Mitral Stenosis in Emergency Medicine Treatment & Management

Updated: May 12, 2020
  • Author: Ethan S Brandler, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Treatment

Prehospital Care

Prehospital care is appropriate for acute pulmonary edema or arrhythmia secondary to mitral stenosis.

Oxygen administration is always indicated for symptomatic patients.

In patients with significant acute dyspnea, appropriately trained personnel may administer agents that promote afterload reduction such as nitrates or ACE inhibitors.

Clinically significant arrhythmias such as atrial fibrillation with rapid ventricular response should be corrected according to local protocols. Medications appropriate for use by prehospital personnel vary according to local protocol but may include diltiazem, amiodarone, esmolol, or metoprolol.

Grossly unstable patients with atrial fibrillation with rapid ventricular response should receive synchronized direct current (DC) cardioversion.

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Emergency Department Care

The goal is to control symptoms, to prevent or retard disease progression, and to treat complications.

Treatment of congestive heart failure

Medications to consider include nitroglycerin, ACE inhibitors, and diuretics.

Patients with severe mitral stenosis should maintain an upright posture and avoid strenuous physical activity.

Sodium intake should be restricted, and maintenance doses of oral diuretics should be continued.

The data on beta-blockers are conflicting; beta-blockade may be useful for patients with exertional symptoms if the symptoms occur primarily at high heart rates.

Prevent or retard disease. Primary and/or secondary prophylaxis against streptococci/endocarditis should be administered.

Penicillin is indicated whenever streptococcal infection is suspected in a patient with known rheumatic disease.

Management of atrial fibrillation

Much of the dyspnea related to mitral stenosis is rate related. Control of atrial fibrillation with rapid ventricular response may be considered with any of the following agents:

  • Metoprolol

  • Esmolol

  • Diltiazem

  • Digoxin

If the patient is unstable and immediate cardioversion is indicated, then heparin should be administered before, during, and after cardioversion. Otherwise, electrical or chemical cardioversion should be performed after 3 weeks of warfarin anticoagulation. Transesophageal echocardiography prior to elective cardioversion should be considered.

Anticoagulation is necessary in many patients who are unable to maintain normal sinus rhythm. Anticoagulation may also be beneficial for patients with normal sinus rhythm with a prior embolic event or a left atrial dimension greater than 55 mm Hg noted by echocardiography.

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Consultations

A cardiologist and/or cardiothoracic surgeon should be consulted in the following situations:

  • Known or suspected cases of mitral stenosis with hemodynamic instability, arrhythmia, or embolization

  • Cases involving a new onset or progression of symptoms

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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. [2]

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.

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.

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