Pathophysiology and natural history of mitral stenosis
- Theo E Meyer, MD, PhD
Theo E Meyer, MD, PhD
- Professor of Medicine
- Chief, Clinical Cardiology
- Director, Advanced Heart Failure Program
- University of Massachusetts Medical School
- UMassMemorial Medical Center
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
The hemodynamic consequence of mitral stenosis (MS) is manifested by increased impedance to transmitral inflow. MS attenuates the atrial contribution to left ventricular filling and it also poses a hydraulic opposition or resistance to early filling. Unlike other valvular lesions, which are often attributable to many etiologies, MS alone, or in combination with other valvular pathology, is almost exclusively secondary to rheumatic heart disease. Progression of MS eventually leads to the development of disabling symptoms (eg, dyspnea, hemoptysis, thromboembolism, and right-sided heart failure). (See "Clinical manifestations and diagnosis of mitral stenosis".)
The natural history and pathophysiology of MS will be reviewed here. Given the widespread use of surgical and percutaneous interventions, information on the natural history of MS comes from older studies and other limited observations of patients in developing countries who did not receive a corrective procedure.
The roles of medical and surgical therapy and the use of percutaneous balloon valvotomy are discussed separately. (See "Medical management and indications for intervention for mitral stenosis" and "Surgical management of mitral stenosis" and "Percutaneous mitral balloon valvotomy for mitral stenosis".)
Rheumatic heart disease (RHD) is the most common cause of mitral stenosis (MS); other causes are much less frequent [1,2]. However, only 50 to 70 percent of patients with MS report a history of rheumatic fever [3-5]. RHD remains a major public health problem in developing countries [6-8]. Rheumatic MS has become less common in developed countries given marked reductions in the incidence of rheumatic fever . Occasional outbreaks of rheumatic fever in the United States appear to be the result of either increased virulence of a streptococcal strain or enhanced immigration from areas where RHD is prevalent . Involvement of the mitral valve is present in approximately 90 percent of individuals with RHD . In many populations, RHD is more common in females than in men . Rheumatic MS is a continuously progressive lifelong disease. (See "Acute rheumatic fever: Epidemiology and pathogenesis".)
The following are other causes of mitral stenosis:
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- Pathoanatomic considerations
- - Rheumatic heart disease
- - Congenital MS
- - Mitral annular calcification
- Hemodynamic and structural sequelae
- - Altered filling dynamics
- - Left atrial remodeling
- Pulmonary hypertension
- NATURAL HISTORY
- Rate of progression
- Asymptomatic phase
- Symptomatic phase
- Effect of pregnancy
- Causes of death