MITRAL STENOSIS   21A

A 45-year-old woman presents with shortness of breath and an irregular heartbeat. Over the past 2 weeks, she has become easily “winded” with minor activities. She has noted a fast heartbeat and a pounding sensation in her chest. In childhood, she had been ill for several weeks after a severe sore throat. On examination, her pulse rate is noted to be 120 to 130 beats/min, and her rhythm is irregularly irregular. She has distended jugular venous pulses and rales at both lung bases Cardiac examination also reveals a soft, low-pitched diastolic decrescendo murmur, heard best at the apex in the left lateral decubitus position. An electrocardiogram (ECG) shows atrial fibrillation and left atrial (LA) enlargement.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Dyspnea; tachycardic, irregularly irregular rhythm; atrial fibrillation on ECG; possible childhood rheumatic fever; jugular venous distention; pulmonary edema; diastolic decrescendo murmur at the apex and axilla; LA enlargement

How to think through: Evaluation of palpitations is more urgent when they are associated with signs of hemodynamic compromise (lightheadedness, syncope, or dyspnea). With the irregularly irregular pulse, an ECG is done, confirming atrial fibrillation. Examination shows left heart failure (HF) with jugular venous distention and pulmonary edema. How might atrial fibrillation lead to subacute HF? (New-onset atrial fibrillation alone may cause inefficient forward flow. Atrial fibrillation also occurs commonly in diastolic HF; with declining ejection fraction in systolic HF, and with LA dilatation, especially in mitral stenosis.) The diastolic murmur here suggests mitral stenosis. Careful history may reveal a decrease in activity level as the mitral stenosis progressed. Should electrical or chemical cardioversion be performed? (No. There is a high risk of systemic embolization in patients with atrial fibrillation for > 48 hours, and those with mitral stenosis are at even higher risk.) How should she be managed? (Initially, rate control and diuresis to improve her symptoms. Echocardiography can characterize the valve area and gradient. Cardiology/cardiac surgery consultations can help decide between percutaneous versus surgical repair.)

MITRAL STENOSIS   21B

What are the essentials of diagnosis and general considerations regarding mitral stenosis?

Essentials of Diagnosis

Exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea; symptoms often precipitated by onset of atrial fibrillation or pregnancy

Moderate mitral stenosis causes pulmonary edema; severe mitral stenosis presents with pulmonary hypertension and low cardiac output

ECG may show LA abnormality and atrial fibrillation; echocardiography is diagnostic

General Considerations

Underlying rheumatic heart disease in almost all patients (although history of rheumatic fever is often absent)

May also occur because of congenital disease, calcification of the annulus invading the leaflets, or prosthetic valve annular ring mismatch

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