Diagnostic Considerations
Important considerations
It is important that clinicians diagnose not only the primary problem but also any additional congenital cardiovascular abnormalities.
Refer patients who demonstrate increasing symptoms, especially those of congestive heart failure.
Special concerns in pregnant women
Patients who are pregnant have a higher risk of developing pulmonary edema because of the increased intravascular volume. For this reason, they should be closely monitored.
Asymptomatic or minimally symptomatic patients may only require close observation, but severely symptomatic patients may require urgent surgical intervention.
Pregnant women who require anticoagulation because of a prosthetic mitral valve should receive heparin, which does not cross the placental barrier. They should not receive warfarin because of its teratogenic effects and fetal wastage.
Pregnant women with underlying heart disease require antibiotic prophylaxis with ampicillin and gentamicin or with amoxicillin if they undergo potentially bacteremic procedures.
Of note, cesarean delivery or uncomplicated abdominal delivery are not indications for antibiotic prophylaxis.
Differential Diagnoses
-
Cor Triatriatum Sinister
-
Pulmonary Vein Stenosis
-
Shone Complex
-
Congenital Mitral Stenosis. 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.
-
Congenital Mitral Stenosis. 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.
-
Congenital Mitral Stenosis. 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.
