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Mitral valve disease
Mitral stenosis is mainly a rheumatic disease that limits diastolic filling, and mitral regurgitation is either primary (a defect of the valve itself, usually prolapse) or secondary (a dilated ventricle) — and treatment differs completely between the two.
Why it matters in the exam
Questions test auscultation: in stenosis — a loud first sound, an opening snap and a low-pitched diastolic rumble at the apex, louder before the first sound and heard with the patient on the left side; in regurgitation — a murmur filling all of systole at the apex and spreading towards the armpit; in prolapse — a mid-systolic click and a late systolic murmur. Manoeuvres are asked often: standing and Valsalva bring the click earlier and lengthen the prolapse murmur, and squatting delays it.
Treatment decisions: in severe stenosis (area 1.5 cm² or less) with symptoms — percutaneous balloon commissurotomy when the anatomy suits and there is no left-atrial thrombus and no significant regurgitation; otherwise surgery. In severe primary regurgitation surgery is timed by symptoms, EF or ventricular size, and repair is preferred over replacement. In secondary regurgitation optimal heart-failure therapy and resynchronisation come first, and only then transcatheter repair. Mitral stenosis with atrial fibrillation requires warfarin.
Key points
- Mitral stenosis: rheumatic, opening snap and apical diastolic rumble; severe at 1.5 cm² or less.
- Treating stenosis: balloon commissurotomy when the anatomy suits; warfarin with AF.
- Severe primary regurgitation: surgery with symptoms, EF 60% or less or end-systolic diameter 40 mm or more; repair preferred.
- Secondary regurgitation: heart-failure therapy and CRT, then transcatheter repair.
- Prolapse: mid-systolic click; standing and Valsalva bring it earlier, squatting delays it.
Summary table
| Disease | Findings | Severity or intervention criterion | Treatment |
|---|---|---|---|
| Mitral stenosis | Opening snap, apical diastolic rumble, atrial fibrillation, large left atrium | Valve area 1.5 cm² or less with symptoms | Balloon commissurotomy; surgery when anatomy is unsuitable |
| Severe primary regurgitation | Holosystolic apical murmur to the axilla | Symptoms, or EF 60% or less, or end-systolic diameter 40 mm or more | Surgery, repair preferred |
| Secondary regurgitation | Dilated left ventricle, heart failure | Remains severe despite optimal therapy | Heart-failure therapy, CRT, then transcatheter repair (TEER) |
| Mitral valve prolapse | Mid-systolic click and late systolic murmur | Severe regurgitation | Follow-up; surgery by regurgitation criteria |
| Acute regurgitation | Sudden pulmonary oedema after infarction or in endocarditis | Papillary muscle or chordal rupture | Urgent surgery |
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Sources
- ESC/EACTS Guidelines for the management of valvular heart disease, 2021 — Mitral regurgitation and mitral stenosis
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Mitral Valve Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.