A 28-year-old woman with a history of rheumatic fever presents with mitral stenosis. Regarding the diagnostic and management aspects of mitral stenosis, all of the following statements are correct EXCEPT:

Explanation

## Diagnosis and Management of Mitral Stenosis **Key Point:** Diuretics and beta-blockers are **palliative** agents that manage symptoms but do **NOT reverse** mitral stenosis. The stenosis is a structural valve lesion that cannot be reversed by medical therapy alone. ### Medical vs. Structural Therapy | Aspect | Details | |--------|----------| | **Diuretics** | Reduce pulmonary congestion and edema; relieve dyspnea and orthopnea | | **Beta-blockers** | Slow AV conduction and increase diastolic filling time; reduce heart rate and improve LV filling | | **Anticoagulation** | Indicated if AF is present (high thromboembolic risk) | | **What they do NOT do** | Cannot enlarge the valve orifice or reverse fibrosis/calcification | **High-Yield:** Medical therapy is **temporizing**. Definitive treatment requires **mechanical intervention**: balloon mitral valvotomy (BMV) or surgical mitral valve replacement. ### Diagnostic Features (Options 1 & 2 Are Correct) **Auscultation:** - **Diastolic murmur** at the apex, best heard in **left lateral decubitus position** (brings apex closer to chest wall) - **Opening snap** (A2–OS interval shortened in severe disease) - **Loud S1** (due to high LA pressure at end-diastole) **Echocardiography (Gold Standard):** - Valve area measurement by planimetry or Doppler - **Severe MS:** valve area **<1.5 cm²** (or <1.0 cm² in some guidelines) - **Moderate MS:** 1.5–2.5 cm² - **Mild MS:** >2.5 cm² ### Contraindications to Balloon Mitral Valvotomy (Option 3 Is Correct) **Absolute contraindications:** - **Left atrial thrombus** (risk of embolization) - Moderate-to-severe mitral regurgitation - Severe aortic stenosis - Severe calcification of the mitral valve **Mnemonic:** **CLAC** — **C**alcification, **L**eft atrial thrombus, **A**ortic stenosis, **C**ompromised MR. **Clinical Pearl:** Before BMV, all patients should undergo **transesophageal echocardiography (TEE)** to exclude LA thrombus, as the procedure carries a 1–2% risk of systemic embolism if thrombus is present. [cite:Harrison 21e Ch 297] --- ## Why Each Distractor Is Correct - **Option 0 (Auscultation position):** True. The left lateral decubitus position optimally positions the apex against the chest wall, making the diastolic murmur louder and easier to detect. - **Option 1 (Echocardiography criteria):** True. Echocardiography is the diagnostic gold standard; valve area <1.5 cm² defines severe mitral stenosis. - **Option 2 (BMV contraindication):** True. LA thrombus is an absolute contraindication to BMV due to high risk of thromboembolic stroke.