AKT · Cardiovascular/Valves & endocardiumlow yield

Mitral stenosis

Narrowed mitral valve — almost always rheumatic — obstructing LA→LV filling

Overview

Narrowing of the mitral orifice, in the vast majority due to rheumatic heart disease. Obstructed left atrial emptying raises LA pressure → pulmonary congestion, AF and pulmonary hypertension. The signs are a loud S1, an opening snap and a low-pitched mid-diastolic rumble at the apex, with a malar flush.

Recognise

Exertional dyspnoea, haemoptysis, fatigue; AF (from LA dilatation) with embolic risk; malar flush
Loud S1, opening snap, and a low-pitched mid-diastolic rumble at the apex (best in the left lateral position)
Right heart failure and pulmonary hypertension as it progresses

Red flags

AF with systemic embolism (stroke) — anticoagulate; mitral stenosis AF needs warfarin, not a DOAC, if rheumatic/moderate-severe
Haemoptysis, severe pulmonary hypertension or right heart failure → urgent valve intervention

Differentials & how to tell them apart

Atrial myxomapositional symptoms, tumour plop, constitutional features — echo distinguishes

Aortic regurgitation (Austin Flint)apical mid-diastolic murmur but with AR signs

Left atrial thrombuson echo; embolic source in AF

Investigations

Echo (valve area, gradient, LA size, pulmonary pressures — diagnostic); ECG (AF, P mitrale); CXR (LA enlargement, pulmonary congestion); assess for rheumatic mitral/aortic disease.

Management

Rate control + anticoagulation (warfarin) for AF; balloon valvuloplasty or surgery for severe symptomatic MS

1Confirm on echo and assess suitability for intervention. Control AF rate and treat congestion with diuretics.Gate: AF in rheumatic/moderate-to-severe mitral stenosis → anticoagulate with WARFARIN, not a DOAC (DOACs are not licensed/effective here).
2Severe symptomatic mitral stenosis → percutaneous mitral balloon valvuloplasty if the valve is suitable (no calcification, significant MR or LA thrombus), otherwise surgical replacement/repair.

Rate control + anticoagulation for AF — warfarin (NOT a DOAC) for AF with rheumatic/moderate-severe mitral stenosis

Diuretics for congestion — symptom relief

Percutaneous mitral balloon valvuloplasty — first-line intervention for suitable (non-calcified, no significant MR/LA thrombus) valves

Surgical valve replacement/repair — if valvuloplasty unsuitable

Key points

Mid-diastolic rumble + opening snap + loud S1 + malar flush, usually rheumatic = mitral stenosis. AF is common and embolic — but in rheumatic/significant MS use WARFARIN not a DOAC. Severe symptomatic disease → balloon valvuloplasty.

Monitor & prognosis

Serial echo, AF/anticoagulation, pulmonary pressures.

Slowly progressive; good after valvuloplasty/replacement; rheumatic disease is declining in the UK.

Source: NICE NG208; ESC valve guideline