Mitral Valve Stenosis: Symptoms, Causes, Risk Factors, and Treatment

When it comes to heart health, many people may only think of heart attacks or high blood pressure. However, there is one condition that is often overlooked but can have serious consequences: mitral valve stenosis.

According to a study at Dr. Mohammad Hoesin Central General Hospital (RSUP) in Palembang, the prevalence of mitral valve abnormalities in the form of stenosis was 63.6%. The study was conducted from September 2017 to May 2021. With growing awareness of heart health, it is important for all of us to understand this condition better and recognize the factors that contribute to it.

01 / Heart Disease

What Is Mitral Valve Stenosis?

Mitral valve stenosis, commonly known as mitral stenosis, is a medical condition that occurs when the mitral valve, one of the four valves in the heart, becomes narrowed. This valve acts as a door between the left atrium and the left ventricle of the heart, allowing blood to flow smoothly from the atrium to the ventricle. Under normal conditions, the mitral valve opens wide when the heart contracts, so that blood can flow well into the ventricle.

However, when stenosis occurs, the valve cannot open fully, so blood flow from the atrium to the ventricle is obstructed. As a result, the left atrium has to work harder to pump blood, which can lead to enlargement of the atrium and increased pressure inside it. If left untreated, this condition can cause various health problems, including heart failure and heart rhythm disorders.

02 / Heart Disease

Causes of Mitral Valve Stenosis

Mitral stenosis can be caused by several factors. One of the most common causes, especially in Indonesia, is rheumatic fever. Rheumatic fever is a complication of infection with Group A Streptococcus (GAS) bacteria, often an untreated throat or skin infection.

According to data from the Indonesian Ministry of Health (Kemenkes) and several studies, the incidence of rheumatic fever in Indonesia ranges from 5 to 15 per 1,000 people each year, with higher rates found in rural areas. About 60% to 70% of mitral valve stenosis cases in Indonesia are associated with a history of rheumatic fever, making it a significant health problem.

If a GAS infection is not treated properly, the body’s immune system can overreact, causing inflammation of the heart, including the mitral valve. This inflammation can cause permanent damage to the valve, leading to narrowing and stiffening over time.

It is important to remember that preventing and treating GAS infections early is essential in reducing the risk of rheumatic fever and the mitral stenosis it can cause. In Indonesia, awareness of this problem and access to proper treatment are crucial to reducing the impact of rheumatic fever.

Besides rheumatic fever, congenital heart disease can also cause mitral valve stenosis. Some people are born with structural abnormalities of the heart that affect the mitral valve, including stenosis. Various types of congenital heart defects can contribute to the development of mitral valve stenosis, including:

1. Atrioventricular Septal Defect (AVSD): This defect involves a hole between the atria and ventricles, which can affect the mitral valve’s ability to work properly. In AVSD, the mitral valve can become deformed or malfunction, and it may narrow over time.
2. Mitral Valve Prolapse: Although it is not always considered a congenital defect, this condition can be related to genetic factors. In mitral valve prolapse, the valve does not close properly, which can cause leakage and contribute to the development of stenosis.
3. Congenital Mitral Stenosis: In some cases, mitral stenosis can appear as a congenital defect without any clear history of infection or damage. This can happen because of abnormal valve tissue from birth, including abnormal growth of the mitral valve tissue.

These congenital heart defects may not be detected in childhood, but they can cause symptoms later in life when the mitral valve starts to narrow. This often requires ongoing medical monitoring.

Other, rarer causes include:

• Carcinoid: A type of cancer that can release substances that cause fibrosis (hardening) of the heart valves, including the mitral valve.
• Infective endocarditis: A bacterial infection of the inner lining of the heart (endocardium) that can damage the heart valves.
• Systemic lupus erythematosus: An autoimmune disease that can cause inflammation in various organs, including the heart, and can potentially cause mitral stenosis.
• Complications of medical procedures: In some cases, complications from medical procedures or heart surgery can cause changes to the mitral valve that lead to stenosis.
• Aging: As we age, heart valve tissue can undergo changes that cause calcification and stiffening. These changes can affect how the mitral valve works and cause stenosis. As a result, the risk of mitral stenosis increases with age.

03 / Heart Disease

Symptoms of Mitral Valve Stenosis

Symptoms of mitral stenosis can vary depending on how severely the valve is narrowed. In the early stages, many people may have no symptoms at all. However, as the valve narrows further, the following symptoms may appear:

1. Mild symptoms
   • Mild shortness of breath: Often occurs during light physical activity, such as walking or climbing stairs, but may not be felt by all patients.
   • Fatigue: Unusual tiredness can appear during activity or exercise, possibly because of a lack of oxygen being pumped throughout the body.
   • Palpitations: Some patients may feel a fast or irregular heartbeat due to arrhythmia, although not everyone with the condition experiences this.
2. Moderate symptoms
   • Increasing shortness of breath: Can occur during heavier activity or even at rest; its severity may differ from one person to another.
   • Cough: A dry cough may get worse when lying down, and in some cases it may be accompanied by pink sputum due to fluid buildup in the lungs.
3. Severe symptoms
   • Swelling (edema) in the legs and ankles: This fluid buildup can occur as a result of developing congestive heart failure, although it is not always visible.
   • Severe shortness of breath: Often gets worse at night or when lying down, but its intensity can vary from one patient to another.
   • Weakness or fainting: Patients may faint or feel weak during activity; this is often linked to inadequate blood flow to the brain.
4. Emergency symptoms
   • Heart attack: May be marked by deep chest pain or discomfort that can spread to the shoulder, arm, neck, or back, although not all patients with mitral valve stenosis have a heart attack.
   • Heart failure symptoms: Include severe shortness of breath that can interfere with daily activities, especially at rest; the response to treatment can also vary.

04 / Heart Disease

Risk Factors for Mitral Stenosis

Mitral stenosis can be influenced by various risk factors, which fall into two categories: controllable risk factors and uncontrollable risk factors. Below is a more detailed look at the controllable risk factors and specific guidance for managing them.

Controllable Risk Factors

1. Treating rheumatic fever
   • The importance of treating throat infections: Seek medical care right away if you or a family member has throat symptoms, such as a sore throat or difficulty swallowing. Antibiotic treatment should be taken as recommended by the doctor to clear the infection.
   • Vaccination: Make sure immunizations are completed according to the recommended vaccination schedule. Pneumococcal and influenza vaccines may also help reduce the risk of infections that could affect the heart.
2. Healthy eating
   • Eat a balanced diet: Focus on a diet rich in fruits, vegetables, whole grains, and healthy protein sources such as fish, nuts and beans, and tofu or tempeh.
   • Limit saturated and trans fats: Avoid processed foods, gorengan (deep-fried snacks), and fast food that contain trans fats. Instead, choose healthy fats such as olive oil and fatty fish rich in omega-3.
   • Reduce salt intake: Limit salt to less than 2,300 mg per day. Choose herbs, spices, and natural ingredients instead of salt to add flavor to food.
   • Avoid excess sugar: Cut back on sweetened drinks, candy, and foods with added sweeteners.
3. Physical activity
   • Regular exercise: Do at least 150 minutes of moderate-intensity physical activity per week, such as brisk walking, cycling, or swimming. This can be divided into smaller sessions, for example 30 minutes, five times a week.
   • Strength training: Add strength training twice a week to build muscle mass. Using your body weight, resistance bands, or weights can be effective.
   • Daily activities: Look for opportunities to move more during your daily routine, such as taking the stairs, walking to nearby places, or doing housework.
4. Smoking
   • Quit smoking: If you smoke, look for a smoking cessation program that can help you. Many hospitals and clinics offer programs and the support you need.
   • Avoid secondhand smoke: People who do not smoke should avoid places with cigarette smoke, as it can have a negative impact on their heart health.
5. Managing blood pressure and blood sugar
   • Regular monitoring: Have your blood pressure and blood sugar checked regularly to detect possible problems early. If the results are abnormal, consult a doctor for proper management.
   • Medications and lifestyle changes: If you are diagnosed with hypertension or diabetes, follow your doctor’s advice on medications and the lifestyle changes you need to make. This may include diet, more physical activity, and weight loss if needed.

Uncontrollable Risks

Some risk factors for mitral stenosis cannot be controlled, but it is important to understand them so that you can anticipate and be prepared for potential health problems. Here is a more detailed explanation of these factors:

1. Age
   • Physiological aging: As we age, physiological changes occur in the heart and blood vessels. Heart valve tissue, including the mitral valve, can thicken, calcify, and lose elasticity. This process can disrupt how the valve opens and closes, potentially causing stenosis.
   • Coexisting conditions: Older individuals are more prone to various other heart conditions, such as hypertension and arteriosclerosis, which can change the dynamics of blood flow and speed up valve damage.
2. Sex: Some studies show that women may be more susceptible to mitral valve stenosis than men. This may be related to hormonal differences and the body’s response to certain health conditions such as rheumatic fever, which is more common in women, especially during adolescence.
3. Family history
   • Genetic factors: Having a family history of heart conditions may indicate a genetic predisposition to heart problems, including mitral stenosis. Certain genes can cause abnormalities in valve structure or heart function that increase the risk.
   • Congenital heart conditions: Many congenital heart conditions have a genetic component, and some can be inherited from parents. A family history may indicate a possible high risk of various heart valve problems.
4. Congenital heart disease
   • Structural abnormalities: Congenital heart disease, such as atrioventricular septal defect (AVSD) or mitral valve prolapse, can cause structural abnormalities in the heart. These abnormalities can disrupt mitral valve function and contribute to the development of stenosis over time.
   • Long-term consequences: In patients born with heart defects, early treatment and surgical intervention may be needed to address the existing problems. Although these interventions can reduce the risk, some individuals still have a higher chance of heart complications in adulthood.

05 / Heart Disease

Diagnosing Mitral Valve Stenosis

Diagnosing mitral stenosis involves a series of comprehensive steps, from a physical examination to the use of modern technology in supporting tests. In Indonesia, various diagnostic methods are now available to support early detection and appropriate treatment. Here are the steps commonly taken in diagnosing mitral stenosis:

1. Physical Examination

The doctor will start with a thorough physical examination. At this stage, the doctor listens to the heart with a stethoscope to detect abnormal heart sounds (for example, a murmur) that may indicate a problem with the mitral valve. The physical examination also includes checking for signs of heart failure, such as swelling in the legs or shortness of breath.

2. Electrocardiogram (ECG)

An ECG is a test that records the heart’s electrical activity. In mitral valve stenosis, an ECG can help detect arrhythmias, such as atrial fibrillation, which often accompany mitral stenosis.

In Indonesia, ECGs are available at many health facilities, including hospitals and clinics, and are generally a standard first step in diagnosing heart problems.

3. Echocardiography

Echocardiography uses sound waves to produce real-time images of the heart and is the main diagnostic tool for mitral stenosis. The types of echocardiography used usually include:

• Transthoracic echocardiography (TTE): A commonly used non-invasive method to assess heart anatomy and valve function. TTE can provide information about the size and shape of the heart and how much the stenosis affects the mitral valve.
• Transesophageal echocardiography (TEE): This method also uses sound waves but requires a probe to be inserted into the esophagus. TEE gives a clearer picture of the valves and inner structures of the heart, so it is often used in more complex cases.

Echocardiography is increasingly available in Indonesia, with many large hospitals and cardiology centers equipped with this modern technology.

4. Cardiac Catheterization

If needed, the doctor may recommend cardiac catheterization. This procedure involves inserting a catheter through an artery into the heart, allowing the doctor to measure the pressures inside the heart and distinguish the type of heart problem present.

Cardiac catheterization can also be used to identify coronary artery disease that may accompany mitral stenosis, and to carry out treatment procedures if needed.

06 / Heart Disease

Treatment Options

Treatment options for mitral valve stenosis depend on the severity of symptoms, the patient’s age, overall heart health, and the patient’s preferences. Treatment can range from medication to interventional procedures.

1. Medical Treatment

Medical treatment is usually used to manage symptoms and slow the progression of the disease. Commonly used medications include:

• Diuretics: Help reduce fluid buildup in the lungs and body, relieving shortness of breath.
• Anticoagulants: Prevent blood clots, which are a high risk in patients with mitral stenosis. Examples include warfarin or novel oral anticoagulants (NOACs).
• Heart failure treatment: If mitral valve stenosis causes heart failure, medications to strengthen the heart muscle or control the heart rhythm may be needed.

2. Interventional Treatment

If medication is not effective enough or symptoms get worse, an interventional procedure may be needed. The options include:

• Balloon Mitral Valvuloplasty (BMV): A minimally invasive cardiac catheterization procedure in which a small balloon is used to open the narrowed mitral valve. This can be one option for certain patients, based on the doctor’s assessment.
• Mitral valve repair or replacement surgery: A more invasive open-heart operation. Mitral valve repair aims to fix the damaged valve, while mitral valve replacement involves replacing the damaged mitral valve with an artificial valve (mechanical or bioprosthetic). This is usually recommended for severe mitral stenosis or if BMV has not been effective.

07 / Heart Disease

Possible Complications

Untreated mitral stenosis can lead to a series of serious complications that can affect quality of life and increase the risk of death. Understanding these potential complications is very important so that medical action can be taken in time. Here are some of the main complications that may occur:

1. Atrial Fibrillation

Atrial fibrillation is a heart rhythm disorder marked by a fast and irregular heartbeat. Mitral valve stenosis increases the pressure in the left atrium, which can lead to atrial fibrillation.

This condition increases the likelihood of blood clots forming, which can cause a stroke. It is important to manage atrial fibrillation to prevent further complications.

2. Heart Failure

Heart failure occurs when the heart cannot pump blood effectively enough to meet the body’s needs. In mitral stenosis, the obstructed blood flow through the mitral valve forces the heart to work harder.

Heart failure is potentially life-threatening and requires immediate medical attention. Its symptoms include shortness of breath, extreme fatigue, and swelling in the legs and abdomen.

3. Pulmonary Hypertension

Increased pressure in the left atrium can also affect the blood vessels in the lungs, causing pulmonary hypertension. This condition forces the right side of the heart to work harder.

If left untreated, pulmonary hypertension can damage the right ventricle and potentially lead to right-sided heart failure.

4. Blood Clots and Stroke

Because blood does not flow as smoothly, the risk of blood clots increases. These clots can travel to other parts of the body and cause a stroke or systemic embolism.

A stroke can cause significant brain damage, resulting in long-term disability or even death. Prevention with anticoagulant treatment may be recommended.

5. Infective Endocarditis

Damage to the heart valves increases the risk of an infection called infective endocarditis. This infection occurs when bacteria or other microorganisms attack the inner lining of the heart and its valves.

Endocarditis can be life-threatening and often requires intensive antibiotic treatment and possibly surgery to replace or repair the infected valve.

08 / Heart Disease

Prognosis of Mitral Valve Stenosis

The prognosis for patients with mitral stenosis depends heavily on several factors, including the severity of the disease, the patient’s age, and how successful the treatment is. Here is a closer look at the prognosis of this condition:

1. Disease severity: Mitral stenosis can range from mild to severe. Patients with mild stenosis often have minimal symptoms and can live with a good quality of life without extensive medical intervention. However, in patients with severe stenosis, symptoms can be very disruptive, and the potential for complications increases. The right care plan is very important to prevent disease progression and serious complications such as heart failure or stroke.
2. Patient age: Age is also an important factor in the prognosis of mitral valve stenosis. Younger patients tend to have a better prognosis because they are usually healthier overall and can recover better from medical procedures. On the other hand, older patients may have more complex health conditions, which can affect their ability to recover and adapt after treatment. In addition, age can affect the type of treatment recommended. Older patients may need a more cautious approach when treatment is being planned.
3. Treatment success: The success of medical intervention, whether medication, cardiac catheterization, or surgery, strongly affects the prognosis. Patients who receive appropriate and effective care to manage the symptoms and complications of mitral stenosis tend to have better outcomes. Some patients may need regular monitoring and follow-up care to make sure their condition stays well managed.

Overall, the prognosis for patients with mitral stenosis varies, and it is difficult to give a specific life expectancy figure. However, with good management, including appropriate treatment and anticipatory measures, many patients can live a good-quality life despite having this condition.

09 / Heart Disease

Preventing Mitral Stenosis

Preventing mitral stenosis is an important step in keeping your heart healthy and reducing the risk of complications. Here are some practical tips you can apply to reduce your risk of mitral valve stenosis:

1. Preventing rheumatic fever
   • Vaccination: Make sure immunizations are completed according to the recommended vaccination schedule. Diphtheria, tetanus, and pertussis vaccines are also important to prevent respiratory infections that can contribute to disease.
   • Treating infections: If you have a sore throat, it is important to get medical care promptly. Antibiotic treatment can help clear the infection and prevent rheumatic fever from developing. Consult a doctor right away if symptoms of a throat infection appear.
2. Blood pressure control
   • Regular monitoring: Have your blood pressure checked regularly. Keeping blood pressure under healthy control is very important to reduce the workload on the heart and prevent further damage to the valves.
   • Medication: If you have hypertension, follow the treatment recommended by your doctor and make lifestyle changes to manage your blood pressure.
3. Healthy lifestyle
   • Balanced diet: Follow a healthy, balanced diet with plenty of fruits, vegetables, whole grains, and lean protein. Limit saturated fat and salt to keep your heart in good health.
   • Physical activity: Exercise regularly for at least 150 minutes per week. Activities such as walking, running, cycling, or swimming can help maintain body weight, improve cardiovascular fitness, and reduce the risk of heart disease.
   • Quit smoking: If you smoke, stop now. Smoking can harm heart health and increase the risk of mitral valve stenosis. Look for support to quit smoking, such as a smoking cessation program or counseling.
4. Stress management
   • Relaxation techniques: Manage stress using relaxation techniques such as yoga, meditation, or breathing exercises. Managing stress well can help keep your heart healthy and improve your quality of life.
5. Regular health checkups
   • Health screening: Have regular health checkups to evaluate your heart health and detect problems early. Talk with your doctor about your risks and preventive steps based on your personal medical history.

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Conclusion

Mitral valve stenosis, although it may not always show early symptoms, is a serious heart condition that requires prompt medical attention. Let us summarize the key points we have covered:

Mitral stenosis is a narrowing of the mitral valve that obstructs blood flow. Its main causes include rheumatic fever and congenital heart disease. Symptoms vary, from mild shortness of breath to severe difficulty breathing. Diagnosis involves a physical examination, an ECG, echocardiography, and possibly cardiac catheterization. Treatment can be medical or interventional, such as cardiac catheterization or surgery. Serious complications can occur if it is not treated. The prognosis depends on the severity of the disease, the patient’s age, and how successful the treatment is.

Because complications of mitral stenosis can be life-threatening, it is very important to seek medical help right away if you have symptoms such as severe shortness of breath, chest pain, or fainting. There is no specific first aid for mitral stenosis itself, but managing symptoms such as shortness of breath, by sitting upright and breathing calmly, may help temporarily until professional medical care is available.

Prevention is key. Look after your heart by maintaining a healthy lifestyle, including a balanced diet, regular exercise, avoiding smoking, and keeping your blood pressure under control. Early treatment of infections, especially GAS infections, is very important to prevent rheumatic fever. Have your heart checked regularly, especially if you have a family history of heart disease or other risk factors.

Remember that the information in this article is for educational purposes and is not a substitute for professional medical advice. If you have symptoms or risk factors for mitral stenosis or other cardiovascular (heart and blood vessel) diseases, consult a specialist right away or visit Heartology Cardiovascular Hospital for proper evaluation and care.