Acquired Mitral Stenosis Differential Diagnoses

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

Important considerations

It is important for clinicians to diagnose the primary problem, recognize worsening symptoms, and recommend prophylaxis to prevent recurrent rheumatic heart disease.

Special concerns

Pregnancy

Acquired mitral stenosis (MS), the most common valvular disease in pregnant women in developing countries, has begun to appear in the United States as a result of immigration.

During pregnancy a 50% increase in plasma volume and a 25% increase in erythrocyte volume occur. Cardiac output increases by 40%, and heart rate also increases; therefore, as transmitral flow increases and diastolic time decreases, mean pulmonary artery pressure augments by approximately 50%. It often manifests for the first time during pregnancy with orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, and hemoptysis. Finding deterioration by 1-2 New York Health Association (NYHA) classes in these patients is not unusual. [9]

Asymptomatic or minimally symptomatic patients who usually have mitral orifice areas larger than 1.5 cm2 may only require close observation. However, patients with smaller mitral orifice areas who are severely symptomatic may require balloon valvuloplasty or surgical commissurotomy before delivery. Balloon valvuloplasty of MS has a very low complication rate in experienced centers. Pregnancy is contraindicated in women with severe MS, and preconception counseling must be offered to these patients because of the high likelihood of a bad outcome.

Pregnant women requiring anticoagulation for a prosthetic mechanical mitral valve should receive heparin. Warfarin should probably be avoided, especially during the first and third trimesters.

In the event of atrial fibrillation, beta-blockers may be used. Cardioversion can be administered if necessary because it has been proven safe during pregnancy. Echocardiography must be accomplished prior to cardioversion in order to evaluate the left atrium and its appendage for thrombi.

Vaginal delivery is the recommended method in women with NYHA class I, and cesarean delivery is seldom indicated. Cesarean delivery or uncomplicated abdominal delivery is not an indication for antibiotic prophylaxis.

Lutembacher syndrome

Lutembacher syndrome is a rare clinical entity that consists of the fortuitous association of a secundum atrial septal defect (ASD) with rheumatic MS.

Because of a stenotic mitral valve, pressures in the left atrium are elevated. Because of the ASD, blood shunts left to right. This produces pulmonary overcirculation with hepatic congestion and low cardiac output.

Differential Diagnoses