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Clinical manifestations and diagnosis of mitral stenosis

Author
Catherine M Otto, MD
Section Editor
William H Gaasch, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

Mitral stenosis (MS) causes an obstruction to blood flow from the left atrium to left ventricle. As a result, there is an increase in pressure within the left atrium, pulmonary vasculature, and right side of the heart, while the left ventricle is unaffected in isolated MS. Nearly all cases of MS are caused by rheumatic heart disease with mitral commissural adhesion; thickened, immobile mitral valve leaflets; and fibrosis, thickening, shortening, fusion, and calcification of the chordae tendineae. Infrequent causes of MS include mitral annular calcification and congenital mitral stenosis (including parachute mitral valve). (See "Pathophysiology and natural history of mitral stenosis".)

This topic will review the clinical features and evaluation of MS [1]. Other issues related to MS, such as the pathophysiology, natural history, medical and surgical therapy, and use of percutaneous balloon valvotomy are discussed separately. (See "Pathophysiology and natural history of mitral stenosis" and "Medical management and indications for intervention for mitral stenosis" and "Surgical management of mitral stenosis" and "Percutaneous mitral balloon valvotomy for mitral stenosis".)

CLINICAL MANIFESTATIONS

Clinical presentation — Mitral stenosis (MS) usually presents with exertional dyspnea and/or decreased exercise tolerance [1]. These symptoms are primarily related to the severity of the valvular stenosis, as it impacts the left atrial pressure, pulmonary pressures, pulmonary vascular resistance, and cardiac output. However, many patients with severe MS do not recognize symptoms because slow progression of disease is accompanied by a gradual reduction in activity. As a result, a careful history regarding exercise tolerance is often required to document a slow decline in functional status. (See 'Staging' below.)

Less common clinical presentations include hemoptysis, chest pain (often due to pulmonary hypertension), fatigue (which may be associated with low forward flow and a low transmitral gradient), ascites and lower extremity edema associated with right heart failure (particularly in patients with severe pulmonary arterial hypertension), stroke or other thromboembolic event (particularly in patients with atrial fibrillation), hoarseness, and infective endocarditis [1].

Dyspnea — The most common and often the only symptom of MS is dyspnea, which occurs in up to 70 percent of symptomatic patients [2]. Dyspnea usually results from the elevation in left atrial pressure, and pulmonary venous hypertension, which leads to reduced compliance of the lungs and a decrease in vital capacity. Dyspnea also may be related to an inability to increase the cardiac output with increased metabolic demands.

                            

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Literature review current through: Nov 2016. | This topic last updated: Tue Aug 09 00:00:00 GMT+00:00 2016.
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References
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  1. Chandrashekhar Y, Westaby S, Narula J. Mitral stenosis. Lancet 2009; 374:1271.
  2. ROWE JC, BLAND EF, SPRAGUE HB, WHITE PD. The course of mitral stenosis without surgery: ten- and twenty-year perspectives. Ann Intern Med 1960; 52:741.
  3. Diker E, Aydogdu S, Ozdemir M, et al. Prevalence and predictors of atrial fibrillation in rheumatic valvular heart disease. Am J Cardiol 1996; 77:96.
  4. Hernandez R, Bañuelos C, Alfonso F, et al. Long-term clinical and echocardiographic follow-up after percutaneous mitral valvuloplasty with the Inoue balloon. Circulation 1999; 99:1580.
  5. Arora R, Kalra GS, Murty GS, et al. Percutaneous transatrial mitral commissurotomy: immediate and intermediate results. J Am Coll Cardiol 1994; 23:1327.
  6. Röthlisberger C, Essop MR, Skudicky D, et al. Results of percutaneous balloon mitral valvotomy in young adults. Am J Cardiol 1993; 72:73.
  7. Orrange SE, Kawanishi DT, Lopez BM, et al. Actuarial outcome after catheter balloon commissurotomy in patients with mitral stenosis. Circulation 1997; 95:382.
  8. Nicod P, Hillis LD, Winniford MD, Firth BG. Importance of the "atrial kick" in determining the effective mitral valve orifice area in mitral stenosis. Am J Cardiol 1986; 57:403.
  9. Chiang CW, Lo SK, Ko YS, et al. Predictors of systemic embolism in patients with mitral stenosis. A prospective study. Ann Intern Med 1998; 128:885.
  10. CASELLA L, ABELMANN WH, ELLIS LB. PATIENTS WITH MITRAL STENOSIS AND SYSTEMIC EMBOLI; HEMODYNAMIC AND CLINICAL OBSERVATIONS. Arch Intern Med 1964; 114:773.
  11. Coulshed N, Epstein EJ, McKendrick CS, et al. Systemic embolism in mitral valve disease. Br Heart J 1970; 32:26.
  12. Abernathy WS, Willis PW 3rd. Thromboembolic complications of rheumatic heart disease. Cardiovasc Clin 1973; 5:131.
  13. WOOD P. An appreciation of mitral stenosis. I. Clinical features. Br Med J 1954; 1:1051.
  14. Runco V, Levin HS, Vahabzadeh H, Booth RW. Basal diastolic murmurs in rheumatic heart disease: intracardiac phonocardiography and cineangiography. Am Heart J 1968; 75:153.
  15. Dreyfus J, Brochet E, Lepage L, et al. Real-time 3D transoesophageal measurement of the mitral valve area in patients with mitral stenosis. Eur J Echocardiogr 2011; 12:750.
  16. Schlosshan D, Aggarwal G, Mathur G, et al. Real-time 3D transesophageal echocardiography for the evaluation of rheumatic mitral stenosis. JACC Cardiovasc Imaging 2011; 4:580.
  17. Marcus RH, Sareli P, Pocock WA, Barlow JB. The spectrum of severe rheumatic mitral valve disease in a developing country. Correlations among clinical presentation, surgical pathologic findings, and hemodynamic sequelae. Ann Intern Med 1994; 120:177.
  18. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  19. Picano E, Pibarot P, Lancellotti P, et al. The emerging role of exercise testing and stress echocardiography in valvular heart disease. J Am Coll Cardiol 2009; 54:2251.
  20. Gordon SP, Douglas PS, Come PC, Manning WJ. Two-dimensional and Doppler echocardiographic determinants of the natural history of mitral valve narrowing in patients with rheumatic mitral stenosis: implications for follow-up. J Am Coll Cardiol 1992; 19:968.
  21. Sagie A, Freitas N, Padial LR, et al. Doppler echocardiographic assessment of long-term progression of mitral stenosis in 103 patients: valve area and right heart disease. J Am Coll Cardiol 1996; 28:472.