, 7, 11, 30]

Primary prophylaxis depends on early diagnosis of GAS pharyngitis. Treatment started within 7-9 days after onset of illness may prevent rheumatic fever. Treatment with penicillin V is recommended. If beta-lactam allergy is present, azithromycin or clarithromycin is now recommended. To date, no strains of streptococci that produce rheumatic fever have been penicillin resistant.

Secondary prophylaxis may delay the progression of mitral stenosis. Secondary prophylaxis may be individually tailored. The duration of prophylaxis depends on the presence of carditis and persistent valvular disease.

Rheumatic fever with carditis and residual heart disease requires prophylaxis for 10 years or until age 40 years, whichever is longer.

Rheumatic fever with carditis but no residual heart disease requires prophylaxis for 10 years or until age 21 years, whichever is longer.

Rheumatic fever without carditis requires prophylaxis for 5 years or until age 21 years, whichever is longer.

Endocarditis prophylaxis for routine dental and respiratory procedures is no longer recommended for patients with mitral stenosis unless they have had implantation of an artificial valve.[30]

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Complications

Complications of mitral stenosis may include all of the following:

  • Thromboembolism
  • Atrial fibrillation
  • Bacterial endocarditis
  • Pulmonary hypertension
  • Pulmonary edema
  • Complications of balloon valvulotomy (eg, stroke, cardiac perforation, development of mitral regurgitation)
  • Complications of mitral valve replacement (eg, perivalvular leak, thromboembolism, infective endocarditis, mechanical dysfunction, bleeding due to anticoagulants)
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Prognosis

Depending on severity of symptoms of mitral stenosis, the 10-year survival rate is as follows:

  • 85% for no symptom (class I)
  • 34-42% for mild symptoms (early class II)
  • 40% for moderate-severe symptoms (late class II, class III)
  • 0% for class IV (Of class IV patients, survival is 42% at 1 year and 10% at 5 years.)

The operative mortality rate is 1-2% for mitral commissurotomy and 2-5% for mitral valve replacement.

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Contributor Information and Disclosures
Author

Ethan S Brandler, MD, MPH Clinical Assistant Professor, Attending Physician, Departments of Emergency Medicine and Internal Medicine, University Hospital of Brooklyn, Kings County Hospital

Ethan S Brandler, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Eric M Suess, MD Clinical Assistant Instructor, Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Eric M Suess, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

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.

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, Arizona Medical Association, American College of Osteopathic Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Robert M McNamara, MD, FAAEM Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors, Yiju Teresa Liu, MD, and Richard H Sinert, DO, to the development and writing of this article.

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Mitral stenosis.
Echocardiography of mitral stenosis. Courtesy of Michael B. Stone, MD, RDMS.
 
 
 
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