Mitral Stenosis

Question 1

How wide is a healthy mitral valve?

Answer 1

4-6 cm

Question 2

Symptoms start showing when the mitral valve is smaller than _cm2

Answer 2

2

Question 3

What are risk factors for mitral stenosis?

Answer 3

Male
History of rheumatic fever
Age

Question 4

What are causes of mitral stenosis?

Answer 4

Rheumatic heart disease (post strep pyogenes infection)

Valve calcification (age)

Infective endocarditis

Question 5

Rheumatic heart disease develops as a complication of…

Answer 5

rheumatic fever

Question 6

What is rheumatic fever?

Answer 6

An inflammatory disease following a Group A strep bacteria, particularly if initial infection isn’t treated

Question 7

Rheumatic fever primarily effects _____ _____ including the heart, joints, skin and brain

Answer 7

connective tissue

Question 8

If inflammation from rheumatic fever affects the heart, overtime it can cause…

Answer 8

Damage and scarring of heart valves causing them to become thickened, narrowed and dysfunctional (rheumatic heart disease)

Question 9

What is a hallmark of rheumatic heart disease?

Answer 9

Valvular damage (most commonly mitral, then aortic)

Question 10

Mitral reactive inflammation from rheumatic heart disease can worsen over years with _____

Answer 10

calcification

Question 11

Mitral valve stenosis can cause ____ _____ hypertrophy and chamber dilation

Answer 11

left atrium

Question 12

What are symptoms of mitral stenosis?

Answer 12

Malar cheek flush

Association with AF (due to stasis and hypertrophy in LA)

Dyspnoea

A wave on JVP

Question 13

Why does mitral stenosis cause malar cheek flush?

Answer 13

(Increased pulmonary pressure, RA hypertrophy, systemic venous hypertension, distended facial veins = malar flush)

Mitral stenosis can cause increased resistance of blood flow from right atrium to ventricle causing increased blood pressure in pulmonary circulation.

In response to pulmonary hypertension, the right atrium may have to work harder and undergo hypertrophy.

Congestion and increased pressure in systemic venous circulation leading to distention of facial veins. This can be seen as malar cheek flush.

The increased systemic venous pressure can lead to distention of the facial veins, which can manifest as malar cheek flush

Question 14

What does an A wave on JVP represent?

Answer 14

Atrial contraction

Atria contract, pushing blood into ventricles. With atrial contraction, the increased pressure also force blood upwards towards the IVJ a pressure wave sent back from right atrium to jugular vein

Increased pressure in the right atrium also forces blood upwards towards and into the IJV.

Question 15

Why does mitral stenosis cause A wave on JVP?

Answer 15

The obstruction of flow to LV means LA works harder. Increased pressure propagated to pulmonary circulation.
Congestion in pulmonary circulation increases resistance to blood flow returning to right side of heart.
Causes increased pressure in RA as it fills. Leads to appearance of A wave.

Question 16

Why does mitral stenosis cause dyspnoea?

Answer 16

Pulmonary congestion

May have fluid leakage into alveoli

Decreased CO

If chronic, pulmonary hypertension can lead to right heart failure

Mitral stenosis is risk factor for AF which further reduces CO

Question 17

Describe the murmur in mitral stenosis

Answer 17

Low pitched, mid-diastolic murmur

Question 18

Where is a mitral stenosis murmur loudest?

Answer 18

Apex of heart (mid-clavicular line,5th intercostal space)

Question 19

When is a mitral stenosis murmur heard best?

Answer 19

Patient lying on left side

On expiration (is left side so e for expiration)

Question 20

Describe the heart sounds in mitral stenosis

Answer 20

Loud S1 snap (due to thickened valve cusps slapping each other)

Mid-diastolic mumbling murmur (turbulent flow)

Question 21

True or false: an earlier and louder snap in mitral stenosis indicates worse obstruction

Answer 21

True

Question 22

How is mitral stenosis diagnosed?

Answer 22

CXR shows LA enlarged

ECG (may show AFib, p. mitrale)

Gold standard = ECHO to assess valve area, gradient and mobility

Question 23

What is p. mitrale?

Answer 23

An ECG finding associated with enlarged left atrium.
Characterised by broad, notched or bifid P wave in lead II (m-shaped)

Question 24

What are treatment options for mitral stenosis?

Answer 24

Percutaneous balloon valvotomy (stent open mitral valve opening)

Mitral valve replacement

Question 25

Mitral stenosis causes increased blood volume in the ___ ____ and leads to h_____

Answer 25

left atrium
hypertrophy

Question 26

There is a greater risk of ______ in mitral stenosis (compared to mitral regurgitation) as there is stasis of blood in the atrium

Answer 26

embolisation

Question 27

Mitral stenosis is associated with _____ ______ which further increases the risk of thrombus formation

Answer 27

atrial fibrillation

Question 28

What are patients with mitral stenosis and atrial fibrillation often prescribed?

Answer 28

DOACs or warfarin to lower risk of thrombus formation and embolisation