Internal Medicine

0521779407-14 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:16

994 Mitral Stenosis (MS)

➣Kerley B lines

➣Calcium in mitral valve (MV) (best seen in lateral view)

■Echo/Doppler (most important test)

➣Motion of mitral valve leaflets reduced

➣Abnormality of subvalvular apparatus

➣Left atrial enlargement

➣Pressure gradient between left atrium and left ventricle

➣Quantitation of mitral valve area (MVA)

(NOTE: if TTE not adequate for above, TEE recommended)

■Cardiac Catheterization (Right and Left heart catheterization)

➣Mitral valve gradient – simultaneous pulmonary wedge (or left

atrium) and left ventricular pressures

➣MVA – Gorlin formula using MV gradient and cardiac output

➣Pulmonary wedge and pulmonary artery pressures during exer-

cise

differential diagnosis

■Left atrial myxoma

■Severe MR (diastolic murmur present without OS)

■Austin-Flint murmur of aortic insufficiency

■Cor triatriatum (congential fibromuscular diaphragm dividing left

atrium)

■Carey-coombs murmur of acute rheumatic fever

management

■Medical treatment

➣Antibiotic prophylaxis for all patients

➣Mild symptoms-diuretics

➣Atrial fibrillation

Warfarin to prevent systemic emboli

Rate control with digoxin, beta-blockers or calcium blockers

(very important to prolong diastolic intervals with MS)

➣Moderate/severe symptoms (see specific therapy below)

specific therapy

■For moderate/severe symptoms (NYHA Class III or IV) and MVA=

or < 1.0 cm2, two options:

➣Percutaneous balloon valvotomy, or

➣Surgical repair/replacement of MV

➣Candidates for percutaneous balloon valvotomy must meet the

following TEE criteria: