Mitral Stenosis


Article Author:
Sandy Shah


Article Editor:
Saurabh Sharma


Editors In Chief:
Stacy Mandras


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
8/14/2019 7:19:36 PM

Introduction

Mitral stenosis (MS) is a form of valvular heart disease. Mitral stenosis is characterized by narrowing of the mitral valve orifice. Today, the most common cause of mitral stenosis is rheumatic fever, but the stenosis usually appears clinically relevant only after several decades.

Etiology

The most common cause of mitral stenosis is rheumatic fever. Uncommon causes of mitral stenosis are calcification of the mitral valve leaflets and congenital heart disease. Other causes of mitral stenosis include infective endocarditis, mitral annular calcification, endomyocardial fibroelastosis, malignant carcinoid syndrome, systemic lupus erythematosus, Whipple disease, Fabry disease, and rheumatoid arthritis.

Epidemiology

The prevalence of rheumatic disease in developed countries is declining with an estimated incidence of 1 in 100,000. The prevalence is higher in developing nations than in the United States. In Africa, for example, the prevalence is 35 cases per 100,000. 

Rheumatic mitral stenosis is more common in females. The onset is usually between the third and fourth decade of life.[1][1][2]

Pathophysiology

The mitral valve is a tri-leaflet valve positioned between the left atrium and left ventricle. The normal mitral orifice area is 4 to 6 square centimeters. Under normal physiologic conditions, the mitral valve opens during left ventricular diastole to allow blood to flow from the left atrium to the left ventricle. The pressure in the left atrium and the left ventricle during diastole are equal. The left ventricle gets filled with blood during early ventricular diastole. There is only a small amount of blood that remains in the left atrium. With the contraction of the left atrium (the "atrial kick") during late ventricular diastole, this small amount of blood fills the left ventricle.[3][4][5]

Mitral valve areas less than 2 square centimeters causes an impediment to the blood flow from the left atrium into the left ventricle. This creates a pressure gradient across the mitral valve. As the gradient across the mitral valve increases, the left ventricle requires the atrial kick to fill with blood.

Mitral valve area less than 1 square centimeter causes an increase in left atrial pressure. The normal left ventricular diastolic pressure is 5 mmHg. A pressure gradient across the mitral valve of 20 mmHg due to severe mitral stenosis will cause a left atrial pressure of about 25 mmHg. This left atrial pressure is transmitted to the pulmonary vasculature resulting in pulmonary hypertension.

As left atrial pressure remains elevated, the left atrium will increase in size. As the left atrium increases in size, there is a greater chance of developing atrial fibrillation. If atrial fibrillation develops, the atrial kick is lost.

Thus, in severe mitral stenosis, the left ventricular filling is dependent on the atrial kick. With the loss of the atrial kick, there is a decrease in cardiac output and sudden development of congestive heart failure.

Mitral stenosis progresses slowly from initial signs of mitral stenosis to NYHA functional class II symptoms to atrial fibrillation to NYHA functional class III or IV symptoms.

History and Physical

Mitral stenosis presents 20 to 40 years after an episode of rheumatic fever. The most common symptoms are orthopnea and paroxysmal nocturnal dyspnea. Patients may have symptoms of palpitations, chest pain, hemoptysis, thromboembolism when the left atrial volume is increased, ascites, edema, and hepatomegaly (if right-side heart failure develops).

There is also an increase in symptoms of fatigue and weakness with exercise and pregnancy.

On auscultation, the first heart sound is usually loud and maybe palpable due to increased force in the closing of the mitral valve.

The P2 (pulmonic) component of the second heart sound (S2) will be loud if severe pulmonary hypertension is due to mitral stenosis. 

An opening snap (OS) is an additional sound that may be heard after the A2 component of the second heart sound (S2). This is the forceful opening of the mitral valve when the pressure in the left atrium is greater than the pressure in the left ventricle.

A mid-diastolic rumbling murmur with presystolic accentuation is heard after the opening snap. This murmur is a low pitch sound. It is best heard with the bell of the stethoscope at the apex. The murmur accentuates in the left lateral decubitus position and with isometric exercise.

Advanced mitral stenosis, presents with signs of right-sided heart failure (jugular venous distension, parasternal heave, hepatomegaly, ascites) and/or pulmonary hypertension.

Other signs include, atrial fibrillation, left parasternal heave (right ventricular hypertrophy due to pulmonary hypertension) and tapping the apical beat.

Evaluation

Mitral stenosis is evaluated using noninvasive and invasive measures. Noninvasive tests are the electrocardiogram (ECG), chest x-ray, echocardiogram, and exercise echocardiogram. An invasive test for mitral stenosis would include a cardiac catheterization.[6][7][8]

On the ECG, the P wave changes suggest left atrial enlargement. A presence of right axis deviation and right ventricular hypertrophy suggest severe pulmonary hypertension. ECG frequently detects atrial arrhythmias such as atrial fibrillation.

On the chest x-ray, the early stages of mitral stenosis findings are normal heart size, straightening of the left border of the cardiac silhouette, prominent main pulmonary arteries, dilatation of the upper pulmonary veins, and displacement of the esophagus by an enlarged left atrium. During the severe chronic stage of mitral stenosis, the chest x-ray will have enlargement of all the chambers, pulmonary arteries, and pulmonary veins.

The echocardiogram is a very useful tool to assess the mitral stenosis etiology, morphology, severity, and treatment intervention. The analysis of the morphology of the mitral valve apparatus includes leaflet mobility and flexibility, leaflet thickness, leaflet calcification, subvalvular fusion, and the appearance of commissures. The Wilkins score grades each of the components of the mitral apparatus from 1 to 4: leaflet mobility, thickness, calcification, and impairment of the subvalvular apparatus.  The Padial score grades the leaflet thickening (each separately), the commissural calcification, and the subvalvular disease from 1 to 4. The Wilkins score less than 8, a Padial score less than 10, and less than moderate regurgitation have better outcomes.

An exercise echocardiogram is performed using an upright treadmill or supine bicycle with Doppler recording of transmitral and tricuspid valve velocities. This measures the transmitral gradient and pulmonary artery systolic pressure at rest and with exercise.

Cardiac catheterization is an invasive procedure. Cardiac catheterization should be performed for assessment of the severity of mitral stenosis when noninvasive tests are inconclusive or when there is a discrepancy between noninvasive tests and clinical findings regarding the severity of mitral stenosis (Class I, Level of Evidence C).

Classification of Severity of Mitral Valve Stenosis 

Mild

  • Mean gradient (mmHg) less than 5
  • Pulmonary artery systolic pressure (mmHg) less than 30
  • Valve area (cm2) less than 1.5

Moderate

  • Mean gradient (mmHg) 5 to 10
  • Pulmonary artery systolic pressure (mmHg) 30 to 50
  • Valve area (cm2) 1.0 to 1.5

Severe

  • Mean gradient (mmHg) less than 10
  • Pulmonary artery systolic pressure (mmHg) greater than 50          
  • Valve area (cm2) less than 1.0                                                  

Mitral Valve Anatomy According to the Wilkins Score

Grade 1

  • Mobility: Highly mobile valve with only leaflet tips restricted
  • Thickening: Leaflet near normal in thickness (4 mm to 5 mm)
  • Calcification: A single area of increased echo brightness
  • Subvalvular Thickening: Minimal thickening just below the mitral leaflets

Grade 2

  • Mobility: Leaflet mid to base portions have normal mobility
  • Thickening: Mid leaflets normal, considerable thickening of margins (5-8 mm)
  • Calcification: Scattered areas of brightness confirmed to leaflet margins
  • Subvalvular Thickening: Thickening of chordal structures extending to one of the chordal length

Grade 3

  • Mobility: Valve continues to move forward in diastole, mainly from the base
  • Thickening: Thickening extending through the entire leaflet (5 mm to 8 mm)
  • Calcification: Brightness extending into the mid portions of the leaflets
  • Subvalvular Thickening: Thickening extended to distal third to the chords

Grade 4:

  • Mobility: No or minimal forward movement of the leaflets in diastole
  • Thickening: Considerable thickening of all leaflet tissue (more than 8 mm to 10 mm)
  • Calcification: Extensive brightness throughout much of the leaflet tissue
  • Subvalvular Thickening: Extensive thickening and shortening of all chordal structures extending down to the papillary muscles. 

Treatment / Management

Treatment for mitral stenosis involves medical therapy, percutaneous mitral valvuloplasty, and surgical therapy. Currently, no medical therapy can relieve a fixed obstruction of the mitral valve. Medical therapy is focused on preventing endocarditis, decreasing new cases of rheumatic fever, improving symptoms, and decreasing the thromboembolic risk.[9][10][11]

Endocarditis prophylaxis should only be given to high-risk patients before dental procedures that involve manipulation of gingival tissue or perforation of the oral mucosa. High-risk patients are those patients with a prosthetic heart valve or prosthetic material used for valve repair, previous history of infective endocarditis, and cardiac valvuloplasty.

Rheumatic fever prophylaxis with Benzathine penicillin is the primary prevention treatment in patients with streptococcal pharyngitis.

If the rhythm is normal sinus, medical therapy is used to improve symptoms. Diuretics are utilized to help relieve congestion.  Beta-blockers and/or calcium channel blockers help with exertional symptoms associated with elevated heart rate.

If the rhythm is atrial fibrillation, the first step is to control the rate using AV node blocking agents such as beta-blockers, calcium channel blockers, and/or digitalis.  In an unstable patient, perform direct current cardioversion.  If you cannot convert atrial fibrillation to normal sinus rhythm, then the primary goal is rate control. In a stable patient, restoration of normal sinus rhythm is preferred over rate control to improve functional capacity and quality of life.

Anticoagulation prevents thromboembolic events. Anticoagulation is indicated in patients with mitral stenosis and atrial fibrillation (paroxysmal, persistent, or permanent), previous embolic events, and the presence of left atrial thrombus.  At present, Warfarin is the anticoagulation of choice. Aspirin or other antiplatelet drugs are not approved to decrease thromboembolic risk in mitral stenosis.  Warfarin should be monitored using the international normalized ratio (INR) to target 2.5.

Percutaneous mitral balloon valvuloplasty (PMBV) is an invasive procedure used to manage mitral stenosis. PMBV improves symptoms by increasing the mitral valve area and reduce mitral valve gradient. PMBV is indicated in symptomatic patients (New York Heart Association functional class greater than II), or asymptomatic patients with pulmonary hypertension with moderate or severe stenosis, and favorable valve morphology in the absence of left atrial thrombus, or moderate to severe mitral regurgitation.

Mitral valve replacement surgery is indicated in patients with symptomatic moderate or severe mitral stenosis when percutaneous mitral balloon valvuloplasty is contraindicated or unfavorable valve morphology (Class I, Level of Evidence B).

Differential Diagnosis

  • Left atrial myxoma
  • Endocarditis

Complications

  • Heart failure
  • Stroke
  • Failure to thrive
  • Pulmonary hypertension
  • Endocarditis

Consultations

Cardiac surgeon

Pearls and Other Issues

Pregnancy during mitral stenosis will increase the patient’s symptoms by one New York Heart Association class. Medical therapy is attempted first to improve symptoms. If symptoms do not improve with medical treatment, then refer the patient for percutaneous mitral balloon valvuloplasty.

Enhancing Healthcare Team Outcomes

Mitral stenosis is a relatively common disorder, which if left untreated is associated with high morbidity and mortality. Mitral stenosis rates had been decreasing in the US 4 decades ago but with the mass migration of individuals from other countries, a resurgence of cases has been observed.  The number one cause for most cases of mitral stenosis is rheumatic fever. The key is to prevent the valvular disorder by ensuring that patients with strep throat are adequately treated. Because of the high morbidity of the disorder, the condition is best managed by an interprofessional team

Once the diagnosis of mitral stenosis is made, the patient should be educated about the need for surgery. Those who remain asymptomatic will need annual exams including echocardiograms. Patients with palpitations may require a Holter monitor to confirm the presence of atrial arrhythmias. Many of these patients will need anticoagulation with warfarin. Hence, the pharmacist should ensure that monthly blood work is done to ensure that therapeutic anticoagulation has been obtained. A dietary consult is often important as failure to thrive is common. A cardiology nurse should monitor the patient for symptoms as they will require surgery. The type of prosthetic valve used depends on patient factors. The cardiac surgery nurses should educate the patient on the type of prosthetic valves available and which may be best suited for him or her. Finally, the primary care provider, pharmacist, and nurse should discuss with the patient the possibility of developing an infection of the valve and the need for prophylaxis when undergoing any type of invasive procedure. Because atrial fibrillation is a persistent problem, anticoagulation will be required in most patients. Hence, close monitoring of the INR by a dedicated nurse is necessary. [12][13](Level V) 

Outcomes

Prior to the era of open-heart surgery, the prognosis for most patients with mitral stenosis was poor. In the era of mitral valve replacement, the prognosis is excellent. Survival is significantly better for patients undergoing an open mitral valve replacement compared to a commissurotomy. Today, there is an 80% survival at ten years, but in patients who have developed pulmonary hypertension, the survival is less than 3 years. Other complications that may result in high morbidity include stroke and persistent atrial fibrillation. [14][15](Level V) 


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Mitral Stenosis - Questions

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Which is false about rheumatic mitral stenosis?



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Which is not used in the treatment of rheumatic mitral stenosis?



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Which is not a common complication of mitral stenosis?



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Which is false about the murmur in rheumatic mitral stenosis?



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What is the most characteristic sign of left atrial enlargement secondary to mitral stenosis on a lateral chest x-ray?



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What is the most common cause of mitral stenosis worldwide?



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What valve area is considered critical mitral valve stenosis?



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What causes the hoarseness heard in patients with chronic mitral stenosis?



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What ECG feature may be an indication that a patient has mitral stenosis?



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Which is not a feature of mitral stenosis on a chest radiograph?



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After a mitral valve is replaced by a tissue valve, what is the most common reason for mitral valve malfunction?



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What is the most likely cause of a diastolic rumble auscultated at the apex on cardiac exam of a middle aged female who presents complaining of dyspnea on exertion and heart palpitations?



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A 31-year-old woman at 30 weeks gestation presents with dyspnea at rest, orthopnea, and a wet cough. She has a history of mitral stenosis secondary to rheumatic fever. On exam she is tachycardic with an irregular pulse and blood pressure is 145/80 mmHg. She has a low diastolic rumble heard best at the apex, prominent neck veins, and bibasilar rales. Echocardiogram reveals normal left ventricular ejection fraction and mitral valve area of 0.8 cm squared. She fails to improve on digoxin and furosemide. Which is the indicated course of treatment for this patient?



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What is the most likely cause of a diastolic rumble auscultated at the apex on cardiac exam of a geriatric female who presents complaining of dyspnea on exertion and heart palpitations?



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A patient presents with progressive shortness of breath and repeated bouts of hemoptysis. Both chest x-ray and CT scan of the chest do not reveal any significant lesions and bronchoscopy is negative. What method is used to make his diagnosis?



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Which of the following statements about mitral stenosis is FALSE?



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An adult with rheumatic mitral stenosis will have elevated pressure in which of the following structures?



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What statement is CORRECT regarding mitral stenosis in adult patients?



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Pulmonary capillary wedge pressure increases in which cardiac disorder?



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A patient with mild mitral stenosis and early symptoms due to rheumatic fever should be treated with which of the following?



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Which of the following findings is not associated with severe mitral valve stenosis?



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A 50-year old patient is evaluated for a mitral stenosis. An echocardiogram shows the valve area to be1.7 cm2. This is consistent with mild disease. Select the test that would be indicated to make the decision to recommend surgical correction.



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Which of the following is incorrect about mitral stenosis?



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Select the finding not characteristic of mitral stenosis.



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A 33-year old G1 P0 woman at 29 weeks gestation presents with dyspnea at rest, orthopnea and cough. She has a prior history of mitral stenosis secondary to rheumatic fever. On exam, she is tachycardic with an irregular pulse and blood pressure of 135/85 mmHg. She has a low diastolic rumble heard best at the apex, prominent neck veins and bibasilar rales. Echocardiogram reveals normal left ventricular ejection fraction and mitral valve area of 0.8 cm2. She fails to improve on diltiazem and furosemide. Which is the indicated course of treatment for this patient?



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What is the procedure of choice for a patient with a mitral valve area of 1.2 cm2 and no other complications?



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What is the most common cause of mitral stenosis?



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What is the common symptom of mitral stenosis?



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Patient's with mitral stenosis commonly have elevated pressures of which of the following?



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Which of the following statements is false with regard to mitral valve stenosis?



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Which of the following statements regarding mitral valve stenosis is not true?



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What cardiac condition is often present with chronic untreated mitral stenosis?



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A 50 year old gentleman with no past medical history presents to local emergency department with symptoms of palpitations. The monitor shows new onset atrial fibrillation. On physical examination, his blood pressure is 120/80 mmHg and heart rate is 110 beats per minute. His heart sounds are irregularly irregular. There is a low-pitched diastolic rumble. Echocardiogram at the bedside show severe mitral stenosis. What is best management options?



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A 32 year-old female with no past medical history is 30 weeks pregnant. She presents with symptoms of dyspnea. On physical exam, her heart rate is 120 and Blood pressure is 120/80. There is jugular venous distension, a parasternal impulse, an opening snap and a grade 2/6 diastolic rumble with presystolic accentuation are heard. What is the diagnosis and treatment?



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A 30 years old male illegally migrated USA. He has no past medical history. He present to the emergency room with symptoms of dyspnea on exertion, orthopnea, hemoptysis, and paroxysmal nocturnal dyspnea. On physical examination, blood pressure is 120/80 mmHg, heart rate is 120, prominent V wave, and bibasilar rales. There is nondisplaced apex beat, a right ventricular heave, loud S4, loud P2, a loud opening snap, a 3/4 low-pitched rumbling holodiastolic murmur. There is presacral area edema and +2 edema of bilateral lower extremities. What is the mortality rate if treated medically?



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Right ventricular failure is most commonly due to:



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A patient with a left parasternal lift and a loud S1 should be suspected of having:



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A 26-year-old pregnant female in the second trimester of her pregnancy is found to have severe mitral stenosis and is symptomatic. She had rheumatic fever as a child. What would be a relatively safe treatment for her condition?



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Which of the following is true about a congenital mitral stenosis?



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What gastrointestinal order is often the first presenting sign of congenital mitral stenosis?



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A 2-month old is diagnosed with congenital mitral stenosis, but because of no symptoms, he is followed medically. He now presents at age 3 with dyspnea and failure to thrive. It is decided that he will need some intervention, as the stenosis is critical. Which of the following therapies has been shown to be effective in children with congenital mitral stenosis?



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A 28-year old male presents with shortness of breath. Work up reveals that he has mitral stenosis. Which of the following features on auscultation is not correct about this disorder?



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Which of the following is not an indication for surgery in patients with mitral valve stenosis?



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A 33-year old female has been admitted with progressive dyspnea and cachexia. She has no exercise endurance and has been in poor health for the past 5 to 7 years. Recently she was treated for joint pains by an alternative health care provider. She is a new immigrant from Asia and unable to provide much of a coherent history, except to say that she had a severe infection of her throat as a child. She has brought along a chest x-ray which the radiologist states has a "double density” sign. What is most likely observed during auscultation?



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A 33-year old female has been admitted with progressive dyspnea and cachexia. She has no exercise endurance and has been in poor health for the past five to seven years. Recently she was treated for joint pains by an alternative health care provider. She is a new immigrant from Asia and unable to provide much of a coherent history, except to say that she had a severe infection of her throat as a child. You are not great at auscultation but you feel that the patient has a diastolic murmur. She has brought along a chest x-ray which the radiologist states has a "double density” sign. What is the most common arrhythmia you are going to serve in this patient?



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A 33-year-old male from Asia is seen in the clinic with complaints of dyspnea and vague chest pain. He claims that his symptoms started a few months ago and are worse with exercise. He recently noted that he had also become hoarse but denied any infection, trauma, or use of any illicit drugs. He is on no medications and has no allergies. The physical exam reveals a blood pressure of 120/85 mmHg, irregular pulse with a rate of 110 bpm, and respiration rate of 20/min. There is jugular vein distension, and ventricular heave is palpable in the left parasternal region. Auscultation reveals a murmur shown in the below diagram with an accentuated first heart sound. What is the most likely cause of his hoarseness?

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  • Image 5291 Not availableImage 5291 Not available
    Contributed by Steve Bhimji, MS, MD, PhD
Attributed To: Contributed by Steve Bhimji, MS, MD, PhD



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A 35-year-old male from the Far East is seen in the clinic with complaints of dyspnea, hoarseness, a 12-pound weight loss, and fatigue that started about 6 months ago. His condition has progressively worsened. He started taking an antibiotic a few weeks ago without improvement. Currently, he is taking no medications and has no allergies. On exam, his vital signs are within normal limits, but he appears cachectic. His pulse is irregular with a normal rate and auscultation reveals a diastolic murmur with an extra heart sound. His chest x-ray is shown below, and the radiologist has outlined the abnormal segment. What is the most likely cause of his hoarseness?

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  • Image 6257 Not availableImage 6257 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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Mitral Stenosis - References

References

Del Rio JM,Grecu L,Nicoara A, Right Ventricular Function in Left Heart Disease: Relevance to the Mitral Valve. Seminars in cardiothoracic and vascular anesthesia. 2018 Sep 19     [PubMed]
Rodrigues I,Branco L,Patrício L,Bernardes L,Abreu J,Cacela D,Galrinho A,Ferreira R, Long-Term Follow Up After Successful Percutaneous Balloon Mitral Valvuloplasty. The Journal of heart valve disease. 2017 Nov     [PubMed]
Imran TF,Awtry EH, Severe Mitral Stenosis. The New England journal of medicine. 2018 Jul 19     [PubMed]
Maeder MT,Weber L,Buser M,Gerhard M,Haager PK,Maisano F,Rickli H, Pulmonary Hypertension in Aortic and Mitral Valve Disease. Frontiers in cardiovascular medicine. 2018     [PubMed]
Banovic M,DaCosta M, Degenerative Mitral Stenosis: From Pathophysiology to Challenging Interventional Treatment. Current problems in cardiology. 2018 Apr 6     [PubMed]
Blanken CPS,Farag ES,Boekholdt SM,Leiner T,Kluin J,Nederveen AJ,van Ooij P,Planken RN, Advanced cardiac MRI techniques for evaluation of left-sided valvular heart disease. Journal of magnetic resonance imaging : JMRI. 2018 Aug     [PubMed]
Wunderlich NC,Beigel R,Ho SY,Nietlispach F,Cheng R,Agricola E,Siegel RJ, Imaging for Mitral Interventions: Methods and Efficacy. JACC. Cardiovascular imaging. 2018 Jun     [PubMed]
Oktay AA,Gilliland YE,Lavie CJ,Ramee SJ,Parrino PE,Bates M,Shah S,Cash ME,Dinshaw H,Qamruddin S, Echocardiographic Assessment of Degenerative Mitral Stenosis: A Diagnostic Challenge of an Emerging Cardiac Disease. Current problems in cardiology. 2017 Mar     [PubMed]
Karády J,Ntalas I,Prendergast B,Blauth C,Niederer S,Maurovich-Horvat P,Rajani R, Transcatheter mitral valve replacement in mitral annulus calcification -     [PubMed]
Hollenberg SM, Valvular Heart Disease in Adults: Etiologies, Classification, and Diagnosis. FP essentials. 2017 Jun     [PubMed]
Baumgartner H,Falk V,Bax JJ,De Bonis M,Hamm C,Holm PJ,Iung B,Lancellotti P,Lansac E,Rodriguez Muñoz D,Rosenhek R,Sjögren J,Tornos Mas P,Vahanian A,Walther T,Wendler O,Windecker S,Zamorano JL, 2017 ESC/EACTS Guidelines for the management of valvular heart disease. European heart journal. 2017 Sep 21     [PubMed]
Hemlata,Goyal P,Tewari S,Chatterjee A, Anaesthetic Considerations for Balloon Mitral Valvuloplasty in Pregnant Patient with Severe Mitral Stenosis: A Case Report and Review of Literature. Journal of clinical and diagnostic research : JCDR. 2017 Sep     [PubMed]
Hart MA,Shroff GR, Infective endocarditis causing mitral valve stenosis - a rare but deadly complication: a case report. Journal of medical case reports. 2017 Feb 17     [PubMed]
Pradhan RR,Jha A,Nepal G,Sharma M, Rheumatic Heart Disease with Multiple Systemic Emboli: A Rare Occurrence in a Single Subject. Cureus. 2018 Jul 11     [PubMed]
Russell EA,Walsh WF,Reid CM,Tran L,Brown A,Bennetts JS,Baker RA,Tam R,Maguire GP, Outcomes after mitral valve surgery for rheumatic heart disease. Heart Asia. 2017     [PubMed]

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