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The role of the physical examination in the evaluation of patients with valvular heart disease is also considered in Chaps. e13 and 227; of electrocardiography (ECG) in Chap. 228; of echocardiography and other noninvasive imaging techniques in Chap. 229; and of cardiac catheterization and angiography in Chap. 230.

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Etiology and Pathology

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Rheumatic fever is the leading cause of mitral stenosis (MS) (Table 237-1). Other less common etiologies of obstruction to left atrial outflow include congenital mitral valve stenosis, cor triatriatum, mitral annular calcification with extension onto the leaflets, systemic lupus erythematosus, rheumatoid arthritis, left atrial myxoma, and infective endocarditis with large vegetations. Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease and a history of rheumatic fever (Chap. 322). In other patients with rheumatic heart disease, lesser degrees of MS may accompany mitral regurgitation (MR) and aortic valve disease. With reductions in the incidence of acute rheumatic fever, particularly in temperate climates and developed countries, the incidence of MS has declined considerably over the past few decades. However, it remains a major problem in developing nations, especially in tropical and semitropical climates (see p. 1949).

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Table 237-1 Major Causes of Valvular Heart Diseases
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In rheumatic MS, the valve leaflets are diffusely thickened by fibrous tissue and/or calcific deposits. The mitral commissures fuse, the chordae tendineae fuse and shorten, the valvular cusps become rigid, and these changes, in turn, lead to narrowing at the apex of the funnel-shaped (“fish-mouth”) valve. Although the initial insult to the mitral valve is rheumatic, the later changes may be ...

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