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Mitral valve stenosis is the narrowing of the valve located at the passage between the left atrium and ventricle of the heart due to thickening, calcification, or fusion in a way that makes it difficult for oxygen-rich blood to pass through. This structural deterioration disrupts the pumping of oxygen-rich blood coming from the lungs to the body and creates a basis for blood to pool backward. The inability of this valve, which acts as a key component of the circulatory system, to open sufficiently is a progressive mechanical obstruction that causes the heart to work under much higher pressure. By directly slowing the oxygen cycle, this process disrupts the structural integrity of the heart and circulatory dynamics, severely limiting the smooth delivery of the vital energy needed by the body to the tissues.
| Definition | It is a heart valve disease that occurs when blood flow from the left atrium to the left ventricle becomes difficult as a result of narrowing of the mitral valve. |
| Most Common Causes | Rheumatic fever (the most common cause), congenital mitral valve abnormalities, age-related valve calcification, and rarely radiotherapy or certain systemic diseases. |
| Risk Factors | Previous rheumatic fever, female sex, advanced age, chronic kidney disease, valve calcification, and congenital heart diseases. |
| Prevalence | It is less common in developed countries, whereas it is seen more frequently in regions where rheumatic fever is widespread. |
| Disease Progression | Due to narrowing of the valve opening, left atrial pressure rises, pressure increases in the pulmonary vessels, and right-sided heart failure may develop over time. |
| Symptoms | Shortness of breath with exertion, easy fatigue, palpitations, chest discomfort, nighttime shortness of breath, coughing up blood (hemoptysis), swelling in the feet, and shortness of breath at rest in advanced stages. |
| Early-Stage Findings | Shortness of breath during mild exertion, reduced performance, and episodes of palpitations. |
| Advanced-Stage Findings | Severe shortness of breath, pulmonary edema, signs of right-sided heart failure, fluid accumulation in the abdomen (ascites), and leg edema. |
| Physical Examination Findings | Diastolic murmur, opening snap, irregular pulse (if atrial fibrillation is present), and signs of fluid in the lungs. |
| Possible Complications | Atrial fibrillation, stroke, heart failure, pulmonary hypertension, right-sided heart failure, pulmonary edema, and blood clot formation. |
| Diagnostic Methods | Physical examination, echocardiography (the most important diagnostic method), electrocardiography (ECG), chest X-ray, transesophageal echocardiography, and cardiac catheterization (when necessary). |
| Importance of Echocardiography | It is the primary method for evaluating valve area, the severity of stenosis, valve structure, pulmonary artery pressure, and accompanying valve diseases. |
| Severity of the Disease | It is classified as mild, moderate, and severe mitral stenosis according to valve area and pressure gradient. |
| Treatment Goals | To reduce symptoms, prevent complications, preserve heart function, and improve quality of life. |
| Medication Treatment | Diuretics, beta blockers or rate-control medications, anticoagulants if atrial fibrillation is present, and rhythm-regulating medications when necessary. |
| Interventional Treatment | Balloon mitral valvuloplasty (percutaneous mitral balloon valvotomy) in suitable patients. |
| Surgical Treatment | If mitral valve repair is not suitable, mitral valve replacement may be performed. |
| Suitability for Balloon Valvuloplasty | The valve structure must be suitable, there must be no significant calcification, no severe mitral regurgitation, and no blood clot in the left atrium. |
| Follow-Up | Regular cardiology check-ups and echocardiography at specific intervals are recommended. |
| Lifestyle Recommendations | Reducing salt intake, planning regular exercise according to a doctor’s recommendation, maintaining an ideal weight, avoiding smoking, and protecting against infections. |
| Pregnancy | Severe mitral stenosis may pose a serious risk to both the mother and baby during pregnancy. Patients planning pregnancy should undergo a cardiological evaluation beforehand. |
| Conditions Requiring Emergency Medical Attention | Sudden severe shortness of breath, chest pain, fainting, coughing up blood, signs of stroke, and rapid and irregular palpitations. |
| Prognosis | If left untreated, the disease may progress, and severe heart failure and a marked reduction in quality of life may occur. With appropriate treatment and regular follow-up, successful long-term outcomes can be achieved in many patients. |
| Prevention | Early and appropriate treatment of rheumatic fever, timely treatment of streptococcal throat infections, and regular cardiological follow-up may reduce disease progression. |
What Is Mitral Valve Stenosis?
It is possible to compare our heart to a perfect pumping system with four separate chambers that works every second of the day. At the transition points between these chambers, there are valves that ensure blood flows in the correct direction and function just like doors that open in one direction. On the left side, this important door that allows oxygen-rich blood to pass from the upper chamber to the lower chamber is called the mitral valve. Mitral valve stenosis, as its name suggests, is a condition in which this passage gradually narrows, loses its flexibility, and begins to create a mechanical obstruction to blood flow. Under normal conditions, these thin, delicate, and freely moving leaflets can make the process of pumping blood throughout the body considerably more difficult when they thicken or fuse together for various reasons. If this condition is not detected and addressed in time, it may initiate a process that strains the overall functioning of the heart and creates a basis for various health problems.
How Does a Healthy Heart Function, and How Is This System Disrupted When the Mitral Valve Narrows?
The blood in our body travels to the lungs to become oxygenated and, after being oxygenated, returns to the upper left chamber of the heart, namely the atrium. From there, it must pass into the lower left chamber, namely the ventricle, to be pumped throughout the body. In a healthy individual, the mitral valve opening is quite wide, and blood flows into the lower chamber without encountering any resistance, almost as if traveling along a broad highway. However, when mitral valve stenosis begins to develop, this door can no longer open sufficiently. Since blood cannot pass easily into the lower chamber, it begins to accumulate and pool in the upper chamber. This accumulation may cause stretching of the heart walls and an increase in backward pressure, namely in the vessels leading to the lungs. The heart is forced to make a greater effort to overcome this obstruction, which may be considered the beginning of processes that cause the heart muscle to become fatigued over time.
What Are the Most Common Underlying Causes of Mitral Valve Stenosis?
The factors involved in the development of this condition are quite varied. However, some conditions play a much larger role in the development of the disease. In particular, certain illnesses experienced in the past or the aging process may directly affect the structure of the valve. Certain responses in which the body damages its own tissues or the gradual accumulation of minerals called calcium on the valve form the primary source of mechanical problems.
The main factors that may lead to the condition are as follows:
- Acute rheumatic fever
- Age-related calcification
- Radiotherapy to the chest area
- Congenital developmental differences
- Certain systemic immune diseases
Among these factors, rheumatic conditions experienced particularly during childhood or adolescence continue to account for a very large proportion of cases encountered in our society.
How Does Childhood Rheumatic Fever Create a Basis for Mitral Valve Stenosis?
The condition commonly known as rheumatic heart disease generally originates from bacterial throat infections that appear simple but are neglected. When a certain type of bacteria settles in the throat, the body’s immune system begins producing special proteins to fight these invaders. However, the immune system may sometimes confuse the structure of the bacteria with the structure of the heart valves. This confusion causes the body to attack not only the microbes but also its own heart valves. As a result of this condition, called a cross-reaction, a long-term, silent inflammation begins in the mitral valve. This chronic process, lasting for years and sometimes even decades, causes the valve tissue to gradually thicken and contract, ultimately creating a basis for the development of mitral valve stenosis. Deformities in the valve may persist even many years after the infection has passed.
How Do Advanced Age and Other Factors Affect the Risk of Mitral Valve Stenosis?
In individuals without a rheumatic history, the most important factor involved in the development of the disease is generally advanced age. Just as lime deposits accumulate over time in aging water pipes and make water flow more difficult, calcium deposits may also form in the heart valves over the years. These calcifications may cause the valve to lose its flexibility and prevent it from opening and closing freely like a hinge. This condition is observed more frequently, particularly in older individuals and in people with a tendency toward calcification around the heart. In addition, although very rare, some individuals may be born with this problem as a result of the mitral valve failing to complete its development in the womb. Furthermore, intensive radiation treatments applied to the chest area in the past for various diseases may also be counted among the factors that can contribute to hardening of the valve structure decades later.
How Do Our Heart and Lungs Respond to This Burden in Mitral Valve Stenosis?
Our bodily systems have an incredible capacity for adaptation and compensation. When faced with a narrowed mitral valve, the heart initially tries to increase the contraction strength of the upper chamber in order to manage the situation and force blood through the narrow opening. However, because a mechanical obstruction is present, this effort may eventually cause the walls of the upper chamber to stretch and expand like a balloon. When the upper chamber becomes excessively enlarged, the backward pressure begins to affect the lungs directly. The capillaries within the lungs may be unable to withstand this high pressure and may leak their fluid into the lung tissue. This leakage results in fluid accumulation around the air sacs responsible for breathing. This pressure may then be reflected backward from the lungs to the right side of the heart, beginning to affect and strain the entire heart system in a chain reaction.
What Symptoms Does Mitral Valve Stenosis Cause in Our Body as the Disease Progresses?
The disease may initially progress quite silently and may not cause any discomfort for a long time. However, when the opening narrows below a certain level and the heart can no longer compensate for the increased pressure, our body begins to send various signals. These signals are actually indications that the system now requires support.
Common complaints include:
- Shortness of breath
- Easy fatigue
- Palpitations
- Dry cough
- Swelling in the ankles
- Prominent neck veins
- A feeling of pressure in the chest
Shortness of breath, which initially occurs only while climbing stairs or exerting oneself, may be felt even while walking on level ground as the condition progresses. Waking from sleep at night with a feeling of suffocation and being able to breathe comfortably only with a high pillow may be considered an important sign that fluid has begun to accumulate in the lungs.
How Do the Symptoms of Mitral Valve Stenosis Indicate the Stage of the Disease?
The degree of difficulty people experience in daily life provides very important clues about the severity of the disease. In medical practice, certain assessments are made according to patients’ exercise capacity. In the initial stage, people can comfortably carry out their daily routines and may experience only mild restriction during very strenuous sports. When the condition reaches the moderate stage, activities such as doing household chores, walking uphill, or carrying shopping bags may frequently force the person to rest. As the disease progresses further, moving from one room to another or even simply getting dressed may become a serious source of fatigue. In the final stages, the person may be unable to breathe comfortably even while resting in bed. The extent to which these complaints disrupt daily life is critically important in determining the timing of treatment and the method to be applied.
What Are the Main Challenges Faced by Patients With Mitral Valve Stenosis in Daily Life?
In addition to physical limitations, living with this condition may deeply affect individuals’ psychological and social lives. A constant state of fatigue may cause people to withdraw from social activities and become isolated. Difficulty fulfilling responsibilities within the family and reduced performance at work are commonly encountered situations. For young female patients in particular, pregnancy may become a period that requires much more careful planning and may sometimes involve risks, because blood volume in the body increases during pregnancy, and this may double the burden on the narrowed valve. Frequent interruption of nighttime sleep due to coughing or palpitations may become a major cycle that causes the person to feel exhausted the following day.
Which Methods Are Used to Establish a Definitive Diagnosis in Individuals Suspected of Having Mitral Valve Stenosis?
When patients present with complaints, various examinations are performed to identify the condition and clarify the state of the valve. First, a comprehensive listening examination and general assessment process is initiated. Listening to the heart with a stethoscope is very valuable for hearing the characteristic sounds produced by blood passing through the valve. However, technological imaging tools are needed to measure the severity of the condition precisely and determine the most appropriate step.
The main assessment tools used are as follows:
- Physical examination with a stethoscope
- Electrocardiography
- Chest X-ray
- Echocardiography
- Transesophageal echocardiography (TEE)
- Exercise stress test
The combined evaluation of these tools provides sufficient data to understand how severely the valve has narrowed, how much the chambers of the heart have been affected, and the pressure status in the lungs.
How Is Echocardiography Used in the Diagnosis and Staging of Mitral Valve Stenosis?
Echocardiography, commonly known as a heart ultrasound, is a painless and harmless method that creates a moving map of the heart with the help of sound waves. When the heart is examined through the chest using surface ultrasound, the area to which the mitral valve can open can be calculated. In addition, the severity of the stenosis is classified as mild, moderate, or severe by measuring the pressure difference created by blood as it passes through the valve. When planning a procedure, much more detailed imaging may sometimes be required. In this case, a flexible tube with a tiny camera at its tip is passed down through the esophagus and positioned directly behind the heart. This method is extremely important, particularly for detecting blood clots that may be hidden in the upper left chamber of the heart. This is because ensuring that there is no clot inside before intervening on the valve is a major safety step.
How Effective Is Medication Treatment in Eliminating Mitral Valve Stenosis?
Although there is a widespread belief in society that medication can restore a narrowed valve to its former flexible state, it is not possible to resolve this mechanical problem with medications. Rather than widening the valve, medication treatment is planned to reduce the workload of the heart and relieve the patient’s symptoms. The aim is to preserve the patient’s quality of life and minimize possible risks during the period before surgery or balloon intervention.
Commonly prescribed medication groups include:
- Diuretics
- Heart rate-slowing medications
- Blood thinners
- Rhythm-regulating medications
Diuretics may make breathing easier by helping remove excess fluid accumulated in the lungs and legs from the body. Medications that slow the heart rate may give the heart more time for blood to pass through the narrow opening. Blood thinners are used to help prevent clot formation, particularly in cases where a rhythm disorder has developed.
What Steps Should Be Taken in Cases of Mitral Valve Stenosis When Medications Are Insufficient?
When the disease progresses and the valve area becomes severely narrowed, patients may experience a marked increase in their complaints even if they use their medications regularly. When symptoms such as breathlessness with the slightest exertion, increasingly frequent episodes of palpitations, or waking at night with a feeling of suffocation become more common, it may be considered that medications are no longer sufficient against the mechanical obstruction. At this point, the aim is to proceed to the next stage of treatment without losing more time and before permanent fatigue develops in the heart muscle. A decision is made that the physical narrowing of the valve must be mechanically opened, and the most suitable interventional or surgical method is planned according to the patient’s condition, age, and valve anatomy. These steps, when taken at an early stage, may greatly help protect the other parts of the heart.
How Is the Non-Surgical Balloon Method (PMBV) Applied in the Treatment of Mitral Valve Stenosis?
Known in the medical field as percutaneous mitral balloon valvuloplasty, this method is a highly refined procedure that aims to widen the narrowed valve in suitable patients without opening the chest. General anesthesia or stopping the patient’s heart is usually not required for this procedure. It is performed in specialized angiography laboratories under the guidance of imaging devices. The basic principle is to use the body’s main vessels like a highway to reach the heart and separate the fused corners of the valve by stretching them with the help of a special balloon. Because the patient’s recovery period is very short and it does not involve the difficulties associated with open surgery, it is one of the first preferred methods as long as the anatomy of the valve is suitable.
What Are the Stages of the Balloon Procedure for Mitral Valve Stenosis Performed Through the Groin?
The procedure is a highly controlled and delicate process that progresses step by step. The patient is generally awake throughout the procedure, and only the area to be treated is numbed.
The main steps of the procedure are as follows:
- Numbing the groin with local anesthesia
- Placing a sheath into the main vein
- Guiding the guidewire and tube toward the heart
- Crossing the wall between the heart chambers
- Positioning the special balloon at the level of the valve
- Inflating the balloon in a controlled manner
- Safely withdrawing the equipment from the vessel
- Applying pressure to the groin area to prevent bleeding
When the balloon is inflated inside the valve, it applies pressure to the fused edges of the valve and aims to gently separate them from each other, widening the area through which blood can pass. When necessary, the balloon may be inflated and deflated several times to achieve the targeted opening.
What Are the Advantages of Balloon Treatment for Mitral Valve Stenosis Compared With Open Heart Surgery?
The balloon procedure offers a highly comfortable option in many respects for suitable patients. Since the chest is not opened, patients do not experience the prolonged pain associated with surgery, and their hospital stay is significantly shortened; they can usually return to their normal lives within a few days. In addition, since general anesthesia is not administered, complications related to anesthesia may be avoided. One of its most important advantages is that the valve is not completely replaced and the patient’s own natural valve is preserved. While patients who receive a mechanical valve must follow a very strict blood-thinner regimen for life, patients treated with a balloon generally do not require such powerful blood thinners unless they have a specific rhythm disorder. This provides a major convenience, particularly for young women planning to become pregnant in the future.
Why Is the Structure of the Valve So Important When Making Treatment Decisions for Mitral Valve Stenosis?
The most fundamental factor determining whether a balloon procedure or surgical operation is suitable for a patient is the tissue characteristics of the narrowed valve itself. During pre-procedure ultrasound assessments, the structure of the valve is evaluated in detail using a scoring system.
The main structural characteristics assessed are as follows:
- The mobility of the valve leaflets
- The degree of thickness of the valve tissue
- The density of calcification on the valve
- The degree of shortening of the fibers supporting the valve
If the valve has not become excessively thickened, the leaflets can still stretch, and there are no hardened calcified deposits, it may be considered a very suitable candidate for balloon dilation. However, if the valve is severely calcified and has become completely rigid, inflating the balloon may cause the valve to tear, so patients may be directed toward surgical operations as a safer option.
What Alternatives Are Considered for Patients With Mitral Valve Stenosis Who Are Not Suitable for the Balloon Procedure?
For patients whose valve structure is too damaged or calcified for the balloon procedure, or who also have severe valve regurgitation, cardiac surgery options come into consideration. With open heart surgery, the patient’s own deformed valve is removed and replaced with a prosthetic valve made of tissue or metal alloys. These operations are extremely valuable methods for stopping the progression of the disease and substantially relieving shortness of breath. However, new technologies offered by medicine continue to be developed for patients who are very elderly and at high risk for open surgery. Technologies that reach the heart through the groin vessels without opening the chest and place a new valve inside or over the existing narrowed valve (transcatheter valve replacements) are also considered among the promising options for suitable cases. All these methods are planned individually to protect the patient’s overall health and improve quality of life.
What Should Individuals Diagnosed With Mitral Valve Stenosis Pay Attention to in Their Diet and Lifestyle?
In addition to medical interventions and medications, certain adjustments patients make in their daily lives may make a major contribution to relieving symptoms. Avoiding habits that increase the workload of the heart is a very valuable step in managing this process.
Some recommended lifestyle adjustments are as follows:
- Significantly reducing daily salt intake
- Maintaining an ideal body weight
- Avoiding activities that require excessive exertion, such as heavy lifting
- Taking regular walks at a pace recommended by the doctor
- Limiting beverages that may cause palpitations, such as tea and coffee
- Establishing regular sleep hours
- Taking care to protect against respiratory tract infections
Since salt may increase pressure in the lungs by causing water retention in the body, salt restriction is extremely critical for these patients. Likewise, since colds or flu-like infections may strain the lungs, avoiding crowded environments may be beneficial.
Why Should Patients Living With Mitral Valve Stenosis Attend Regular Specialist Check-Ups?
By its nature, this disease is a process that may progress gradually over time. Even during periods when symptoms are very mild, narrowing of the valve or pressure changes in the heart may continue to increase silently. Regular doctor visits and heart ultrasounds are very important for monitoring this silent progression. During check-ups, it can be examined whether the chambers of the heart have enlarged, whether pulmonary pressure has exceeded normal limits, or whether a silent rhythm disorder has begun. It is very important not to neglect follow-up appointments in order to prevent unexpected situations, update medication doses, or identify at the most appropriate time whether the moment for intervention has arrived.
Frequently Asked Questions
Prof. Dr. Kadriye Orta Kılıçkesmez is one of the leading figures in the field of Turkish cardiology. She was born on January 24, 1974, in Tekirdağ. After completing her undergraduate education at Istanbul University Cerrahpaşa Faculty of Medicine, she chose cardiology as her specialty and received her specialist training at the Cardiology Institute of the same university. In 2015, she was appointed by the university to establish the Şişli Etfal cardiology clinic and Angio laboratory. Becoming a professor in 2017, Kadriye Kılıçkesmez established the cardiology clinic and Angio laboratory of Prof. Dr. Cemil Taşçı Hospital in 2020 and ensured that the clinic became a training clinic.
