d o
t o r e g . c o m
Dr. Mete ALPASLAN
Mitral Stenosis and ECG
Mitral stenosis has no diagnostic ECG findings.
Mild mitral stenosis patients may have normal ECGs.
However moderate to severe mitral stenosis patients usually have nonspecific ECG abnormalities.
These ECG abnormalities result from the abnormal hemodynamics that develop during the progression of mitral stenosis.
Even if the 12-second resting ECG is normal in patients with mitral stenosis, 24-hour ambulatory ECG monitoring frequently demonstrates attacks of various types of arrhythmias.
Especially in elderly patients, coexistent valvular/coronary artery disease or systemic arterial hypertension may result in additional ECG abnormalities.
ECG abnormalities that may be seen in mitral stenosis:
Left atrial abnormality
ECG signs of right ventricular hypertrophy
Right bundle branch block due to right ventricular dilation
Biatrial abnormality
Interatrial block
Atrial fibrillation
Left atrial standstill (by intracardiac ECG recording)
Non-sustained arrhythmias which may be detected by ambulatory ECG (Holter) monitoring
in mitral stenosis patients with sinus rhythm on resting ECG:
Atrial fibrillation
Atrial flutter
Multifocal atrial tachycardia
Ectopic atrial rhythm
Ectopic atrial tachycardia
ECG abnormalities that may develop during percutaneous mitral valvuloplasty:
Atrioventricular blocks.
ECG signs of acute myocardial ischemia may develope due to coronary embolism of valvular debris.
ECG change which may be observed after successful percutaneous mitral valvuloplasty:
ECG signs of left atrial abnormality may regress.
References
J Heart Valve Dis 2011;20:619-623.
Eur Heart J 1987;8:164-170.
Cathet Cardiovasc Diagn 1990;21:7-9.
Clin Cardiol 1988;11:793-796.
Rev Esp Cardiol 1990;43:56-58.
Arq Bras Cardiol 2006;87:359-363.
Europace 2012;14:954-961.
Eur Heart J 2008;29:2234-2243.
Heart 2003;89:1173.
ECG 1. The compact ECG above is from a 68 years-old woman with mild mitral stenosis.
Her mitral valve area is 2.0 cm2.
Isolated mild mitral stenosis may not result in ECG abnormalities, as seen above.
The above compact ECG is normal.
ECG 2. The ECG above belongs to a 66 years-old man with mitral stenosis.
His mitral valve area was measured as 1.8 cm2 by ECHOcardiography.
Interatrial block is seen.
Click here for a more detailed ECG
ECG 3. The ECG above belongs to a 26 years-old man with mitral stenosis.
His mitral valve area is measured as 1.1 cm2 by ECHOcardiography (severe mitral stenosis).
At such a young age, the coexistence of coronary artery disease or systemic arterial hypertension is very rare.
This young man had isolated severe mitral stenosis, but not mitral regurgitation.
His ECG shows signs of biatrial dilation and right ventricular hypertrophy.
Click here for a more detailed ECG
ECG 4. The ECG above belongs to a 50 years-old man with mitral stenosis and acute coronary syndrome.
It was recorded 10 minutes before stenting of a totally occluded right coronary artery.
His mitral valve area was measured as 1.3 cm2 by ECHOcardiography.
Type 3 (complete) interatrial block, left atrial abnormality and notching of the P wave in anterior leads are seen.
ECG 5. The ECG above belongs to a 60 years-old woman with mitral stenosis.
ECHOcardiography showed only biatrial abnormality, the right ventricle was not dilated.
Her mitral valve area was measured as 1.3 cm2 by ECHOcardiography.
Click here for a more detailed ECG
ECG 6. The ECG above belongs to a 55 years-old woman with mitral stenosis. The rhythm is atrial fibrillation.
Her mitral valve area was measured as 1.5 cm2 by ECHOcardiography.
Not only the atria, but the right ventricle was also significantly dilated.
Right bundle branch block in the presence of right ventricular dilation is not rare.
Click here for a more detailed ECG
ECG 7. Coexistent diseases modify the ECG signs of mitral stenosis.
The ECG above is from a 74 years-old man with mitral stenosis and coronary artery to pulmonary artery fistula.
ECHOcardiography measured mitral valve area as 1.2 cm2.
His left ventricle was dilated and systolic function was depressed.
The R wave amplitude in lead V4 is 64 mms.
ECG 8a. The above ECG is from a 52 years-old man. He was diagnosed as having severe mitral stenosis just 2 weeks ago.
(with a mitral valve area of 0.7 cm2). The wide and fragmented P waves denote interatrial block.
The duration of the P wave is more than 4 small squares (>160msec).
The initial portion of the P wave and the second part of it are easily discernible.
ECG 8b. The above ECG belongs to the same man. It was recorded 1 week after ECG 8a when he complained of palpitations.
Interatrial block is associated with the development of atrial fibrillation.
Click here for a more detailed ECG
ECG 9. The ECG above belongs to a 39 years-old man with mitral valve stenosis.
Type 1 interatrial block (widened P wave) is best seen in lead II. PR interval is prolonged.
ECHOcardiography showed severe mitral valve stenosis, left atrial dilation and moderate pulmonary hypertension.
Click here for a more detailed ECG
Mitral stenosis has no diagnostic ECG findings.
Mild mitral stenosis patients may have normal ECGs.
However moderate to severe mitral stenosis patients usually have nonspecific ECG abnormalities.
These ECG abnormalities result from the abnormal hemodynamics that develop during the progression of mitral stenosis.
Even if the 12-second resting ECG is normal in patients with mitral stenosis, 24-hour ambulatory ECG monitoring frequently demonstrates attacks of various types of arrhythmias.
Especially in elderly patients, coexistent valvular/coronary artery disease or systemic arterial hypertension may result in additional ECG abnormalities.
ECG abnormalities that may be seen in mitral stenosis:
Left atrial abnormality
ECG signs of right ventricular hypertrophy
Right bundle branch block due to right ventricular dilation
Biatrial abnormality
Interatrial block
Atrial fibrillation
Left atrial standstill (by intracardiac ECG recording)
Non-sustained arrhythmias which may be detected by ambulatory ECG (Holter) monitoring
in mitral stenosis patients with sinus rhythm on resting ECG:
Atrial fibrillation
Atrial flutter
Multifocal atrial tachycardia
Ectopic atrial rhythm
Ectopic atrial tachycardia
ECG abnormalities that may develop during percutaneous mitral valvuloplasty:
Atrioventricular blocks.
ECG signs of acute myocardial ischemia may develope due to coronary embolism of valvular debris.
ECG change which may be observed after successful percutaneous mitral valvuloplasty:
ECG signs of left atrial abnormality may regress.
References
J Heart Valve Dis 2011;20:619-623.
Eur Heart J 1987;8:164-170.
Cathet Cardiovasc Diagn 1990;21:7-9.
Clin Cardiol 1988;11:793-796.
Rev Esp Cardiol 1990;43:56-58.
Arq Bras Cardiol 2006;87:359-363.
Europace 2012;14:954-961.
Eur Heart J 2008;29:2234-2243.
Heart 2003;89:1173.
ECG 1. The compact ECG above is from a 68 years-old woman with mild mitral stenosis.
Her mitral valve area is 2.0 cm2.
Isolated mild mitral stenosis may not result in ECG abnormalities, as seen above.
The above compact ECG is normal.
ECG 2. The ECG above belongs to a 66 years-old man with mitral stenosis.
His mitral valve area was measured as 1.8 cm2 by ECHOcardiography.
Interatrial block is seen.
Click here for a more detailed ECG
ECG 3. The ECG above belongs to a 26 years-old man with mitral stenosis.
His mitral valve area is measured as 1.1 cm2 by ECHOcardiography (severe mitral stenosis).
At such a young age, the coexistence of coronary artery disease or systemic arterial hypertension is very rare.
This young man had isolated severe mitral stenosis, but not mitral regurgitation.
His ECG shows signs of biatrial dilation and right ventricular hypertrophy.
Click here for a more detailed ECG
ECG 4. The ECG above belongs to a 50 years-old man with mitral stenosis and acute coronary syndrome.
It was recorded 10 minutes before stenting of a totally occluded right coronary artery.
His mitral valve area was measured as 1.3 cm2 by ECHOcardiography.
Type 3 (complete) interatrial block, left atrial abnormality and notching of the P wave in anterior leads are seen.
ECG 5. The ECG above belongs to a 60 years-old woman with mitral stenosis.
ECHOcardiography showed only biatrial abnormality, the right ventricle was not dilated.
Her mitral valve area was measured as 1.3 cm2 by ECHOcardiography.
Click here for a more detailed ECG
ECG 6. The ECG above belongs to a 55 years-old woman with mitral stenosis. The rhythm is atrial fibrillation.
Her mitral valve area was measured as 1.5 cm2 by ECHOcardiography.
Not only the atria, but the right ventricle was also significantly dilated.
Right bundle branch block in the presence of right ventricular dilation is not rare.
Click here for a more detailed ECG
ECG 7. Coexistent diseases modify the ECG signs of mitral stenosis.
The ECG above is from a 74 years-old man with mitral stenosis and coronary artery to pulmonary artery fistula.
ECHOcardiography measured mitral valve area as 1.2 cm2.
His left ventricle was dilated and systolic function was depressed.
The R wave amplitude in lead V4 is 64 mms.
ECG 8a. The above ECG is from a 52 years-old man. He was diagnosed as having severe mitral stenosis just 2 weeks ago.
(with a mitral valve area of 0.7 cm2). The wide and fragmented P waves denote interatrial block.
The duration of the P wave is more than 4 small squares (>160msec).
The initial portion of the P wave and the second part of it are easily discernible.
ECG 8b. The above ECG belongs to the same man. It was recorded 1 week after ECG 8a when he complained of palpitations.
Interatrial block is associated with the development of atrial fibrillation.
Click here for a more detailed ECG
ECG 9. The ECG above belongs to a 39 years-old man with mitral valve stenosis.
Type 1 interatrial block (widened P wave) is best seen in lead II. PR interval is prolonged.
ECHOcardiography showed severe mitral valve stenosis, left atrial dilation and moderate pulmonary hypertension.
Click here for a more detailed ECG