Sandbox/MS

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