Questions on mitral stenosis

Definition

  • What is the most common valvular heart disease? H170
  • What is paroxysmal nocturnal dyspnea (PND)? A
  • What is Lutembacher’s syndrome? A, hl, as
  • What is opening snap? A
  • What is mitral facies? A, as
  • What is malar flash (mitral facies)? What are the causes? Hl

Epidemiology

  • Q

Etiology and Pathophysiology

  • Which valve is most commonly affected in rheumatic fever? H169
  • What are the causes of MS? hl, as
  • What is the most common cause of mitral stenosis? H172
  • If there is no history of rheumatic fever, then what would be the cause? a
  • Why syncope may occur in MS? A, as
  • What is the cause of hemoptysis in MS? A, as
  • What are the causes of PND? A
  • What are the causes of mid diastolic murmur (MDM)? A, hl
  • Why the apex beat is tapping? A, hl, as
  • What is the mechanism of loud first heart sound? Hl
    • What are the causes of loud first heart sound? Hl
  • When and why the pre-systolic accentuation is present? A, hl, as
    • What is the significance of pre-systolic accentuation? Hl
  • What is the mechanism of opening snap? A, hl
  • What is the feature of non-pliable mitral valve? A
  • Why there is pulmonary hypertension in MS? A/ What are the mechanism of pulmonary hypertension in MS? hl, as
  • When des S1 become soft in mitral stenosis? Hl
  • In which trimester of pregnancy does asymptomatic MS become symptomatic? hl

Clinical manifestations

  • What are the characters of Austin-Flint murmur in aortic regurgitation? A
  • What is the significance of opening snap? A, hl
  • What are the features of pulmonary hypertension? Hl

Examinations

  • What will you get by examining precordium of this patient? H173
  • What are the signs of PH? A, as
  • How to assess the severity of MS (is it severe)? A
  • How to assess the severity of MS clinically? Hl
  • How to assess the pliable mitral valve? a

Investigations

  • What investigations should be done in mitral stenosis? A, hl, as
  • What are the radiological features of mitral stenosis? A, hl, as
  • What is the barium swallow of esophagus (right anterior oblique view) finding? A
  • What are the echocardiogram findings in mitral stenosis? A, hl, as

Diagnosis

  • What are the main points in favor of your diagnosis? A
  • Why do you think MS? Hl
  • Why do you think pulmonary hypertension? hl
  • What are your differential diagnoses? A, as
  • Why not this is tricuspid stenosis? A, as
  • Why not this is left atrial myxoma? A, as
  • If the patient with MS suddenly becomes unconscious, what is the likely cause? A, as
    • What may be the cause of CVD in this case? A, as
  • A 35–year–old female presents with right-sided hemiplegia. On examination you found irregularly irregular pulse, right-sided upper motor neuron lesion and mid-diastolic murmur on heart auscultation. What is your diagnosis? H171
  • How can you classify severity of MS according to mitral valve area? hl
    • What is the normal cross-sectional area of mitral valve?

Treatment

  • How can you treat mitral stenosis? Hl
  • How to treat MS medically? A, as
  • What are the indications of anticoagulant (warfarin) in MS? A, as
  • What are the indications of surgery in MS? A, hl, as
  • What surgery is usually done? A. as
  • What are the criteria for valvuloplasty? A, hl, as
  • What are the indications of valve replacement? A, hl, as
  • What is the contraindication of surgery in MS? A, hl, as
  • How to treat MS in pregnancy? a, as

Complications

  • What are the complications of MS? A, hl, as
  • What are the complications of surgery? a, as

Additional

  • What is myxoma of the heart? What are the features? How to investigate and treat? A, as

Special situations

  • Mitral stenosis with CCF. A
    • Diagnosis
    • Treatment
  • Mitral stenosis with CVD. A
    • Investigations
    • Treatment
  • Mitral stenosis with AF. a
    • Diagnosis
    • What would be examination finding if AF is present? hl
    • Why presystolic accentuation is absent in AF?
    • What do you think the cause in this case?
    • What are the causes of irregularly irregular pulse?
    • How to differentiate atrial fibrillation and multiple ectopics at bedside?
    • What are the causes of atrial fibrillation?
    • If the patient is young, what are the causes of atrial fibrillation?
    • If the patient is elderly, what are the causes of atrial fibrillation?
    • What are the complications of atrial fibrillation?
    • What is lone atrial fibrillation?
    • What is atrial fibrillation?
    • What are the types of atrial fibrillation?
    • If a patient with atrial fibrillation is unconscious, what is the likely cause?
    • How to treat atrial fibrillation?
    • What is the role of anticoagulant in atrial fibrillation?

Rimikri

SOLVES


Definition and Classification
What is the most common valvular heart disease?

Mitral stenosis is the most common valvular heart disease.

* Pre-exam preparation for medicine, HN Sarker
What is paroxysmal nocturnal dyspnea (PND)?

See details at Symptoms of cardiovascular disease: Breathlessness / dyspnoea

What is Lutembacher’s syndrome?

Combination of ASD with acquired rheumatic MS (it occurs in 4% cases of ASD).

* Short Cases in Clinical Medicine, ABM Abdullah Page: 76, Short and Long Cases in Clinical Medicine, HN Sarker Page:  275
What is opening snap?

It is a short, sharp high pitched sound, heard immediately after 2nd heart sound (during diastole), produced by sudden opening of mitral valve, due to raised left atrial pressure.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 167
What is malar flash (mitral facies)?

It is the rosy coloration of cheeks, may be bluish tinge, due to arteriovenous anastomosis and vascu­lar stasis on the cheeks.

  • It is not pathognomonic and may be present in normal person, and persons with hypothyroidism, polycythaemia and pulmonary hypertension.
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 76
Epidemiology
Etiology and Pathophysiology
Which valve is most commonly affected in rheumatic fever?

Mitral valve is most commonly affected in rheumatic fever.

* Pre-exam preparation for medicine, HN Sarker
What are the causes of MS?
  1. Chronic rheumatic heart disease ( the commonest cause). In 50% cases, there may be history of RF or rheumatic chorea.
  2. Others (very rare causes, do not mention unless asked)
    • Congenital
    • Calcification of valve ( usually in elderly)
    • Rheumatoid arthritis
    • SLE
    • Carcinoid syndrome

Note:

MS is more common in females. F:M = 2:1.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 274; Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 76
What is the most common cause of mitral stenosis?

The most common cause of mitral stenosis is chronic rheumatic heart disease.

* Pre-exam preparation for medicine, HN Sarker
If there is no history of rheumatic fever, then what would be the cause?

Still it is likely to be rheumatic fever, because history of rheumatic fever may be absent in 40% cases.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 164
Why syncope may occur in MS?
  • Due to reduction of cardiac output.
  • Also, may be due to
    • atrial fibrillation with fast ventricular rate,
    • pulmonary hypertension,
    • pulmonary embolism,
    • ball valve thrombus,
    • cerebral embolism.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 166
What is the cause of hemoptysis in MS?
  • Rupture of pulmonary or bronchial veins associated with pulmonary hypertension (pulmonary apoplexy).
  • Also hemoptysis may be due to pulmonary infarction.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 166
What are the causes of mid diastolic murmur (MDM)?

As follows:

  • Mitral stenosis
  • ASD (due to increased flow through tricuspid valve)
  • Tricuspid stenosis
  • Left atrial myxoma
  • Austin-Flint murmur in aortic regurgitation
  • Carey Coomb’s murmur (a soft MDM due to mitral valvulitis in acute rheumatic fever)
  • Left atrial ball valve thrombus.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 167; Short and Long Cases in Clinical Medicine, HN Sarker Page:  273
Why the apex beat is tapping?

It is due to accentuated (loud) first heart sound.

* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 76; Short and Long Cases in Clinical Medicine, HN Sarker Page:  Page: 273
What is the mechanism of loud first heart sound?

Loud first heart sound occurs due to sudden slammed shut of mobile mitral valve during systole.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 273
What are the causes of loud first heart sound?
When and why the pre-systolic accentuation is present?
What is the significance of pre-systolic accentuation?
What is the mechanism of opening snap?
What is the feature of non-pliable mitral valve?

Muffled first heart sound and no opening snap.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 168
Why there is pulmonary hypertension in MS? A/ What are the mechanism of pulmonary hypertension in MS?

Because of:

  • Passive backward transmission of raised left atrial pressure
  • Reflex pulmonary artery vasoconstriction
  • Organic obliterative change in pulmonary vascular bed.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 168; Short and Long Cases in Clinical Medicine, HN Sarker Page:  274
When does S1 become soft in mitral stenosis?

S1 becomes soft when mitral stenosis is severe or valve cusps are calcified.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 274
In which trimester of pregnancy does asymptomatic MS become symptomatic?

In second trimester due to significantly increased blood volume.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 274
Clinical Manifestations
What are the clinical features (and their causes) in mitral stenosis?

Symptoms

  • Breathlessness (pulmonary congestion)
  • Fatigue (low cardiac output)
  • Oedema, ascites (right heart failure)
  • Palpitation (atrial fibrillation)
  • Haemoptysis (pulmonary congestion, pulmonary embolism)
  • Cough (pulmonary congestion)
  • Chest pain (pulmonary hypertension)
  • Thromboembolic complications (e.g. stroke, ischaemic limb)

Signs

  • Atrial fibrillation
  • Mitral facies
  • Auscultation
    • Loud first heart sound, opening snap
    • Mid-diastolic murmur
  • Crepitations, pulmonary oedema, effusions (raised pulmonary
  • capillary pressure)
  • RV heave, loud P2 (pulmonary hypertension)
* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 616
What are the characters of Austin-Flint murmur in aortic regurgitation?

As follows:

  • It is not associated with loud first heart sound or presystolic accentuation
  • No diastolic thrill
  • No opening snap
  • Patient will have features of aortic regurgitation.

Note:

These features are present in organic MS.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 167
What is the significance of opening snap?

As follows:

  • It indicates that the valve cusp is still mobile
  • Presence of opening snap indicates valve cusps are pliable, not rigid and calcified.
  • The gap between second heart sound and opening snap indicates the severity of MS. The diminishing gap indicates severe MS
  • It is always due to organic MS.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 167; Short and Long Cases in Clinical Medicine, HN Sarker Page:  273
What are the features of pulmonary hypertension?
Examination
What are the causes of malar flash?

As follows

  • Mitral stenosis
  • Hypothyroidism,
  • Polycythaemia,
  • Pulmonary hypertension
  • It may be present in normal person
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 76; Short and Long Cases in Clinical Medicine, HN Sarker Page: 273
What will you get by examining precordium of this patient?
  1. Inspection
    • Normal. (There may be visible cardiac impulse in mitral area.)
  2. Palpation
    • Tapping apex beat, may have diastolic thrill in the apex. (also see in left lateral position with breath held after expiration).
    • Left parasternal heave and palpable P2 if pulmonary hypertension.
  3. Auscultation
    • First heart sound: Loud in all areas (occasionally only in mitral area and normal in other areas).
    • Second heart sound: Normal in all areas [if pulmonary hypertension (PH), P2 is loud].
    • There is an MDM in mitral area, which is low pitched-localised-rough-rumbling (LLRR), best heard with bell of stethoscope in left lateral position, breathing held after expiration, with presystolic accentuation.
    • Opening snap (tell, if present).

Note:

If the murmur is not audible, ask permission that the patient should perform physical exercise. This will increase the heart rate, increase the flow across the mitral valve and murmur will be prominent. However, exercise should be avoided in very ill patient.

* Pre-exam preparation for medicine, HN Sarker; Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 75

Mitral stenosis- murmur and the diastolic pressure gradient between LA and LV - davidson 617

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 617

 

What are the signs of PH?

As follows:

  • Low-volume pulse
  • Palpable P2
  • Prominent ‘a’ wave in JVP
  • Left parasternal heave (indicates RVH)
  • Epigastric pulsation (indicates RVH)
  • Loud P2 on auscultation
  • Early diastolic murmur (Graham-Steell murmur due to pulmonary regurgitation).
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 75; Short and Long Cases in Clinical Medicine, HN Sarker Page:  273
How to assess the severity of MS clinically (is it severe)?

Normal area of mitral valve is 4 to 6 cm2, if severe it may be <1 cm2 (tight MS).

Signs of severe MS are:

  • Pulse: Low volume
  • Early opening snap: Nearer to the 2nd sound
  • Increasing length of the murmur: Prolonged MDM
  • Signs of pulmonary hypertension and pulmonary congestion
  • Graham-Stell murmur (pulmonary regurgitation)
  • In more severe stage, S1 becomes soft, opening snap disappears and MDM becomes inaudible (the only clinical findings are of pulmonary hypertension)
* Long Cases in Clinical Medicine, ABM Abdullah Page: 167; Short and Long Cases in Clinical Medicine, HN Sarker Page:  274
How to assess the pliable mitral valve?

Short, sharp, accentuated first sound and presence of opening snap.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 168
Investigations
What investigations should be done in mitral stenosis?
  1. ECG
    • Right ventricular hypertrophy: tall R waves in V1–V3
    • P mitrale or atrial fibrillation
  2. Chest X-ray
    • Enlarged LA and appendage
    • Signs of pulmonary venous congestion
  3. Echocardiogram
    • Thickened immobile cusps
    • Reduced valve area
    • Enlarged LA
    • Reduced rate of diastolic filling of LV
  4. Color Doppler
    • Pressure gradient across mitral valve
    • Pulmonary artery pressure
    • Left ventricular function
  5. Cardiac catheterisation
    • Coronary artery disease
    • Pulmonary artery pressure
    • Mitral stenosis and regurgitation
* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 617
What are the radiological features of mitral stenosis?

Chest X-ray shows:

  • Upper lobe veins are dilated (early feature) called upper lobe diversion (normally, ratio between upper and lower lobe veins is 1:3, which is altered to 1:1).
  • Straightening of left border of heart (also called mitralization): It is due to fullness of pulmonary conus (due to dilated pulmonary artery) and filling of pulmonary bay (due to prominent left atrial appendage due to left atrial enlargement).
  • Kerley’s B-lines (horizontal septal lines in costophrenic angle indicates pulmonary hypertension).
  • Double shadow in right border of heart (due to enlarged left atrium).
  • Widening of carina.
  • Left bronchus is horizontal (due to enlarged left atrium).
  • Pulmonary oedema.
  • Miliary mottling or reticulonodular shadow due to pulmonary haemosiderosis.
  • Calcified shadow of mitral valve (it is best seen in fluoroscopy).
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 77; Short and Long Cases in Clinical Medicine, HN Sarker Page:  274; Long Cases in Clinical Medicine, ABM Abdullah Page: 165
What is the barium swallow of esophagus (right anterior oblique view) finding?

Indentation of the esophagus due to enlarged left atrium (it is not done now a days, because echocardiogram is more diagnostic).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 166
What are the echocardiogram findings in mitral stenosis?

As follows:

  • Thick mitral valve leaflet (with restricted opening), diastolic doming of anterior mitral leaflet and restricted movement of posterior mitral leaflet.
  • Reduction of valvular area (narrow): button like or funnel shaped.
  • Calcification of valves (increased echogenecity).
  • Shortening of chordae tendinae.
  • Enlarged left atrium.
  • Characteristic “M” shape movement of anterior leaflet normally seen in diastole is lost and the diastolic slope (EF) is reduced.
  • Thrombus may be seen.
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 77; Short and Long Cases in Clinical Medicine, HN Sarker Page:  274
Diagnosis
What are the main points in favor of your diagnosis?

The points in favor are:

  • Apex beat is tapping in nature
  • Diastolic thrill in mitral area
  • Loud first heart sound
  • Presence of MDM in mitral area with presystolic accentuation
  • Presence of opening snap.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 164
Why do you think MS?
Why do you think pulmonary hypertension?
What are your differential diagnoses?

As follows:

  • Left atrial myxoma
  • Ball valve thrombus in left atrium
  • Tricuspid stenosis
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 76
Why not this is tricuspid stenosis?

In TS, MDM is prominent in left lower parasternal edge, which increases during inspiration. Also, there may be other features such as raised JVP and signs of right heart failure.

* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 76
Why not this is left atrial myxoma?

In left atrial myxoma, physical signs and murmur change with posture. Also, there may be history of fever, weight loss, myalgia, arthralgia, skin rash, Raynaud’s phenomenon (which are absent in this case). To be confirmed, 2D echocardiography should be done.

* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 76
If the patient with MS suddenly becomes unconscious, what is the likely cause?

Cerebrovascular disease [(CVD) cerebral infarction], usually with right sided hemiplegia. Usually CVD occurs when there is associated atrial fibrilla­tion (AF).

* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 77
What may be the cause of CVD in this case?

Cerebral embolism (involving lenticulostriate branch of the left middle cerebral artery, causing infarction of the internal capsule).

* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 77
A 35–year–old female presents with right-sided hemiplegia. On examination you found irregularly irregular pulse, right-sided upper motor neuron lesion and mid-diastolic murmur on heart auscultation. What is your diagnosis?

CVD (right-sided hemiplegia) due to cerebral embolism as a result of atrial fibrillation from mitral stenosis.

Pre-exam preparation for medicine, HN Sarker
How can you classify severity of MS according to mitral valve area?

Severity of MS can be classified according to mitral valve area as follows:

  • Mild: >1.5 cm
  • Moderate: 1–1.5 cm
  • Severe: <1.0 cm
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 274
What is the normal cross-sectional area of mitral valve?

It is 4 to 6 cm2

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 274
Treatment
How can you treat mitral stenosis?
How to treat MS medically?

As follows:

  • Restrictive activity.
  • Anticoagulant to reduce the risk of embolism.
  • If atrial fibrillation:  Digoxin, β blocker, rate limiting calcium antagonsist (e.g. verapamil, diltiazem).
  • If there is CCF:  Diuretics (to control pulmonary congestion), digoxin.
  • Infective endocarditis is very unusual in MS. So, routine prophylaxis with antibiotic is not recommended.
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 77; Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 618
What are the indications of anticoagulant (warfarin) in MS?

As follows:

  • Systemic and pulmonary embolism.
  • Atrial fibrillation.
  • Left atrial thrombus.
  • Left ventricular systolic dysfunction
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 78
What are the indications of surgery in MS?

As follows:

  • Symptomatic moderate or severe MS when balloon valvuloplasty is unavailable
  • Moderate or severe MS with moderate or severe MR
  • Recurrent thromboembolic events despite therapeutic anticoagulant
  • Episodes of pulmonary edema without precipitating cause
  • Associated atrial fibrillation which does not respond to medical therapy
  • Pulmonary hypertension or recurrent hemoptysis
  • Occasionally in pregnancy, with pulmonary edema (surgery may be done in second trimester as blood volume increases significantly with increased pulmonary pressure).
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 78; Short and Long Cases in Clinical Medicine, HN Sarker Page:  275
What surgery is usually done?

As follows:

  1. Valvotomy
    • CMC—closed mitral commissurotomy,
    • OMC—open mitral commissurotomy
  2. Valvuloplasty
    • Percutaneous balloon mitral valvuloplasty (PTMC)— treatment of choice
  3. Valve replacement
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 78
What are the criteria for valvuloplasty?

Criteria for mitral valvuloplasty

  • Significant symptoms
  • Isolated mitral stenosis
  • No (or trivial) mitral regurgitation
  • Mobile, non-calcified valve/subvalve apparatus on echo
  • Left atrium free of thrombus
* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 618
What are the indications of valve replacement?

As follows:

  • Associated MR
  • If the valve and subvalvular apparatus are is calcified and rigid
  • Thrombus in left atrium despite anticoagulation.
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 78; Short and Long Cases in Clinical Medicine, HN Sarker Page: 275
What is the contraindication of surgery in MS?

Active rheumatic carditis.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 275
How to treat MS in pregnancy?

As follows:

  • Bed rest
  • Correction of anemia
  • Correction of nutrition
  • If severe, symptomatic and tight MS— Mitral valvotomy may be done (usually in middletrimester)
  • All patients should go into full term and Cesarean section should be done
  • Advice the patient to restrict number of pregnancy (1 to 2).

Note:

Symptoms of MS are usually more marked in second trimester, which is due to increase in blood volume that increase pulmonary pressure. The symptoms improve in third trimester due to decrease in blood volume.

* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 78

 

Complications
What are the complications of MS?

As follows:

  • Atrial fibrillation.
  • Pulmonary edema (left atrial failure).
  • Pulmonary hypertension leading to CCF.
  • Left atrial thrombus with systemic embolism—commonly cerebral (cerebral infarction withhemiplegia), also in mesenteric, renal and peripheral.
  • Ball valve thrombus (which is a big thrombus) may lead to sudden death.
  • Hemoptysis.
  • Pulmonary congestion, embolism, infarction.
  • Left atrial enlargement
  • Ortner’s syndrome (enlarged left atrium gives pressure on left recurrent laryngeal nerve, causing hoarseness of voice. It is rare).
  • Dysphagia due to enlarged left atrium.
  • Chest pain in 10% cases (due to pulmonary hypertension).
  • Long standing MS may cause interstitial lung disease (due to prolonged pulmonary edema) and
  • Infective endocarditis:  very rare (common in mitral regurgitation).
Long Cases in Clinical Medicine, ABM Abdullah Page: 168; Short and Long Cases in Clinical Medicine, HN Sarker Page: 274
What are the complications of surgery?

As follows:

  • Mitral regurgitation
  • Thromboembolism
  • Restenosis.
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 78
Notes
What is myxoma of the heart? What are the features? How to investigate and treat?

It is the common primary tumor of heart, usually benign, may be pedunculated, polypoid, gelatinous, attached by a pedicle to the atrial septum. It may be sporadic and familial. It occurs in any age (third to sixth decade), and any sex (more in female).

Sites of origin:

  • Left atrium (75%), near the fossa ovalis or its margin
  • Right atrium, rarely from ventricles.

Clinical features:  There are 3 groups of manifestations:

  1. Obstructive features: Such as MS, signs vary with posture. Occasionally, there is a low-pitched sound called tumor plop. There may be syncope or vertigo.
  2. Embolic features: Either systemic or pulmonary embolism.
  3. Constitutional features: Such as fever, malaise, weakness, loss of weight, myalgia, arthralgia, clubbing, skin rash, Raynaud’s phenomenon.

Investigations:

  • CBC: May be anemia, leukocytosis, polycythemia, high ESR, thrombocytopenia or thrombocytosis
  • Hypergammaglobulinemia
  • Chest x -ray (may be similar to MS)
  • Echocardiogram: 2D or transesophageal
  • CT scan or MRI may be done.

Treatment:  Surgical excision. Recurrence may occur.

 

Note

Other tumors of the heart are rhabdomyoma and sarcoma. All are rare.

* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 78

Special situations

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