Mitral stenosis resident survival guide: Difference between revisions
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==Complete Diagnostic Approach== | ==Complete Diagnostic Approach== | ||
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br> | A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>.<br> | ||
<span style="font-size:85%">'''Abbreviations:''' '''[[AF]]''': [[Atrial fibrillation]]; '''PMBC''': Percutaneous mitral ballon commissurotomy; '''[[TR]]''': [[Tricuspid regurgitation]]; '''[[S1]]''': First heart sound; '''[[P2]]''': Pulmonary component of second heart sound; '''[[EKG]]''': [[Electrocardiogram]]; '''[[TTE]]''': [[Transthoracic echocardiography]]; '''[[MS]]''': [[Mitral stenosis]] </span> <br> | <span style="font-size:85%">'''Abbreviations:''' '''[[AF]]''': [[Atrial fibrillation]]; '''[[PMBV|PMBC]]''': Percutaneous mitral ballon commissurotomy; '''[[TR]]''': [[Tricuspid regurgitation]]; '''[[S1]]''': First heart sound; '''[[P2]]''': Pulmonary component of second heart sound; '''[[EKG]]''': [[Electrocardiogram]]; '''[[TTE]]''': [[Transthoracic echocardiography]]; '''[[MS]]''': [[Mitral stenosis]] </span> <br> | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br> | {{familytree | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Characterize the symptoms:'''<br> | ||
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❑ [[Murmur]]<br> | ❑ [[Murmur]]<br> | ||
: ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br> | : ❑ [[Mid diastolic murmur]] (low pitched, rumbling)<br> | ||
: ❑ [[Holosystolic murmur]] | : ❑ [[Holosystolic murmur]] (suggestive of [[TR]])<br> | ||
: ❑ [[Graham-Steell murmur]] | : ❑ [[Graham-Steell murmur]] (suggestive of [[pulmonary regurgitation]])<br> | ||
{{#ev:youtube|HW2pk1icYdM|250}}<br> | {{#ev:youtube|HW2pk1icYdM|250}}<br> | ||
<SMALL>''Video adapted from Youtube.com''</SMALL><br> | <SMALL>''Video adapted from Youtube.com''</SMALL><br> | ||
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❑ Perform [[EKG]]<br> | ❑ Perform [[EKG]]<br> | ||
:❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br> | :❑ [[Left atrial enlargement electrocardiogram|Left atrial enlargement]]<br> | ||
::❑ Broad, bifid P wave in lead II (P mitrale)<br> | ::❑ Broad, bifid [[P wave]] in lead II (P mitrale)<br> | ||
[[Image:P mitrale.gif|200px]]<br> | [[Image:P mitrale.gif|200px]]<br> | ||
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br> | <SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br> | ||
::❑ Biphasic P wave with terminal negative portion<br> | ::❑ Biphasic [[P wave]] with terminal negative portion<br> | ||
[[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br> | [[Image:LAE-v1.png|Left atrial enlargement as seen in lead V1|200px]]<br> | ||
<SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br> | <SMALL>''Picture adapted from en.ecgpedia.org''</SMALL><br> | ||
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❑ Perform [[chest X-ray]]<br> | ❑ Perform [[chest X-ray]]<br> | ||
:❑ Double right heart border (suggestive of [[left atrial hypertrophy]]) | :❑ Double right heart border (suggestive of [[left atrial hypertrophy]]) | ||
:❑ Prominent pulmonary artery | :❑ Prominent [[pulmonary artery]] | ||
:❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]]) | :❑ [[Kerley lines]] (suggestive of interstitial [[pulmonary edema]]) | ||
[[File:M.S chest X-ray.jpg|200px]]<br> | [[File:M.S chest X-ray.jpg|200px]]<br> | ||
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:❑ Assess valve area<br> | :❑ Assess valve area<br> | ||
:❑ Assess disease of other valves <br> | :❑ Assess disease of other valves <br> | ||
:❑ Assess mean pressure gradient<br> | :❑ Assess mean [[pressure gradient]]<br> | ||
:❑ Assess pulmonary artery pressure<br> | :❑ Assess [[pulmonary artery]] pressure<br> | ||
:❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br> | :❑ Assess suitability of valve morphology for [[PMBV|PMBC]]<br> | ||
</div>}} | </div>}} | ||
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❑ [[Myxoma]] | ❑ [[Myxoma]] | ||
:❑ Obstruct the mitral orifice | :❑ Obstruct the mitral orifice | ||
:❑ Exclude with echocardiography | :❑ Exclude with [[echocardiography]] | ||
❑ [[Atrial fibrillation]] | ❑ [[Atrial fibrillation]] | ||
:❑ Order echocardiography to exclude [[mitral stenosis]] | :❑ Order [[echocardiography]] to exclude [[mitral stenosis]] | ||
</div>}} | </div>}} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }} |
Revision as of 18:00, 17 April 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]; Mohamed Moubarak, M.D. [3]
Synonyms and keywords: Mitral valve stenosis; narrowing of mitral valve
Overview
Mitral stenosis refers to abnormal narrowing of mitral orifice, which leads to obstruction of blood flow from left atrium to left ventricle. The most common presentations of mitral stenosis are dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. Mitral stenosis has a characteristic low-pitched, rumbling diastolic murmur, heard best at the apex during physical examination. The definitive therapy for mitral stenosis include percutaneous balloon valvotomy, surgical mitral valve repair, or mitral valve replacement.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Common Causes
Complete Diagnostic Approach
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2].
Abbreviations: AF: Atrial fibrillation; PMBC: Percutaneous mitral ballon commissurotomy; TR: Tricuspid regurgitation; S1: First heart sound; P2: Pulmonary component of second heart sound; EKG: Electrocardiogram; TTE: Transthoracic echocardiography; MS: Mitral stenosis
Characterize the symptoms: ❑ History of rheumatic fever | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: Appearance of the patient Vital signs ❑ Pulse
Neck: Chest examination: Auscultation
{{#ev:youtube|HW2pk1icYdM|250}} | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Order tests:
❑ Perform EKG
❑ Perform chest X-ray
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Consider alternative diagnosis: ❑ Myxoma
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Treatment
The filling of the left ventricle depends upon the diastole time which is limited by mitral stenosis. Therefore, slowing the heart rate is crucial in the initial management of mitral stenosis in order to improve the diastole time and consequently improve the filling of the left ventricle.
Medical therapy ❑ Consider heart rate control in MS patients with:
❑ Consider anticoagulation therapy in MS patients with:
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Shown below is an algorithm summarizing the approach to management of rheumatic mitral stenosis according to 2014 AHA/ACC guidelines for management of valvular heart disease.[2]
MVA: Mitral valve area; PMBC: Percutaneous mitral ballon commissurotomy; PCWP: Pulmonary capillary wedge pressure; ms: milliseconds; NYHA: New York Heart Association; AF: Atrial fibrillation
❑ Assess the presence of symptoms | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Symptomatic | Asymptomatic | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Assess the severity of mitral stenosis | ❑ Assess the severity of mitral stenosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Progressive ❑ MVA > 1.5 cm2 Pressure half time < 150 ms | Progressive ❑ MVA > 1.5 cm2 Pressure half time < 150 ms | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Assess if valve morphology is favorable for PMBC | ❑ Perform exercise testing | ❑ Assess if valve morphology is favorable for PMBC | ❑ Assess if the new onset AF is present | ❑ Monitor patient periodically | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ❑ Assess PCWP on exercise | Yes | No | No | Yes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Proceed with PMBC | If patient is severely symptomatic (NYHA III/IV): ❑ Assess the surgical risk of patient | ❑ Proceed with PMBC | ❑ Monitor patient periodically | ❑ Assess if the valve morphology is favorable for PMBC | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Proceed with PMBC | ❑ Proceed with mitral valve surgery | ❑ Proceed with PMBC | ❑ Monitor patient periodically | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Rheumatic Fever Prophylaxis
Shown below is the table depicting the secondary prophylaxis of rheumatic fever according to the 2014 AHA/ACC guideline for the management of valvular heart disease:[3]
|
Indications | Duration of prophylaxis |
▸ Rheumatic fever with carditis and persistent valvular heart disease | ▸ 10 years or until the patient is 40 years (whichever is longer) |
▸ Rheumatic fever with carditis but no valvular heart disease | ▸ 10 years or until the patient is 21 years (whichever is longer) |
▸ Rheumatic fever without carditis | ▸ 5 years or until the patient is 21 years (whichever is longer) |
Do's
- Perform transesophageal echocardiography (TEE) in patients considered for PMBC to rule out left atrial thrombus and to determine mitral regurgitation severity.
- Perform exercise testing or invasive hemodynamic testing, when clinical signs and symptoms don't co-relate with echocardiographic findings.
- Perform mitral valve surgery in stage C and stage D mitral stenosis, if patient is undergoing cardiac surgery for some other indication.
- Perform mitral valve surgery in moderate mitral stenosis (mitral valve area: 1.6 - 2 cm2) if the patient is undergoing cardiac surgery for other indications.
- Perform mitral valve surgery with excision of left atrial appendage in stage C and stage D mitral stenosis patients who have had recurrent embolic events despite being on anticoagulation therapy.
- Perform TTE every 3-5 years in asymptomatic stage B MS patients and every 1-2 years in asymptomatic stage C MS patients who have mitral valve area 1-1.5 cm2 .
- Perform TTE once every year in asymptomatic stage C MS patients who have mitral valve area < 1 cm2.
- In cases of senile calcific mitral stenosis, intervention is done only when symptoms are severe and cannot be controlled with heart rate control and diuretics.
References
- ↑ Tadele, H.; Mekonnen, W.; Tefera, E. (2013). "Rheumatic mitral stenosis in Children: more accelerated course in sub-Saharan Patients". BMC Cardiovasc Disord. 13 (1): 95. doi:10.1186/1471-2261-13-95. PMID 24180350. Unknown parameter
|month=
ignored (help) - ↑ 2.0 2.1 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
- ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "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". Circulation. doi:10.1161/CIR.0000000000000031. PMID 24589853.