Mitral Stenosis



  • Majority of cases worldwide are due to rheumatic heart disease (most commonly affects the mitral valve)
  • In high-income countries calcific mitral stenosis is increasingly more common

Stages of Valve Disease

  • Stage A – Risk Factors
  • Stage B – Progressive valve dysfunction
  • Stage C – Severe asymptomatic disease
    (C2 – severe asymptomatic with LV dysfunction)
  • Stage D – Severe symptomatic disease
Stages of MS

History & Physical


  • Patients generally present with shortness of breath on exertion and decreased exercise tolerance 
  • Less commonly they may have hemoptysis (elevated pulmonary pressure), palpitations (atrial fibrillation), fatigue, or stroke (thromboembolism from atrial fibrillation)

Physical exam

  • Cardiac exam:
    • Palpation: RV heave may be present with pulmonary hypertension 
    • Heart Sounds: loud S1 that becomes softer as stenosis becomes worse, loud P2 (pulmonary hypertension), and progressively single S2
    • Opening snap is heard at the apex after S2
    • Diastolic murmur best heard at the apex
  • Volume: crackles may be present if there is pulmonary edema and in advanced disease, right heart failure may be present


  • ECG: Most important feature to assess for is presence of atrial fibrillation. Left atrial enlargement (p wave >0.12s in lead II) or p-mitrale may be present.

  • Chest Xray: Assess for heart failure and evidence of left atrial enlargement

  • Echocardiography: Transthoracic echocardiography is used to confirm severity of mitral stenosis and determine etiology (ie. rheumatic vs non-rheumatic). In addition can look for consequences, such as left atrial enlargement, pulmonary hypertension, and right ventricular size/function. Left ventricle is usually unaffected. Finally echocardiography (TTE +/- TEE) is important to assess for suitability for balloon commissurotomy if rheumatic mitral stenosis.


Asymptomatic MS

  • In asymptomatic MS, serial monitoring with echo is indicated. Timing of follow-up interval is based on severity of MS.
  • If patients have elevated pulmonary pressures or new AF, can be considered symptom correlates. See algorithm below

Stroke Prevention

  • Prevention of thromboembolism is very important as high rate of atrial fibrillation
  • If patient has severe MS, anticoagulation is recommended if have 1. atrial fibrillation 2. history of embolism (even without atrial fibrillation), and 3. LA thrombus
  • Warfarin is first line for patients with moderate-severe mitral stenosis (rheumatic or nonrheumatic) as per CCS 2020 Atrial Fibrillation guidelines

Symptomatic severe MS

Medical Management

  • Heart failure management with diuretics as needed
  • Patients with severe MS do not tolerate tachycardia (sinus or AF) given reliance of diastolic filling time for preload, thus heart rate control is important

Valve Intervention

  • Rheumatic Mitral Stenosis Indications for Intervention:
    • Severe MS + symptoms (Class 1)
    • Severe MS + pulmonary hypertension or new AF (Class 2)
    • First line if favorable valve anatomy and less than moderate MR is to go for percutaneous balloon commissurotomy (PMBC)
      • Otherwise should go for mitral valve surgery
  • Nonrheumatic Calcific Mitral Stenosis
    • No Class 1 indication for surgery
    • If severe MS and severely symptomatic, should have a risk benefit discussion with patients
      • Patients with calcific MS are often older and multiple co-morbidities thus generally higher risk for surgery
Intervention for Rheumatic MS


  • Primary Author: Dr. Atul Jaidka (MD, FRCPC, Cardiology Fellow)
  • Reviewer: 
  • Last Updated: June 17, 2021
  • Comments or questions please email
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