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Congenital Mitral Stenosis Workup

  • Author: M Silvana Horenstein, MD; Chief Editor: Stuart Berger, MD  more...
 
Updated: Apr 29, 2014
 

Laboratory Studies

Measure electrolyte balance and renal function if congestive heart failure is suspected.

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Electrocardiography

Electrocardiography findings may be normal in patients with mild MS. Hemodynamically significant stenosis results in ECG findings of left atrial or biatrial enlargement and RV enlargement in proportion to severity of the obstruction.

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Procedures

Cardiac catheterization

This may be used to obtain direct intracardiac pressure measurements, the mitral valve gradient, pulmonary vascular resistance, and systemic cardiac output.

The mitral valve effective orifice can be calculated using the Gorlin formula.

The diagnosis and hemodynamic assessment of most patients with MS is performed noninvasively with echocardiography. However, cardiac catheterization is used only when echocardiography does not provide complete information or if the patient undergoes mitral balloon valvuloplasty.

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Chest Radiography

Chest radiographic findings may include may the following:

  • Left atrial dilation
  • Posteroanterior (PA) dilation secondary to high pulmonary vascular pressure and resistance
  • Pulmonary venous congestion
  • Right ventricular enlargement
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Echocardiography

Echocardiography is the most important diagnostic tool to evaluate patients with mitral stenosis (MS). This noninvasive imaging modality provides excellent anatomic and hemodynamic assessment of MS.

Echocardiography provides the following:

  • Direct anatomic data, such as visualization of valve leaflet morphology and motility as well as measurement of valve orifice dimensions
  • Evaluation of left atrial size and detection of left atrial thrombi
  • Indirect physiologic data (ie, estimation of pressure gradients across the mitral valve and right ventricular systolic pressure), which may be measured using Doppler echocardiography

Transesophageal echocardiography

Transesophageal echocardiography is used when transthoracic echocardiographic pictures are inadequate. It may also be used to guide intervention and assess results in the operating room and cardiac catheterization laboratory.

Dynamic 3-dimensional transthoracic or transesophageal echocardiography

These techniques can provide good insight into valvular motion and help preoperative planning in situations in which valve reconstruction is considered.[1] However, the accuracy of these techniques is currently limited by the quality of the original 2-dimensional echo cross-sectional images, which can be adversely affected by patient motion, breathing, and cardiac arrhythmia such as atrial fibrillation.

A 2-dimensional echocardiogram of a boy with congenital MS is depicted below.

Two-dimensional echocardiograph, parasternal long Two-dimensional echocardiograph, parasternal long axis view of a 5-month-old boy with congenital mitral valve stenosis. A small mitral valve annulus (star) is appreciated when compared with the normal-sized tricuspid valve annulus. Mitral valve stenosis has caused left atrial (LA) enlargement. AoV = Aorta; LA = Left atrium; LV = Left ventricle; RA = Right atrium; RV = Right ventricle.

A 2-dimensional echocardiogram of a patient requiring mitral valve replacement is depicted below.

Two-dimensional echocardiograph, parasternal long Two-dimensional echocardiograph, parasternal long axis view of a patient who required mitral valve replacement with a St. Jude's prosthetic mitral valve (star). He developed a stroke one month after mitral valve replacement despite anticoagulation with warfarin and required re-replacement of the prosthetic mitral valve. He will eventually outgrow this new prosthetic mitral valve and require subsequent mitral valve replacements with a larger mitral valve prosthesis. AoV = Aorta; LA = Left atrium; LV = Left ventricle; RA = Right atrium; RV = Right ventricle.
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Magnetic Resonance Imaging

MRI is used infrequently; however, experience with this imaging modality in MS is more limited than with echocardiography.

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Contributor Information and Disclosures
Author

M Silvana Horenstein, MD Assistant Professor, Department of Pediatrics, University of Texas Medical School at Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc

M Silvana Horenstein, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Henry Walters, III, MD Associate Professor of Surgery, Wayne State University School of Medicine; Chief, Department of Surgery, Division of Cardiovascular Surgery, Children's Hospital of Michigan

Henry Walters, III, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Michael D Pettersen, MD Consulting Staff, Rocky Mountain Pediatric Cardiology, Pediatrix Medical Group

Michael D Pettersen, MD is a member of the following medical societies: American Society of Echocardiography

Disclosure: Received income in an amount equal to or greater than $250 from: Fuji Medical Imaging.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Julian M Stewart, MD, PhD Associate Chairman of Pediatrics, Director, Center for Hypotension, Westchester Medical Center; Professor of Pediatrics and Physiology, New York Medical College

Julian M Stewart, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Autonomic Society, American Physiological Society

Disclosure: Received grant/research funds from Lundbeck Pharmaceuticals for none.

Chief Editor

Stuart Berger, MD Medical Director of The Heart Center, Children's Hospital of Wisconsin; Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Additional Contributors

Ira H Gessner, MD Professor Emeritus, Pediatric Cardiology, University of Florida College of Medicine

Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

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Hemodynamic changes in severe congenital mitral valve stenosis (MS). MS causes an obstruction (in diastole) to blood flow from the left atrium (LA) to the left ventricle (LV). Increased LA pressures are transmitted retrograde to pulmonary veins and pulmonary capillaries, resulting in capillary leak with subsequent development of pulmonary edema. To overcome pulmonary edema, the arterioles constrict, increasing pulmonary pressures. With time, capillaries develop intimal thickening, causing fixed (permanent) pulmonary hypertension. The right ventricle (RV) hypertrophies to generate enough pressure to overcome the increased afterload. Eventually, the RV fails, which manifests as hepatomegaly and/or ascites, edema of the extremities, and cardiomegaly on radiography.
Two-dimensional echocardiograph, parasternal long axis view of a 5-month-old boy with congenital mitral valve stenosis. A small mitral valve annulus (star) is appreciated when compared with the normal-sized tricuspid valve annulus. Mitral valve stenosis has caused left atrial (LA) enlargement. AoV = Aorta; LA = Left atrium; LV = Left ventricle; RA = Right atrium; RV = Right ventricle.
Two-dimensional echocardiograph, parasternal long axis view of a patient who required mitral valve replacement with a St. Jude's prosthetic mitral valve (star). He developed a stroke one month after mitral valve replacement despite anticoagulation with warfarin and required re-replacement of the prosthetic mitral valve. He will eventually outgrow this new prosthetic mitral valve and require subsequent mitral valve replacements with a larger mitral valve prosthesis. AoV = Aorta; LA = Left atrium; LV = Left ventricle; RA = Right atrium; RV = Right ventricle.
 
 
 
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