Valvular Heart Disease

• Mitral stenosis


  A condition where the mitral valve narrows, restricting blood flow from the lungs into the heart
• Most common cause of mitral stenosis


  • Rheumatic heart disease secondary to previous rheumatic fever due to infection with group A β-hemolytic streptococcus
  • More common in women than men
  • Inflammation leads to commissural fusion and a reduction in mitral valve orifice area
  • Over many years the condition progresses to valve thickening, cusp fusion, calcium deposition, a severely narrowed (stenotic) valve orifice and progressive immobility of the valve cusps
• Other causes of mitral stenosis

  • Lutembacher's syndrome (combination of acquired mitral stenosis and an atrial septal defect)
  • Rare form of congenital mitral stenosis
  • In the elderly, a syndrome similar to mitral stenosis, which develops because of calcification and fibrosis of the valve, valve ring and subvalvular apparatus (chordae tendineae)
  • Carcinoid tumours metastasizing to the lung, or primary bronchial carcinoid
• Mitral stenosis


  Severe when normal valve orifice area of 4–6 cm2 is reduced to <1 cm2
• Consequences of severe mitral stenosis

  1. Left atrial pressure increases

  2. Left atrial hypertrophy and dilatation occur

  3. Pulmonary venous, pulmonary arterial and right heart pressures increase

  4. Pulmonary capillary pressure increases

  5. Pulmonary oedema develops

  6. Alveolar and capillary thickening and pulmonary arterial vasoconstriction occur

  7. Pulmonary hypertension leads to right ventricular hypertrophy, dilatation and failure with subsequent tricuspid regurgitation
• Trans-septal balloon valvotomy


  • Ideal for patients with pliable valves, little subvalvular involvement, minimal mitral regurgitation
  • Contraindicated in heavy calcification, >mild mitral regurgitation, left atrial thrombus
• Closed valvotomy


  • Advised for mobile, non-calcified, non-regurgitant mitral valves
  • May produce good result for 10 years but valve cusps often re-fuse
• Open valvotomy


  • Preferred to closed valvotomy, reduces likelihood of traumatic mitral regurgitation
• Mitral valve replacement


  • Necessary if mitral regurgitation is also present, badly diseased/calcified valve, moderate/severe stenosis with left atrial thrombus
  • Artificial valves may work successfully for >20 years, anticoagulants generally required