Sandbox/MS

Classify mitral stenosis based on TTE: ❑ Valve anatomy ❑ Valve hemodynamics gradient ❑ Hemodynamic consequences

Stage A

Stage B

Stage C

Stage D

❑ Yearly follow up is recommended with history and physical examination in asymptomatic patients with mild MS ❑ For mild MS repeat echocardiography every 3-5 years ❑ For moderate MS repeat echocardiography every 1-2 years ❑ The onset of symptoms require medical therapy and re-evaluation of the stage as the patient may also need intervention in moderate and severe disease

Continue with the summary for mitral stenosis intervention below

The presence of symptoms is an indication for intervention Indications for pharmacotherapy: ❑ Alleviate symptoms before surgery ❑ Control symptoms precipitated by intercurrent illness or during pregnancy ❑ Persistent symptoms after intervention Medications: ❑ Diuretics: used to relieve symptoms of pulmonary vascular congestion (shortness of breath, orthopnea and paroxysmal nocturnal dyspnea) and in case of right sided heart failure ❑ Beta blockers: useful to control exertional symptoms as it decreases heart rate and cardiac output during exercise, thus decreasing the rise in transmitral gradient ❑ Digoxin: used in case of right or left ventricular systolic dysfunction and also during atrial fibrillation (not the first line) ❑ Statin therapy: slower progression of rheumatic mitral stenosis Antithrombotic recommendations: Consider anticoagulation therapy in MS patients with: ❑ AF ❑ Prior embolic event ❑ Left atrial thrombus Long term oral anticoagulation (2.0-3.0 INR) Prevention of endocarditits: No longer require antimicrobial prophylaxis

Continue with the summary for mitral stenosis intervention below

Classify mitral stenosis based on the following findings on TTE: ❑ Valve anatomy ❑ Valve hemodynamics gradient ❑ Hemodynamic consequences

Stage A ❑ Patient at risk of developing mitral stenosis ❑ Mild valve doming during diastole ❑ Normal transmitral flow velocity

Stage B ❑ Progressive mitral stenosis ❑ Valve area > 1.5 cm² ❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets ❑ Increased transmitral flow velocities ❑ Diastolic pressure half-time < 150 ms ❑ Mild to moderate left atrial enlargement ❑ Normal pulmonary pressure at rest

Stage C ❑ Asymptomatic severe mitral stenosis ❑ Valve area ≤ 1.5 cm² (≤ 1 cm² in severe mitral stenosis) ❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets ❑ Diastolic pressure half-time ≥ 150 ms (≥ 220 ms with very severe mitral stenosis) ❑ Elevated pulmonary artery systolic pressure > 30 mmHg ❑ Severe left atrial enlargement

Stage D ❑ Symptomatic severe mitral stenosis ❑ Valve area ≤ 1.5 cm² (≤ 1 cm² in severe mitral stenosis) ❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets ❑ Diastolic pressure half-time ≥ 150 ms (≥ 220 ms with very severe mitral stenosis) ❑ Elevated pulmonary artery systolic pressure > 30 mmHg ❑ Severe left atrial enlargement

Identify cardinal findings that increase the pretest probability of mitral stenosis ❑ Mid diastolic murmur ❑ Low-pitched diastolic rumble ❑ Associated with an opening snap ❑ Best heard at the cardiac apex ❑ Radiating to the axilla ❑ Increases with lying down, raising the legs and with exercise ❑ Decreases with valsalva maneuver and amyl nitrate ❑ Reduced pulse pressure

Does the patient have any of the following findings of decompensated mitral stenosis that require urgent management? ❑ Tachycardia ❑ Hypotension ❑ Severe dyspnea ❑ Loss of consciousness ❑ Chest pain

Yes

No

What is the complication of mitral stenosis that is causing decompensation?

Continue with the complete diagnostic approach below

Stroke ❑ Suspect in case of: ❑ Sudden weakness or paralysis - face, arm or leg ❑ Speech or visual difficulties ❑ Altered level of consciousness ❑ Sudden severe headache

Atrial fibrillation ❑ Suspect in case of palpitations ❑ Order an ECG immediately looking for ❑ Irregularly irregular rhythm, and ❑ Absent P waves

Pulmonary embolism ❑ Suspect in case of: ❑ Acute onset of exertional dyspnea or dyspnea at rest ❑ Pleuritic or substernal chest pain ❑ Hemoptysis

Pulmonary hypertension ± right sided heart failure ❑ Suspect in case of severe dyspnea ❑ Increased jugular venous pressure immediately ❑ Hepatomegaly ± pulsatile liver

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Click here for Pulmonary hypertension resident survival guide, or Click here for Acute heart failure resident survival guide