Mitral valve stenosis: The effect of other valve problems on diagnosis and treatment
Mitral valve stenosis can occur with other heart valve
problems. When this happens, diagnosis can be difficult, and treatment options
may be less clear.
Multiple valve problems are generally caused
rheumatic fever, although
Marfan's syndrome, other connective tissue disorders,
endocarditis can also be causes. Most problems occur
with the aortic valve (both stenosis and regurgitation), although there can be
problems with the tricuspid or pulmonic valve. Malfunctions of the latter two
valves typically happen as a result of earlier problems with the mitral valve,
which in turn cause expansion of the base of the pulmonic and tricuspid valves,
stretching them out of shape.
Mitral valve stenosis and aortic valve regurgitation
Some people with mitral valve stenosis also have aortic valve
regurgitation. In aortic valve regurgitation, the aortic valve leaks, allowing
some blood to flow back into the left ventricle after it leaves the chamber.
Most of the time this aortic valve regurgitation is of little or no
Having aortic and mitral valve stenosis together can
make diagnosis difficult because each can mask the symptoms of the other.
Aortic valve regurgitation is usually recognized by a wide pulse pressure (the
systolic pressure is much higher than diastolic pressure) and an enlarged left
ventricle. But mitral valve stenosis can cause the wide pulse pressure to be
absent. Mitral valve stenosis is usually suspected through a heart murmur, but
aortic valve regurgitation can cause a similar sound that can either hide the
mitral valve stenosis or cause aortic valve regurgitation alone to be diagnosed
as mitral valve stenosis and aortic valve regurgitation.
Whichever valve problem is masking the other is considered the dominant
valve malfunction, and treatment will be dictated by the treatment guidelines
for that valve malfunction.
Mitral valve stenosis and aortic valve stenosis
combination of mitral valve stenosis and aortic valve stenosis (AS) is serious
and can be particularly dangerous when the mitral valve stenosis is treated
surgically and the AS is not. When the two conditions occur together, mitral
valve stenosis often obscures the AS, making diagnosis of the AS difficult. To
confuse the issue further, the combination of mitral valve stenosis and AS can
alleviate some of the problems caused by aortic valve stenosis.
For instance, mitral valve stenosis and AS will reduce the pressure gradient
and the force at which the left ventricle pumps. This will reduce the rate at
which the aortic valve calcifies and the left ventricle muscle enlarges
(hypertrophy). It will probably also reduce any angina (chest pain) that occurs
because of AS.
Unfortunately, the combination of mitral valve
stenosis and AS also tends to exacerbate the problems caused by the mitral
valve stenosis. The blood pressure in the lungs (pulmonary hypertension) is
elevated, resulting in more congestion buildup in the lungs and hemoptysis
(coughing up blood due to blood vessel rupture).
Atrial fibrillation also occurs more frequently, as
the stress of the two valve malfunctions stretches out the left atrium. As
incidences of atrial fibrillation happen more frequently and the atrium
stretches, the harder it is to induce the heart to start beating normally
again. More frequent atrial fibrillation leads to a greater risk of blood clots
developing in your heart and to a greater risk of
Combined mitral valve stenosis
and AS should be recognized before treatment begins. If you fix your mitral
valve and not your aortic valve, your heart will suddenly be confronted with
compensating for aortic valve stenosis. Since it has not had time to develop
these compensations, your heart may suddenly begin to fail. Typically this can
lead to acute swelling in your lungs (pulmonary edema), which can be
How does treatment for other valve problems affect mitral valve stenosis treatment?
A problem with the aortic valve will limit
the treatment options for mitral valve stenosis. Because the only way to treat
aortic valve malfunctions is through valve replacement surgery, it follows that
other valve problems occurring with aortic valve problems will also be treated
surgically. But when you replace more than one valve during surgery, you are at
increased risk for a shorter life span.
The cause of the mitral
valve malfunction can become important in deciding treatment. It may be
possible to repair the mitral valve, which is preferable to replacing both
valves. Unfortunately, though, it is sometimes impossible to determine either
angiography whether the mitral valve can be repaired
or must be replaced. Often the decision to repair or replace is made during the
Because multiple valve replacement surgery carries
a greater risk of death than single valve replacement, the doctor will usually
recommend waiting as long as possible before having multiple valve replacement
surgery. Unfortunately, replacing both the aortic and mitral valves carries the
highest risk of all of the multiple valve replacement combinations. This
reinforces the importance of repairing rather than replacing the mitral valve
if at all possible.
Robin Parks, MS
Kathleen M. Ariss, MS
Pat Truman, MATC
Primary Medical Reviewer
E. Gregory Thompson, MD - Internal Medicine
Specialist Medical Reviewer
Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology
March 18, 2008
WebMD Medical Reference from Healthwise
March 18, 2008
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