MioAtlas
G1: Left-sided valves

Rheumatic mitral stenosis

Mitral valve stenosis due to cicatricial sequelae of rheumatic fever, characterized by commissural fusion, thickening and retraction of leaflet free edges, and chordal shortening or fusion.

Open in 3D simulator

Definition

Mitral valve stenosis due to cicatricial sequelae of rheumatic fever, characterized by commissural fusion, thickening and retraction of leaflet free edges, and chordal shortening or fusion, creating mechanical obstruction to left ventricular diastolic filling with secondary left atrial hypertension and pulmonary venocapillary congestion [V1] [G1-01] [G1-04].

Severity criteria

  • Clinically significant / severe mitral stenosis: Mitral valve area (MVA) ≤ 1.5 cm² (or indexed ≤ 0.9 cm²/m²; very severe if MVA < 1.0 cm² or PHT ≥ 220 ms) [V1] [V2].
  • Mean gradient: Current guidelines [V1] [V2] do not grade severity by mean transmitral gradient as an independent defining criterion, because the gradient depends directly on transmitral flow and heart rate (an elevated gradient may reflect tachycardia and a low gradient can occur in low cardiac output). Classical plan criteria (based on EAE/ASE 2009 [G1-01]): The project plan follows the 3-step scale of the EAE/ASE 2009 recommendation [G1-01, Tabla 3]:
  • Mild (L): MVA > 1.5 cm²; Mean transmitral gradient < 5 mmHg; Pulmonary artery systolic pressure (PASP) < 30 mmHg; Pressure half-time (PHT) < 150 ms [G1-01].
  • Moderate (M): MVA 1.0–1.5 cm²; Mean gradient 5–10 mmHg; PASP 30–50 mmHg; PHT 150–220 ms [G1-01].
  • Severe (G): MVA < 1.0 cm²; Mean gradient > 10 mmHg; PASP > 50 mmHg at rest; PHT ≥ 220 ms [G1-01].

Findings by layer

Hemodynamics

  • Mean transmitral gradient: L < 5 mmHg, M 5–10 mmHg, G > 10 mmHg (according to plan G1-01; in current V1/V2 guidelines interpreted conditional on HR) [G1-01] [V1].
  • Left atrial pressure (mean pulmonary capillary wedge pressure / retrograde mean right atrial pressure): Elevated proportionally to stenosis severity and heart rate [G1-01] [V1].
  • Pulmonary artery systolic pressure: Elevated in moderate and severe stages (> 30–50 mmHg) [V1] [G1-01].

Rhythm

  • Initial rhythm: Normal sinus rhythm in early stages [V1].
  • In advanced stages: Frequent atrial fibrillation due to dilation and fibrotic remodeling of the left atrium [V1] [G1-04].

ECG

  • Left atrial enlargement (left atrial enlargement, broad notched P mitrale in lead II > 0.12 s and prominent negative component in V1 > 0.04 s·mm) in sinus rhythm [E1].
  • Right ventricular hypertrophy or strain (right ventricular hypertrophy, tall R wave in V1, right axis deviation) in stages with moderate to severe pulmonary hypertension [E1].

Heart sounds and murmurs

  • First heart sound (S1): Loud, snappy, and tapping (loud S1) in mild/moderate forms due to vigorous closure of pliable leaflets; softens in very advanced stages if the valve is heavily calcified [G1-01] [G1-10].
  • Opening Snap (OS): High-pitched, sharp early diastolic sound following the second heart sound (A2). The A2-OS interval is inversely proportional to severity (the higher the left atrial pressure, the earlier the mitral valve opens: interval < 60–80 ms in severe stenosis vs > 100 ms in mild stenosis) [G1-01] [G1-15].
  • Diastolic rumble: Low-pitched, rolling mid-diastolic murmur (rumble) auscultated with stethoscope bell at the apex in the left lateral decubitus position [G1-01] [G1-15].
  • Presystolic accentuation: Late systolic / presystolic crescendo increase of rumble intensity due to active atrial contraction. Present only in sinus rhythm; completely absent once atrial fibrillation supervenes [G1-01] [G1-15].
  • Second heart sound (S2): Accentuated pulmonary component (P2) in the presence of pulmonary hypertension [G1-11].

Arterial pulse

  • Normal amplitude in mild stages; small volume pulse (pulsus parvus) in severe forms with restricted forward output [B4].

Jugular venous pulse

  • Prominent 'a' wave in sinus rhythm if pulmonary hypertension is present; prominent 'v' wave and loss of 'a' wave if atrial fibrillation or secondary tricuspid regurgitation supervenes [B3] [G1-04].

Maneuvers

  • Left lateral decubitus position with mild exercise (squatting / handgrip): Increases venous return and heart rate, magnifying the transmitral gradient and the intensity of the diastolic rumble [G1-15] [V1].
  • Valsalva maneuver (strain phase): Decreases venous return and softens the rumble [G1-15].
  • Inspiration: Does not increase the mitral rumble (distinguishing it from tricuspid rumble) [G1-15].

Simulator severity grades

Simulator severity grades: Mild, Moderate, Severe
Baseline rhythm: Atrial Fibrillation

Also known as: Rheumatic mitral stenosis · Rheumatic mitral valve disease · Rheumatic mitral valve stenosis · Mitral stenosis · MS

Other pathologies in this group

Related clinical comparisons

Sources

  1. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  2. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  3. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  4. [G1-01] Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice . J Am Soc Echocardiogr (2009) . DOI: 10.1016/j.echo.2008.11.029 PubMed: 19130998
  5. [G1-04] Acute rheumatic fever and rheumatic heart disease . Nat Rev Dis Primers (2016) . DOI: 10.1038/nrdp.2015.84 PubMed: 27188830
  6. [G1-10] The First Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250175
  7. [G1-11] The Second Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250183
  8. [G1-15] Diastolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250187
  9. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  10. [V2] 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines . Circulation (2021) . DOI: 10.1161/CIR.0000000000000923 PubMed: 33332150