Left atrial overload in mitral
stenosis→hemoptysis and
atrial fibrillation.Mitral Stenosis
Mitral valve stenosis most commonly results from rheumatic heart disease.
Other causes include atrial myxoma, congenital abnormalities, and calcific valve
degeneration. Atrial fibrillation is the most commonly associated complication.
PATHOPHYSIOLOGY
■ Mitral valve narrowing →increasing pressures across the mitral valve →
left atrial hypertrophy and eventual dilation with left heart failure.
■ Increased pulmonary venous pressure →hemoptysis.
SYMPTOMS
■ Exertional dyspnea, orthopnea
■ Fatigue
■ Palpitations (from atrial fibrillation)
■ Hemoptysis
EXAM
■ Opening snap, then diastolic murmur heard best at the apex
■ Loud S1
■ Pulmonary edema if severe disease
DIAGNOSIS
■ Suspect diagnosis based on symptoms and examination.
■ ECG: Left atrial enlargement, possibly atrial fibrillation
■ CXR: Often normal, may see left atrial enlargement, CHF
■ Echocardiogram is confirmative.
TREATMENT
■ Treat atrial fibrillation (consider anticoagulation).
■ Anticoagulate if systemic embolization occurs.
■ Prophylaxis for endocarditis
■ Elective valve replacement
COMPLICATIONS
■ Atrial fibrillation (very common)
■ Massivepulmonary hemorrhage
■ Pulmonary HTN and right heart failure
■ Systemic emboli from left atrial thrombus
A 67-year-old man presents to the ED with sudden onset of chest pain
and shortness of breath. He is 5 days status-post inferior wall myocardial
infarction. On examination the patient has pulmonary edema and a loud
holosystolic murmur heard best at the left lateral sternal border, with radiation
to the base. What is the most appropriate initial management?
Based on the presentation following recent MI, this patient likely has acute
mitral valve regurgitation from papillary muscle rupture. This is a surgical emer-
gency that requires immediate valve replacement. Nitroprusside and dobuta-
mine can be used together to help improvement forward flow. Intra-aortic
balloon pump may also be used as a bridge to surgery.CARDIOVASCULAR EMERGENCIES