Review Question - QID 204254

The physical exam findings suggests this patient has a new murmur secondary to mitral valve stenosis. All new diastolic murmurs as well as loud, harsh or new systolic murmurs should be evaluated by transthoracic echocardiography.

The murmur of mitral stenosis occurs during diastole, often following an opening snap. It has a rumbling quality that is usually loudest at the start of diastole. If the degree of stenosis is mild, the murmur may be difficult to auscultate. The murmur can be enhanced by having the patient lie on his left side and using the bell of the stethoscope or by having the patient engage in mild exercise such as walking. Echocardiography is used to confirm the diagnosis, determine the valve area and ventricular function, and assess whether the patient is a good candidate for balloon valvotomy.

Shipton and Wahba discuss management of someone with mitral stenosis. For those who are asymptomatic, annual visits to a physician, chest radiograph, and ECG are recommended. When symptoms, such as dyspnea on exertion develop, diuretics may be helpful. Rate control medications may be started if atrial fibrillation occurs. Potential interventions include balloon valvotomy, mitral valve reconstruction and replacement.

Douglas et al. discuss appropriate use of transthoracic echocardiography (TTE) for evaluation of valvular function. An initial evaluation is reasonable when there is a suspicion of valvular or structural heart disease. Additionally, re-evaluation can occur when there is a change in clinical status and in routine surveillance for mild stenosis (every 3 years) or moderate to severe stenosis (every year).

Illustration A demonstrates a parasternal view from an echocardiograph of a patient with mitral stenosis. The left atrium is enlarged from pumping against the increased pressure of the mitral valve.

Incorrect answers:
Answer 1: A Still's murmur is a systolic murmur that often occurs in childhood and is not associated with any cardiac defects.
Answer 3: The diagnosis can be made with a transthoracic echocardiogram. There is no reason to proceed to the transesophageal technique and expose the patient to greater risk of complications.
Answer 4: An electrocardiogram can be used to follow the patient over time, but initial assessment should include echocardiography.
Answer 5: Though rheumatic heart disease is a common cause of mitral stenosis, this is not acute rheumatic fever and ASO titers will not aid in diagnosis or management.