mitral stenosis


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Related to mitral stenosis: mitral regurgitation

stenosis

 [stĕ-no´sis] (pl. steno´ses)
an abnormal narrowing or contraction of a body passage or opening; called also arctation, coarctation, and stricture.
aortic stenosis obstruction to the outflow of blood from the left ventricle into the aorta; in the majority of adult cases the etiology is degenerative calcific disease of the valve.
hypertrophic subaortic stenosis (idiopathic hypertrophic subaortic stenosis) a cardiomyopathy of unknown cause, in which the left ventricle is hypertrophied and the cavity is small; it is marked by obstruction to left ventricular outflow.
mitral stenosis a narrowing of the left atrioventricular orifice (mitral valve) due to inflammation and scarring; the cause is almost always rheumatic heart disease. Normally the leaflets open with each pulsation of the heart, allowing blood to flow from the left atrium into the left ventricle, and close as the ventricle fills again so that they prevent a backward flow of blood. In mitral stenosis there is a resultant increase of pressure in the pulmonary artery and hypertrophy of the left ventricle. The usual treatment is surgical replacement of the valve.
pulmonary stenosis (PS) narrowing of the opening between the pulmonary artery and the right ventricle.
pyloric stenosis see pyloric stenosis.
renal artery stenosis narrowing of one or both renal arteries by atherosclerosis or by fibrous dysplasia or hyperplasia, so that renal function is impaired (see ischemic nephropathy). Increased renin release by the affected kidney causes renovascular hypertension, and bilateral stenosis may result in chronic renal failure.
spinal stenosis narrowing of the vertebral canal, nerve root canals, or intervertebral foramina of the lumbar spine, caused by encroachment of bone upon the space; symptoms are caused by compression of the cauda equina and include pain, paresthesias, and neurogenic claudication. The condition may be either congenital or due to spinal degeneration.
subaortic stenosis aortic stenosis due to an obstructive lesion in the left ventricle below the aortic valve, causing a pressure gradient across the obstruction within the ventricle. See also idiopathic hypertrophic subaortic stenosis.
subglottic stenosis stenosis of the trachea below the glottis. A congenital form results in neonatal stridor or laryngotracheitis, often requiring tracheotomy but resolving with age. An acquired form is caused by repeated intubations.
tracheal stenosis scarring of the trachea with narrowing, usually as a result of injury from an artificial airway or trauma.
tricuspid stenosis (TS) narrowing or stricture of the tricuspid orifice of the heart, a condition often seen in patients with severe congestive heart failure, usually the result of volume overload and pulmonary hypertension with right ventricular and tricuspid annular dilation.

mi·tral ste·no·sis (MS),

pathologic narrowing of the orifice of the mitral valve.

mitral stenosis

n.
A narrowing of the mitral valve, usually caused by disease and resulting in an obstruction to the flow of blood from the left atrium to the left ventricle.

mitral stenosis

Mitral valve obstruction Cardiology A sequela of rheumatic heart disease, primarily affecting ♀ and more common in developing nations Clinical Left-sided heart failure–DOE, orthopnea, paroxysmal nocturnal dyspnea; less commonly, hemoptysis, hoarseness, signs of right-sided heart failure; Sx may be triggered by A Fib, pregnancy or other stress–eg, RTI, endocarditis or other heart disease Examination Diastolic rumble after opening snap; S1 is usually load, because the mitral valve remains open by a transient gradient until closed by the systolic force; pulmonary HTN is indicated by a loud P2, right ventricular lift, ↑ neck veins, ascites, edema Workup Doppler echocardiography–↓ valve diameter, severity of stenosis Management Medical therapy in asymptomatic Pts–antibiotics for endocarditis; mild Sx–diuretics; with A Fib, digoxin, beta-blocker, or CCB; moderate Sx–balloon valvotomy if calcification not excessive, otherwise, valve repair or replacement. See Mitral valve.

mi·tral ste·no·sis

(MS) (mī'trăl stĕ-nō'sis)
Pathologic narrowing of the orifice of the mitral valve.

mitral stenosis

Narrowing of the MITRAL VALVE of the heart. This is usually the result of damage from RHEUMATIC FEVER. The narrowing imposes a back pressure on the blood coming from the lungs and an early sign is breathlessness. The left ATRIUM enlarges and may beat irregularly (ATRIAL FIBRILLATION) and clots may form in the atrium. Disablement from reduced exercise tolerance may be severe and surgery may be required to widen or replace the damaged valve.

Mitral stenosis

Narrowing or constricting of the mitral valve, which separates the left atrium from the left ventricle.
Mentioned in: Pulmonary Edema

Mitral Stenosis

DRG Category:216
Mean LOS:16.5 days
Description:SURGICAL: Cardiac Valve and Other Major Cardiothoracic Procedure With Cardiac Catheterization and With Major CC
DRG Category:218
Mean LOS:7.4 days
Description:SURGICAL: Cardiac Valve and Other Major Cardiothoracic Procedures With Cardiac Catheterization and Without CC or Major CC
DRG Category:219
Mean LOS:12.5 days
Description:SURGICAL: Cardiac Valve and Other Major Cardiothoracic Procedures Without Cardiac Catheterization and With Major CC
DRG Category:221
Mean LOS:5.6 days
Description:SURGICAL: Cardiac Valve and Other Major Cardiothoracic Procedures Without Cardiac Catheterization and Without CC or Major CC
DRG Category:307
Mean LOS:3.3 days
Description:MEDICAL: Cardiac Congenital and Valvular Disorders Without Major CC

Mitral stenosis, a pathological narrowing of the orifice of the mitral valve, occurs when the mitral valve is unable to open fully. The opening of the mitral valve, normally 4 to 6 cm2 in area, is decreased to half normal size or even smaller because of a series of changes in valve structure. The mitral valve leaflets fuse together and become stiff and thickened by fibrosis and calcification. The chordae tendineae fuse together and shorten, and the valvular cusps lose their flexibility.

The mitral valve is located between the left atrium and the left ventricle. When mitral stenosis occurs, blood can flow from the left atrium to the left ventricle only if it is moved forward by an abnormally elevated left atrial pressure. The elevated left atrial pressure leads to increased pulmonary venous and capillary pressures, decreased pulmonary compliance, and exertional dyspnea. Left atrial dilatation, an increase in pulmonary artery pressure, and right ventricular hypertrophy follow as the heart compensates for the stenotic valve.

Complications of mitral stenosis can be serious. With no surgical intervention, 20 years after the onset of symptoms, the condition can result in an 85% mortality rate. Pulmonary edema develops with sudden changes in flow across the mitral valve, such as the increased flow that occurs in exercise. Atrial dysrhythmias, particularly paroxysmal atrial tachycardia, atrial flutter, and atrial fibrillation, occur with more long-standing disease. Pulmonary hypertension can cause fibrosis of the alveoli and pulmonary capillaries. Recurrent pulmonary emboli, pulmonary infections, infective endocarditis, and systemic embolization are all potential complications.

Causes

The predominant cause of mitral stenosis is rheumatic fever. Approximately 40% of individuals with rheumatic heart disease have pure or predominant mitral stenosis. A congenital absence of one of the papillary muscles, resulting in a parachute deformity of the mitral valve, is rare. This deformity is observed almost exclusively in infants and young children. Other uncommon causes of mitral stenosis include malignant carcinoid syndrome, systemic lupus erythematosus, rheumatoid arthritis, thrombus formation, and the mucopolysaccharidoses of the Hunter-Hurley phenotype.

Genetic considerations

Cardiac congenital valve anomalies can produce mitral stenosis, and there have been reports of families with heritable disease affecting the mitral valve.

Gender, ethnic/racial, and life span considerations

Approximately two-thirds of the patients with mitral stenosis are female. Two-thirds of all women with rheumatic mitral stenosis are younger than age 45. There are no known racial and ethnic considerations for mitral stenosis.

Global health considerations

Rheumatic fever and related mitral valve disease are more common in developing than in developed nations.

Assessment

History

Because patients generally have a history of either rheumatic fever or a genetic predisposition to valvular heart disease, ask about specific dates and treatments related to the initial episode of rheumatic fever. Note the use of prophylactic antibiotics against the recurrence of rheumatic fever.

Patients may remain asymptomatic for a period of 10 to 15 years after the diagnosis. Once the valve orifice decreases to less than 2.5 cm2, however, any physiological state that causes an increase in cardiac output (exercise, fever, anxiety, pain, pregnancy) or a decrease in diastolic filling time (tachycardias, atrial fibrillation) may cause the patient to complain of excessive fatigue, malaise, decreased tolerance to exercise, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and dry cough.

Physical examination

As the valve orifice becomes increasingly narrowed, symptoms of right-sided heart failure may occur. Inspect the patient for neck vein distention and pitting peripheral edema. Pulmonary edema may also occur and lead to orthopnea, tachypnea, diaphoresis, pallor, cyanosis, and pink frothy sputum. Palpate the patient’s abdomen for hepatomegaly and auscultate the patient’s lungs for crackles.

You may note a normal apical pulse or an irregular rate associated with atrial fibrillation when the heart is auscultated. There are four principal findings: (1) a loud apical first heart sound (closure of the stenotic mitral valve); (2) an opening snap (the snapping of the stenotic mitral valve); (3) a rumbling, apical diastolic low-frequency murmur (blood flowing with difficulty and under increased pressure through the stenotic mitral valve); and (4) an increased pulmonic second sound associated with pulmonary hypertension.

Psychosocial

Often, patients have been living with the diagnosis for more than 10 years. The possibility of open heart surgery presents a crisis for patients who fear for their lives. In addition, their symptoms may interfere with activities of daily living. Assess the patient’s degree of anxiety and ability to cope with the disease.

Diagnostic highlights

TestNormal ResultAbnormality With ConditionExplanation
Transesophageal echocardiogramNormal mitral valveStenotic mitral valve, left atrial enlargementOpening of mitral valve is narrow, which elevates left atrial pressure and leads to left atrial hypertrophy and right ventricular hypertrophy
Cardiac catheterizationNormal mitral valveStenotic mitral valve; elevation of left atrial pressure, elevation of pulmonary capillary pressures and venous pressures, left atrial enlargementSame as above
Doppler echocardiographyNormal mitral valveStenotic mitral valve; left atrial enlargementSame as above

Other Tests: Electrocardiogram may show atrial fibrillation, chest radiography, prothrombin time, activated partial thromboplastin time

Primary nursing diagnosis

Diagnosis

Activity intolerance related to pulmonary congestion and decreased blood supply to meet the demands of the body

Outcomes

Energy conservation; Coping; Knowledge: Disease process; Mood equilibrium; Symptom severity; Health beliefs: Perceived control; Knowledge: Medication; Treatment regimen

Interventions

Energy management; Counseling; Exercise promotion; Hope instillation; Security management; Security enhancement; Presence; Medication management; Teaching: Prescribed diet and medications

Planning and implementation

Collaborative

Once symptomatic, a patient usually progresses from mild to total disability in 5 to 10 years. This downhill course can be accelerated by conversion from a normal cardiac rhythm to atrial fibrillation or by pregnancy, bacterial endocarditis, or embolization.

Patients with mitral valve area less than 1.5 cm2 may be considered for percutaneous balloon valvuloplasty if the pulmonary pressure is appropriate and they have reparable valves. The procedure is also used in young patients without calcification, symptomatic pregnant women, and by elderly individuals who are poor candidates for open heart surgery. Definitive therapy for mitral stenosis is surgical replacement of the stenotic valve, particularly when the valve has marked stenosis with an orifice less than 1 cm2. Postoperative anticoagulation is not required. Therefore, even patients with mild symptoms are candidates for surgery. Patients who have more severe, disabling symptoms are more likely to require valve replacement. Either a bioprosthetic or a mechanical valve is used by the surgeon, depending on the patient’s condition and the surgeon’s preference. (See Coronary Artery Disease, p. 282, for collaborative and independent interventions for the patient who is undergoing open heart surgery.)

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
DiureticsVaries with drugThiazides; loop diureticsManage fluid overload and congestive symptoms
Calcium channel blockersVaries with drugDiltiazemDepresses impulse formation and conduction
Coronary vasodilatorsVaries with drugNitroglycerine, nitroprusside, captopril, enalapril, hydralazineDecrease preload and afterload; decrease regurgitant blood flow; reduce ventricular size
WarfarinInitially 10–15 mg, then 2–10 mg/day maintenanceAnticoagulantPrevents thrombi from forming on the synthetic valve
Heparin or low-molecular-weight heparinInitially 80 units/kg IV bolus, followed by an infusion of 18 units/kg; serial monitoring of activated partial thromboplastin to guide future dosesAnticoagulantPrevents thrombi initially until warfarin therapy is well regulated

Other Drugs: Inotropic agents (dobutamine [Dobutrex], digoxin) are used to enhance the heart’s pumping ability. If they are present, dysrhythmias are treated with antidysrhythmics, such as propranolol (Inderal), amriodarone, or quinidine. Antibiotics are used prophylactically against bacterial endocarditis and prior to interventional therapies and dental procedures (manipulation of gingival tissue, procedures on the apex of a tooth, or perforation of oral mucosa); common antibiotics are ampicillin, amoxicillin, clindamycin, gentamicin.

Independent

Focus on early detection and management of symptoms and the prevention of complications. Interventions depend on the stage of the disease process. If the patient is newly diagnosed, patient teaching becomes important because of the patient’s knowledge deficit. If the patient has severe symptoms that interfere with the ability to perform daily functions, strategies to maintain rest and conserve energy become important. If the patient is a surgical candidate, preoperative and postoperative management are the priority.

During periods of activity intolerance, encourage the patient to maintain bedrest and to allow full assistance with hygiene activities. Provide a bedside commode rather than a bedpan to decrease energy expenditure during voiding. Encourage the patient to keep the head of the bed elevated to at least 30 degrees. Support both arms with pillows to ease breathing and to augment chest excursion. Explore with the patient preferred diversionary activities, such as reading, watching television, needlework, listening to the radio, or quiet visitation with friends and family. Monitor the number of visitors to ensure that the patient is not overfatigued.

Encourage the patient and family to discuss their fears about the progress of the symptoms or the possibility of surgery. Answer questions honestly, provide accurate information, and allow the patient and significant others time to digest information before adding additional content. If the patient needs surgical intervention, evaluate the patient’s home situation to determine if additional home assistance will be needed after discharge.

Evidence-Based Practice and Health Policy

Eleid, M., Nishimura, R., & Sorajja, P. (2012). Impact of left ventricular diastolic dysfunction in patients with symptomatic mitral stenosis. Journal of the American College of Cardiology, 59(13s1), E2036. doi 10.1016/S0735-1097(12)62037-3

  • Investigators examined 104 patients with mitral stenosis who underwent percutaneous balloon mitral valvotomy and found that recurrent, severe cardiovascular symptoms were more prevalent in the patients with higher left ventricular end diastolic pressure (LVEDP; ≥ 16 mmHg) compared to patients with LVEDP < 16 mmHg (83% versus 54%) (p = 0.002).
  • Thirty-six percent of the patients had an elevated LVEDP prior to the procedure. A history of obesity (p = 0.002) and diabetes (p = 0.02) were significantly associated with increased LVEDP.

Documentation guidelines

  • Physical findings of the cardiopulmonary and renal systems: Heart and breath sounds, vital signs, capillary refill, pulmonary artery pressure readings if applicable, intake and output, daily weights
  • Presence of complications associated with mitral stenosis: Atrial fibrillation, pulmonary edema, heart failure
  • Response to medications used to treat the symptoms and complications that are associated with mitral stenosis
  • Tolerance to activity
  • Response to surgical intervention: Wound healing, fluid balance, pulmonary artery pressures and cardiac output, urine output, chest tube drainage

Discharge and home healthcare guidelines

Assess the patient’s home environment to determine if additional assistance will be needed after discharge. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Instruct the patient to report orthopnea, tachypnea, diaphoresis, frothy sputum, irregular pulse, and chest discomfort.

References in periodicals archive ?
Evaluation of the long-term effect of percutaneous balloon valvuloplasty on right ventricular function using tissue Doppler imaging in patients with mitral stenosis. Turk Kardiyol Dernegi Ars 2014; 42: 35-43.
Percutaneous mitral balloon valvotomy (PMBV) has been practiced in patients with stage C2 and stage D mitral stenosis patients in place of closed and open surgical mitral valvotomy and mitral valve replacement since 1984.
In a study by Radha Krishnan, out of 100 cases of acquired valvular heart disease the maximum brunt is borne by mitral valve and was involved in 56%, 27% had isolated mitral stenosis, 14% cases had isolated mitral regurgitation, 17% cases had mitral stenosis and mitral regurgitation, 13% cases were aortic stenosis with aortic regurgitation and 26% with multivalvular heart disease.
Caso et al., "Two-Dimensional atrial systolic strain imaging predicts atrial fibrillation at 4-year follow-up in asymptomatic rheumatic mitral stenosis," Journal of the American Society of Echocardiography, vol.
In this study, we aimed to evaluate whether clinical and echocardiographic parameters might predict WRF in patients with mild-to-moderate mitral stenosis. Male gender, mPAP, TRmax velocity, sPAP, digitalis and antiplatelet agent usage, right atrial diameter and TEI index were found to be univariate predictors of worsening renal function.
Balloon mitral valvotomy using Inoue technique in a patient of isolated dextrocardia with rheumatic mitral stenosis. Indian Heart J.
"Mitral stenosis in pregnancy: A four-year experience at King Edward VIII Hospital, Durban, South Africa," Br J Obstet Gynecol., Vol.107, pp.953-58
Very rarely, however, a flushed face can also be a sign of the heart condition mitral stenosis, in which the heart valve doesn't work properly, leading to increased blood pressure.
It is important to remember that, until 50 years ago, it was common to see young patients, young men and women in their teens and twenties, crippled and, indeed, dying, with severe mitral stenosis, often with atrial fibrillation, as a result of rheumatic carditis.
He had mitral regurtation (leak), mitral stenosis and aortic valve regurtation (leak).The patient was put on a bypass machine and the heart was stopped.
A diagnosis of RHD was made by echo-doppler if one or more of the following were present: a) Mitral stenosis; b) Mitral regurgitation (MR) and / or aortic regurgitation (AR) with regurgitation jet length of more than 2 cm in at least two echo planes, along with abnormal valve morphology (a bicuspid aortic valve to be excluded in cases with AR); c) MR and / or AR with regurgitant jet length of 1 -2 cm, and abnormal valve morphology, in the presence of a history suggestive of rheumatic fever.
Only the very rare entities of cor triatrium and congenital mitral stenosis could mimic the radiographic pattern but, in reality, these diagnoses can usually be diffentiated by recognising atrial enlargement.