Dumirieh
Start free

Rapid Review·Cardiovascular

Select any text to highlight it or add a note.

Valvular Heart Disease

T1Must know

Mitral Stenosis

Focus on

Almost always rheumatic: a young immigrant woman, often pregnant, with dyspnea, hemoptysis or a stroke from atrial fibrillation, a loud S1, an opening snap and a low-pitched apical diastolic rumble. The closer the snap to S2, the tighter the valve. Balloon valvotomy is the fix; warfarin, not a DOAC, for the AF.

Key takeaways

What it is and what causes it

Mitral stenosis hemodynamics: the narrow valve raises pressure backward (left atrium, then the lungs, then the right heart) and lowers flow forward. High pulmonary capillary wedge pressure gives orthopnea, paroxysmal nocturnal dyspnea and hemoptysis; high central venous pressure gives jugular venous distension, hepatomegaly and leg edema; low cardiac output gives dyspnea and fatigue.
What this shows
Mitral stenosis hemodynamics: the narrow valve raises pressure backward (left atrium, then the lungs, then the right heart) and lowers flow forward. High pulmonary capillary wedge pressure gives orthopnea, paroxysmal nocturnal dyspnea and hemoptysis; high central venous pressure gives jugular venous distension, hepatomegaly and leg edema; low cardiac output gives dyspnea and fatigue.

Mitral stenosis

obstruction of flow from the left atrium into the left ventricle.
  • Pressure rises in the left atrium and the pulmonary circulation while left ventricular diastolic pressure stays normal.

Rheumatic heart disease

the most common cause.

Senile calcification of the mitral annulus

usually mild.

Clinical features

Left heart failure and pulmonary edema

exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, hemoptysis; right heart failure follows.

Atrial fibrillation

from the dilated atrium, with systemic thromboembolism (stroke).
Mitral facies: pinkish-purple patches over the cheeks in a patient with mitral stenosis.
Mitral facies: pinkish-purple patches over the cheeks in a patient with mitral stenosis.

Mitral facies

pink-purple patches on the cheeks.

Hoarseness (Ortner syndrome)

the enlarged atrium compresses the recurrent laryngeal nerve.
Mitral stenosis on a phonocardiogram: a loud S1, then after S2 an opening snap (OS) followed by a low-pitched mid-diastolic rumble. The shorter the gap between S2 and the opening snap, the tighter the valve.
What this shows
Mitral stenosis on a phonocardiogram: a loud S1, then after S2 an opening snap (OS) followed by a low-pitched mid-diastolic rumble. The shorter the gap between S2 and the opening snap, the tighter the valve.

Auscultation

an opening snap followed by a mid-diastolic rumble at the apex.
  • A loud S1 (the stenotic valve snaps shut).
  • A loud P2 if pulmonary hypertension has developed.

Diagnosis

Transthoracic echocardiography is the gold standard

thickened, calcified, poorly mobile leaflets, a raised trans-mitral flow velocity, and left atrial enlargement.

Severe stenosis

a mitral valve area of 1.5 cm2 or less.
P mitrale: a broad, notched (double-humped) P wave, the sign of left atrial enlargement in mitral stenosis.
P mitrale: a broad, notched (double-humped) P wave, the sign of left atrial enlargement in mitral stenosis.

Electrocardiogram

right ventricular hypertrophy (tall R waves in V1 and V2), P mitrale (broad, notched P waves), atrial fibrillation.

Chest radiograph

left atrial enlargement and pulmonary congestion.

Management

Percutaneous balloon valvotomy

the definitive therapy.
  • Indicated for severe stenosis (under 1.5 cm2) that is symptomatic, or asymptomatic with pulmonary hypertension.

Medical therapy

for the atrial fibrillation and heart failure.

Warfarin

the first-line anticoagulant for valvular atrial fibrillation.
A 30-year-old immigrant woman, pregnant, has new orthopnea and hemoptysis, a loud S1, an opening snap soon after S2 and a low-pitched apical diastolic rumble. What is the cause, what is the definitive treatment, and which anticoagulant is used if she develops atrial fibrillation?

Rheumatic mitral stenosis (an early opening snap means a tight valve). The definitive treatment is percutaneous balloon valvotomy. Atrial fibrillation here is treated with warfarin, not a direct oral anticoagulant.

How it's tested

A 32-year-old immigrant at 24 weeks of pregnancy with new orthopnea, a loud S1, an opening snap and an apical diastolic rumble: rheumatic mitral stenosis unmasked by pregnancy — beta blocker, diuretics, and balloon valvotomy if refractory.

Mitral stenosis with new atrial fibrillation — which anticoagulant: warfarin; DOACs are not used in moderate-to-severe rheumatic MS.

Which finding means the stenosis is more severe: an opening snap closer to S2.

Hoarseness and dysphagia in a woman with a diastolic rumble: giant left atrium compressing the recurrent laryngeal nerve and esophagus — Ortner syndrome.

Severe symptomatic MS with a pliable non-calcified valve, no MR, no thrombus: percutaneous balloon valvotomy.

Go deeper

Guidelines: 2020 ACC/AHA Valvular Heart Disease Guideline

Related Step 2 pages: Acute Rheumatic Fever & Rheumatic Heart Disease, Mitral Regurgitation, Atrial Fibrillation, Heart Sounds & Murmurs, Cardiac Tumors, Cardiac Anatomy

High-yield images4
Mitral stenosis hemodynamics: the narrow valve raises pressure backward (left atrium, then the lungs, then the right heart) and lowers flow forward. High pulmonary capillary wedge pressure gives orthopnea, paroxysmal nocturnal dyspnea and hemoptysis; high central venous pressure gives jugular venous distension, hepatomegaly and leg edema; low cardiac output gives dyspnea and fatigue.
Mitral facies: pinkish-purple patches over the cheeks in a patient with mitral stenosis.
Mitral stenosis on a phonocardiogram: a loud S1, then after S2 an opening snap (OS) followed by a low-pitched mid-diastolic rumble. The shorter the gap between S2 and the opening snap, the tighter the valve.
P mitrale: a broad, notched (double-humped) P wave, the sign of left atrial enlargement in mitral stenosis.

Flashcards for this page

Card 1 of 5 · try-out only, nothing is saved

What is the likely diagnosis in a young patient from a developing country that presents with dyspnea, hemoptysis, and occasional palpitations?

(...) 
PreviousAortic RegurgitationNextMitral Valve Prolapse

You just read one page of 236

The rest of Step 2 CK, written exactly like this.

Rapid Review is the reading layer of a full Step 1 platform: a schedule fitted to your exam date, flashcards for every page, and a mentor a message away.

  • Every Step 1 system

    Written the same way: what to know, how it’s tested, where to go deeper.

  • A plan built to your exam date

    Tell us when you sit, and the schedule fits the whole library and your question bank to it.

  • Flashcards for every page

    Ready-made spaced-repetition decks linked to each topic, so nothing you read gets forgotten.

Start 14 days free
No card needed.·See pricing