Synopsis
Recognise clinically significant mitral stenosis, manage congestion and atrial fibrillation safely, and select transcatheter commissurotomy versus surgery.
- Rheumatic commissural fusion is the classic cause; degenerative mitral-annular calcification is increasingly important in older adults and is not treated like pliable rheumatic disease.
- Exertional dyspnoea, orthopnoea, haemoptysis and declining exercise tolerance reflect raised left-atrial and pulmonary pressure.
- An opening snap followed by a low-pitched mid-diastolic apical rumble is typical; a longer murmur and shorter A2-to-opening-snap interval suggest greater severity.
Key red flags
Focal neurological deficit, limb ischaemia or organ infarction can arise from left-atrial thrombus and requires emergency assessment.
Investigation priorities
Measure valve area, mean gradient at the recorded heart rate, MR, LA size, RV function and pulmonary pressure.
Management branches
MS presents with respiratory failure, hypotension, ischaemia, syncope or shock.
- Use ABCDE care, monitoring, IV access and oxygen for hypoxaemia; call cardiology/critical care urgently.
- If tachyarrhythmia is causing life-threatening compromise, perform synchronised electrical cardioversion with sedation/anaesthesia support when feasible.
Symptomatic clinically significant MS is unsuitable for balloon commissurotomy.
Key medicines
WarfarinDose orally once daily and adjust to INR; typical maintenance is 3–9 mg once daily, but the exact dose is individual. For AF with rheumatic MS, the usual INR target is 2.0–3.0.
BisoprololA common adult starting dose is 2.5–5 mg orally once daily, titrated to symptoms and ventricular rate; the SmPC hypertension/angina usual dose is 10 mg once daily and maximum 20 mg/day.