Q. What are the Symptoms of Mitral stenosis?

The cardinal symptom of mitral stenosis is dyspnoea on exertion. Typically it progresses over a period of years. As the severity increases patient will have orthopnoea and paroxysmal nocturnal dyspnoea and class IV dyspnoea. The proximate reason for dyspnoea in mitral stenosis is increased pulmonary artery wedge pressure, which in turn depends upon the left atrial pressure. The pressure gradient across the mitral valve depends upon the size of the valve orifice, quantum of blood flow, i.e., cardiac output and the diastolic time period during which the blood flow occurs. As the valve size decreases the gradient increases. Increase in cardiac output either due to exercise, pregnancy, anemia, fever or any other condition would increase the pressure gradient and there by the left atrial pressure. During sinus tachycardia or atrial fibrillation with fast ventricular rate, the diastolic time decreases and the pressure gradient and left atrial pressure increases. In all these situations in which the left atrial pressure increases patient will have increasing dyspnoea.

Patients with mitral stenosis sometimes report chest pain. This can be secondary to pulmonary artery hypertension and right ventricular ischaemia. Sometimes pulmonary infarction due to pulmonary embolism can cause pleuritic type of chest pain in these patients.

Palpitations in a patient with mitral stenosis usually herald the onset of atrial fibrillation. They may be paroxysmal or occur continuously at rest with increase on exertion. Some times they may precipitate pulmonary edema and heart failure. However, over a period of time symptoms tend to become quiescent.

Giddiness and syncope are unusual. They suggest severe mitral stenosis with limited cardiac reserve or fixed cardiac output. They should also raise a suspicion of ball valve thrombus in left atrium or left atrial myxoma.

Pedal edema is a late manifestation in the natural history of mitral stenosis. It suggests right heart failure due to severe pulmonary hypertension or associated organic tricuspid valve disease or combination of both.