Mitral Stenosis


  • MCC by rheumatic fever (in the past)

  • Autoimmune, congenital

  • Blood stuck behind stenotic valve ➔ dilated left atrium ➔ afib & left HF sx (pulmonary congestion)

  • ↑ pressure in atria backs into the lungs ➔ ↑ pulmonary capillary pressure, pulmonary HTN ➔ RVH (later)

  • Blood not making it into left ventricle ➔ ↓ end diastolic volume/cardiac output


  • Hx of rheumatic fever

  • Left sided HF sx (initially), Right sided HF (later)

    • Dyspnea (MC)

  • Hemoptysis (↑ pulmonary capillary pressure ➔ hemoptysis)

  • Dysphagia & hoarseness (enlarged left atrium compresses laryngeal nerve)

  • Mitral Facies: flushed cheeks/facial pallor (↓ cardiac output ➔ systemic vasoconstriction ➔ red cheeks)

  • Diastolic ejection murmur (rumble with opening snap)

    • Heard best in LLR

    • ↑ intensity with ↑ preload (squatting/supine)

    • ↓ intensity with ↓ left side preload (inspiration) & valsalva


  • ECHO shows leaflet thickening, calcification; assesses for severity (< 15mm2 is bad)

    • Assess for thrombus and MR

  • EKG shows P mitrale/LAE (biphasic p-wave), RVH with RAD

  • CXR shows LAE (raised left bronchus and posterior esophagus)

  • Cardiac cath/angiography


  • Conservative TX: diuretics for fluid overload

  • A-fib: β-blockers, CCB, digoxin for rate & anticoagulation

  • Percutaneous balloon valvuloplasty

    • As long as valve not calcified or congenital defect, no severe cooccurring MR, no atrial thrombus

  • Valve replacement if balloon contraindicated

  • DO NOT GIVE ACEi/ARB or dihydropyridine CCB because they ↓ afterload ➔ worsening HF