MBBS OSCE · Cardiology / General Medicine

OSCE — assessment of severe symptomatic mitral stenosis

An 8-minute OSCE station assessing the candidate's structured bedside assessment of a patient with severe mitral stenosis — recognising the auscultatory triad and mitral facies, grading severity from echocardiography, stating the Class I indication for percutaneous balloon mitral valvotomy versus mitral valve replacement by valve anatomy, and the anticoagulation strategy. Marks for the bedside signs, the severity thresholds, and the anatomy-based management plan.

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NEET-PGINICET

Brief (to candidate)

A 30-year-old woman is referred with four months of exertional dyspnoea and palpitations. She is in atrial fibrillation at 108/min, BP 102/68, and has a pinkish-purple malar flush, a tapping undisplaced apex, a loud S1, an opening snap, and a low-pitched mid-diastolic rumble with presystolic accentuation at the apex. An echocardiogram shows a mitral valve area of 1.0 cm², mean gradient 13 mmHg, pressure half-time 260 ms, pliable non-calcified leaflets, Wilkins score 6, no left atrial thrombus, no mitral regurgitation, pulmonary artery systolic pressure 52 mmHg. You have 8 minutes to assess her, confirm the bedside findings, grade the severity, state the indication for and choice of intervention, and outline the anticoagulation and medical management.

Candidate instructions

  1. Take a focused history (dyspnoea, orthopnoea, palpitations, embolic symptoms) and examine the cardiovascular system, demonstrating the apex character, auscultatory triad, and signs of pulmonary hypertension.
  2. Grade the severity of MS from the echocardiographic parameters (valve area, gradient, pressure half-time).
  3. State the indication for intervention and which intervention (PMC vs MVR), justifying it by valve anatomy (Wilkins score, calcification, LA thrombus, MR grade).
  4. Outline the anticoagulation strategy and the medical management (rate control, secondary prophylaxis).

Examiner checklist (mark each domain / 10)

DomainKey actions expected
History / symptomsElicits exertional dyspnoea, orthopnoea/PND, palpitations (AF), haemoptysis, systemic embolism; recognises that symptoms make intervention indicated
Bedside signsMalar flush (mitral facies); irregularly irregular pulse (AF); tapping undisplaced apex; loud S1, opening snap, mid-diastolic rumble with presystolic accentuation at the apex (bell, left lateral position); a loud P2 / RV heave if pulmonary hypertension is present[4]
Severity gradingStates very severe MS: valve area ≤ 1.5 cm² is severe and ≤ 1.0 cm² very severe; pressure half-time ≥ 150 ms supports severe MS (MVA = 220 ÷ PHT, so 260 ms corresponds to an area under 1.0 cm²); mean gradient ≥ 10 mmHg fits very severe disease; PASP > 50 mmHg at rest is an intervention threshold[1][2]
Intervention choiceFavourable anatomy → PMC (pliable, non-calcified, Wilkins ≤ 8, no LA thrombus, less than moderate 2+ MR) is the treatment of choice — Class 1, level A in ACC/AHA 2020 and Class I in ESC 2021 for symptomatic (NYHA II–IV) severe MS; unfavourable → MVR; states that a TOE must exclude LA thrombus first[1][2][3]
AnticoagulationMS + AF = valvular AF → warfarin INR 2.0–3.0; DOACs NOT recommended; same for prior embolism or LA thrombus[11]
Medical therapyRate control (beta-blocker) to lengthen diastole; cautious loop diuretic for congestion; secondary rheumatic prophylaxis (benzathine penicillin G)[1]
Safety-net & pitfallsRecognises that AF/tachycardia precipitates pulmonary oedema (rate control is the immediate priority); avoids PMC in calcified/thrombus-bearing valves; avoids DOACs in valvular AF

Model key actions

  • Assess: confirm the malar flush, tapping apex, loud S1, opening snap and mid-diastolic rumble (bell, left lateral position); elicit a loud P2/RV heave for pulmonary hypertension.[4]
  • Grade: very severe MS (MVA 1.0 cm², mean gradient 13 mmHg, PHT 260 ms, PASP 52 mmHg). Symptomatic with PASP > 50 mmHg → intervention indicated.[1][2]
  • Plan: favourable anatomy (pliable, Wilkins 6, no LA thrombus, no MR) → percutaneous balloon mitral valvotomy (PMC), the Class 1 treatment of choice; TOE to exclude LA thrombus first.[1][2][3]
  • Protect: anticoagulate with warfarin INR 2.0–3.0 (valvular AF — not a DOAC); beta-blocker for rate control; secondary rheumatic prophylaxis.[11][1]

Common errors

  • Grading severity by the murmur rather than the valve area — severity is anatomical; a very tight valve may have a quiet murmur.
  • Offering PMC to an unfavourable valve — calcification, LA thrombus or ≥ moderate MR mandate MVR.
  • Using a DOAC for valvular AF — moderate-severe MS with AF requires warfarin (INR 2.0–3.0).
  • Missing the immediate priority in decompensation — rate control (restoring diastole) comes before anything else in AF-triggered pulmonary oedema.
  • Omitting transoesophageal echo before PMC — LA/LAA thrombus must be excluded to avoid systemic embolism.
References5Show
  1. [1]Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal, 2022.PMID 34453165
  2. [2]Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. Circulation, 2021.PMID 33332150
  3. [3]Wilkins GT, Weyman AE, Abascal VM, et al. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. British Heart Journal, 1988.PMID 3190958
  4. [4]Chandrashekhar Y, Westaby S, Narula J. Mitral stenosis. Lancet, 2009.PMID 19747723
  5. [11]Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation. European Heart Journal, 2021.PMID 32860505
OSCE — assessment of severe symptomatic mitral stenosis · MBBS OSCE · NeetVellum