para>Volume expansion during pregnancy can exacerbate heart failure symptoms. Hence, MS often presents during the intrapartum period. For patients with known severe MS, intervention should be pursued before pregnancy. Such patients have a high rate of both maternal and fetal complications, including death. Percutaneous balloon valvotomy can be performed in symptomatic pregnant patients. ‚
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Ascertain the valve gradient and pulmonary arterial pressure with ECG.
- Follow-up will depend on the severity of the MS and the patient 's symptoms.
- Asymptomatic patients: annual history and examination; follow-up serial echocardiography based on the severity of MS
- Symptomatic patients are reviewed according to individual therapy, symptoms, and signs; ECG to evaluate for changes (1)[C]
DIET
Salt restriction for pulmonary congestion ‚
PROGNOSIS
Natural history ‚
- Asymptomatic latent period after rheumatic fever for 10 to 30 years. 10-Year survival for asymptomatic or minimally symptomatic patients is 80%. 10-Year survival after onset of symptoms is 50 " “60%.
- Symptoms typically become debilitating 10 years after onset.
- 10-Year survival after onset of debilitating symptoms is only 0 " “15%.
- Mean survival with significant HTN is <3 years.
- The severity of MS progresses over time in almost all patients. There are no known definitive medical therapies, apart from prevention of recurrent rheumatic fever, that alter its natural history. When symptoms develop, balloon valvotomy, open mitral commissurotomy, or closed mitral commissurotomy provides effective means of reducing stenosis but is not curative. Restenosis sometimes occurs and can be early (<5 years) or late (>20 years).
- Appropriate medical treatment can delay necessity for surgery, and surgical treatment substantially prolongs survival in patients with severe MS.
COMPLICATIONS
Left and right heart failure, atrial fibrillation and systemic embolization, pulmonary HTN, bacterial endocarditis ‚
REFERENCES
11 Nishimura ‚ RA, Otto ‚ CM, Bonow ‚ RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg. 2014;148(1):e1 " “e132.22 Ray ‚ S. Changing epidemiology and natural history of valvular heart disease. Clin Med (Lond). 2010;10(2):168 " “171.33 Ramakrishna ‚ CD, Khadar ‚ SA, George ‚ R, et al. The age-specific clinical and anatomical profile of mitral stenosis. Singapore Med J. 2009;50(7):680 " “685.44 Maganti ‚ K, Rigolin ‚ VH, Sarano ‚ ME, et al. Valvular heart disease: diagnosis and management. Mayo Clin Proc. 2010;85(5):483 " “500.55 Bruce ‚ CJ, Nishimura ‚ RA. Newer advances in the diagnosis and treatment of mitral stenosis. Curr Probl Cardiol. 1998;23(3):125 " “192.66 Anderson ‚ JL, Halperin ‚ JL, Albert ‚ NM, et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(18):1935 " “1944.77 Manyemba ‚ J, Mayosi ‚ BM. Penicillin for secondary prevention of rheumatic fever. Cochrane Database Syst Rev. 2002;(3):CD002227.88 Zakkar ‚ M, Amirak ‚ E, Chan ‚ KM, et al. Rheumatic mitral valve disease: current surgical status. Prog Cardiovasc Dis. 2009;51(6):478 " “481.
ADDITIONAL READING
- Chandrashekhar ‚ Y, Westaby ‚ S, Narula ‚ J. Mitral stenosis. Lancet. 2009;374(9697):1271 " “1283.
- Guerios ‚ EE, Bueno ‚ R, Nercolini ‚ D, et al. Mitral stenosis and percutaneous mitral valvuloplasty (part 1). J Invasive Cardiol. 2005;17(7):382 " “386.
CODES
ICD10
- I05.0 Rheumatic mitral stenosis
- I05.8 Other rheumatic mitral valve diseases
- I34.2 Nonrheumatic mitral (valve) stenosis
- I05.2 Rheumatic mitral stenosis with insufficiency
- Q23.2 Congenital mitral stenosis
- I05.1 Rheumatic mitral insufficiency
ICD9
- 394.0 Mitral stenosis
- 424.0 Mitral valve disorders
- 394.1 Rheumatic mitral insufficiency
- 394.2 Mitral stenosis with insufficiency
- 746.5 Congenital mitral stenosis
SNOMED
- 79619009 Mitral valve stenosis (disorder)
- 86466006 Rheumatic mitral stenosis (disorder)
- 194727002 Non-rheumatic mitral valve stenosis
- 194726006 Mitral stenosis with insufficiency (disorder)
- 82458004 Congenital stenosis of mitral valve (disorder)
CLINICAL PEARLS
- Asymptomatic patients may be followed clinically with yearly exams for development of symptoms with periodic echo to evaluate valve area.
- Once symptoms of MS develop, initiate appropriate medical therapy but advise patient that, for most, surgical therapy will be needed to prolong survival. Almost all cases of MV stenosis progress in severity over time.
- MS often presents during the intrapartum period. For patients with known severe MS, intervention should be pursued prior to pregnancy. Pregnancy in a patient with severe MS has a high rate of both maternal and fetal complications, including death.