copy of mitral-stenosis

7/29/2019 Copy of Mitral-Stenosis

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Dr. Abdul Ghani Waseem


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The mitral valve (also known as the bicuspidvalve or left atrioventricular valve) that liesbetween the left atrium (LA) and the leftventricle (LV).


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http://localhost/var/www/apps/conversion/tmp/scratch_10//upload.wikimedia.org/wikipedia/commons/e/e5/Diagram_of_the_human_heart_(cropped).svg


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The mitral valve is typically 46 cm in area.

It has two cusps, or leaflets, (the

anteromedial leafletand the posterolateralleaflet) that guard the opening.

The opening is surrounded by a fibrous ring

known as the mitral valve annulus.
http://en.wikipedia.org/wiki/Mitral_annulushttp://en.wikipedia.org/wiki/Mitral_annulus


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The anterior cusp protects approximately

two-thirds of the valve.

These valve leaflets are prevented fromprolapsing into the left atrium by the action

of tendons attached to the posterior surfaceof the valve, chordae tendineae.
http://en.wikipedia.org/wiki/Mitral_valve_prolapsehttp://en.wikipedia.org/wiki/Chordae_tendineaehttp://en.wikipedia.org/wiki/Chordae_tendineaehttp://en.wikipedia.org/wiki/Mitral_valve_prolapse


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The inelastic chordae tendineae are attached at one end tothe papillary muscles and the other to the valve cusps.

Papillary muscles are fingerlike projections from the wallof the left ventricle.

Chordae tendineae from each muscle are attached to bothleaflets of the mitral valve. Thus, when the left ventriclecontracts, the intraventricular pressure forces the valve toclose, while the tendons keep the leaflets coating together

and prevent the valve from opening in the wrong direction(thus preventing blood to flow back to the left atrium).
http://en.wikipedia.org/wiki/Papillary_musclehttp://en.wikipedia.org/wiki/Papillary_musclehttp://en.wikipedia.org/wiki/Papillary_muscle


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During left ventriculardiastole, after the pressuredrops in the left ventricle due to relaxation of theventricular myocardium, the mitral valve opens,

and blood travels from the left atrium to the leftventricle.

70-80% of the blood that travels across the

mitral valve occurs during the early filling phaseof the left ventricle.

This early filling phase is due to active relaxationof the ventricular myocardium, causing a

pressure gradient that allows a rapid flow ofblood from the left atrium, across the mitralvalve.
http://en.wikipedia.org/wiki/Left_ventriclehttp://en.wikipedia.org/wiki/Diastolehttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Diastolehttp://en.wikipedia.org/wiki/Left_ventricle


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Left atrial contraction (left atrial systole)(during left ventricular diastole) causes addedblood to flow across the mitral valveimmediately before left ventricular systole..

The late filling of the LV contributes about

20% to the volume in the left ventricle.
http://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Systole_(medicine)


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The closing of the mitral valve and thetricuspid valve constitutes the first heartsound (S1).

Flow of blood into the heart during rapid

filling is not normally heard except in certainpathological states where it constitutes thethird heart sound (S3).


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Mitral Stenosis


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Mitral Stenosis

Mitral valve is present between LA & LV.

Normal mitral valve orifice area (MVA): 4-6cm2..

MVA


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Mitral Stenosis

Decrease in Mitral valve orifice area leading to chronic & fixed

mechanical obstruction to LV filling is termed as MS.


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Causes

Rheumatic Heart disease

SLE

Carcinoid syndrome

Active Infective Endocarditis Left atrial myxoma

Congenital mitral stenosis

Massive Annular Calcification


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Rheumatic mitral stenosis

More common in females (2/3rd of all pts)

Symptoms occur two decades after onset of Rheumatic fever

Age of presentation

Earlier in 20s-30s Now in 40s-50s (slower progression)

Isolated MS in 40% cases of RHD

Remaining 60% cases associated with other valvular diseases-

MR/AR


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Patho-physiology

Immunological disorder initiated by Group A beta hemolyticstreptococcus.

Antibodies produced against streptococcal cell wall proteins & sugarsreact with connective tissues & heart; result in rheumatic fever and

symptoms like Carditis

Arthritis

Subcutaneous nodules

Chorea Erythema marginatum


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Chronic cardiac & valvular inflammation leads to cardiac & valvularpathology

Valvular pathologyRheumatic fever involving mitral valves

Valve leaflet thickening and fusion of commissures

Increased rigidity of valve leaflets

Thickening, fusion and contracture of chordae & papillary heads

Leaflet calcification (long standing MS)

Progressive reduction in mitral valve orifice area

Mitral Stenosis


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Mechanical obstruction to left ventricular diastolic filling

Adaptative in LAP to maintain LV filling

-------------------------------------------------------------------------

LA enlargement in pulmonary venous pressure in pulmonary arterial pressure*

Atrial fibrillation Transudation of fluid into pulmonary interstitial spaceThrombus formation

Systemic thrombo-embolism ed pulmonary complianceWork of breathing

Progressive dyspnoea on exertion/rest

pulmonary edema

in pulmonary arterial pressure*-------- Pulmonary arterial hypertrophy (Pulmonary HTN)

RV hypertrophy and dilatation

RV failure


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Effect of Atrial fibrillation in MS Increased chances of thrombus formation and systemic thrombo-

embolism.

Normally effective atrial contraction is important in LV diastolic filling.

In presence of AF

Loss of effective atrial contraction

Impaired LV filling (ed LV preload)

decreased cardiac output


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Clinical presentation

Dyspnea, Orthopnea, PND

Fatigue,

Cough.

Hemoptysis.

Systemic thromboembolism (first symptom in 20% cases).


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Physical examination

Low volume pulse.

Sign & Symptoms of right sided heart failure - engorged neck

veins, enlarged tender liver


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Physical examination

Mitral facies

Pink purple patches on the cheeks,

Cyanotic skin changes from low cardiac output

Cardiac auscultation

Opening snap

Rumbling diastolic murmur best heard at apex radiating to the

axilla

Loud S2: pulmonary hypertension


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ECG

Broad notched Pwave (left atrial

enlargement)

Atrial fibrillation


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Chest X-ray

Normal to ed cardiac

shadow

Straightening of the left

heart of border and

elevation of left main

bronchus (left atrialenlargement)

mitral calcification

Evidence of pulmonary

edema/ HTN

LAA: Left atrial appendages, MPA: Main pulmonary artery, LPA: left

pulmonary artery, RPA: Right pulmonary artery, Ao- Aorticknuckle (Ao)


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MS - chest x-ray


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Echocardiography

Anatomy/size of mitral valve & its appendages

severity of MS (area of orifice)

Size & function of ventricles

Estimation of pulmonary artery pressure

Cardiac catheterization and invasive measurement Are almost never necessary

Reserved for situations ECHO sub-optimal/conflict with clinical

presentation

S it f MS


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Severity of MS

Presence of

pulmonary hypertension.

Length of MDM is proportional to

severity


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TREATMENT


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Therapeutic goals in patients

with mitral stenosis

Reduce symptoms of pulmonary congestion

(dyspnea on exertion, PND, pulmonary edema):

diuretics

Prevent arterial embolism (cerebral or

peripheral arterial embolism): anticoagulation

Prevent infectious endocarditis: prophylactic

antibiotics


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Treat bacterial endocarditis: antibiotics

Prevent/treat atrial fibrillation: digoxin, blockers, antiarrhythmic agents,

anticoagulants


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Mitral stenosis

Indications for anticoagulation

AF (chronic / paroxysmal)

Prior embolism

Severe MS

Large LA:

> 50 mm


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Mitral stenosis

Indications for mechanical reliefSymptomatic + MVA < 1 cm2.

Mitral stenosis


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Mitral stenosis

Options for mechanical relief Percutaneous balloon mitral valvuloplasty

(PBMV)

Closed mitral commisurotomy

Open mitral commisurotomy

Mitral valve replacement

Mechanical

Biological


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Trasseptal ballon valvatomy

balloon


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TSBV


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Open mitral commissurotomy


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Mitral Regurgitation


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Retrograde flow of blood from LV to LA through

incompetent mitral valve during systolic phase


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Causes

MR is almost always (90%) associated with MS in RHD

Infective endocarditis

Ischemic heart disease (Ischemic MR)

Myocarditis

Idiopathic dilated cardiomyopathy


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Pathophysiology of MR

Mitral regurgitation

Systolic (Retrograde) ejection into LA

Acute Chronic

Volume overload in LA & LV ed LV afterload (into LA)

ed LA, LV Pressure ed LA/LV size/ compliance

Pulmonary edema ed Cardiac output LA dilatation ed contractility

AF CO

Pulmonary congestion


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MR MS

Cli i l t ti


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Clinical presentation

Fatigue.

Dyspnoea.

orthopnoea.

Systemic thrombo-embolis

ys ca exam nat on


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ys ca exam nat on

Signs of RVF like JVP

Systolic thrill at apex (hyperdynamic circulation)

ys ca exam nat on


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ys ca exam nat on

Cardiac auscultation

Pansystolic murmur

S1 is absent, soft or buried in the systolic murmur


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ECG

Non-specific findings Atrial fibrillation

LA enlargement/LV hypertrophy

Chest X-ray

Left heart chamber enlargement

Pulmonary congestion


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Echocardiography

Diagnosis/mechanism/severity of MR/MS

Impact on cardiac chamber size, pressure & function Pulmonary artery pressure

Presence of thrombus

Cardiac catheterization with left ventriculography

invasive Reserved for pts in whom ECHO is sub-optimal


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Management

Th ti l i ti t


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with mitral regurgitation

Reduce symptoms of pulmonary congestion

(dyspnea on exertion, PND, pulmonary edema):

diuretics

Prevent arterial embolism (cerebral or

peripheral arterial embolism): anticoagulation

Prevent infectious endocarditis: prophylactic

antibiotics

Th ti l i ti t


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Treat bacterial endocarditis: antibiotics

Prevent/treat atrial fibrillation: digoxin, blockers, antiarrhythmic agents,

anticoagulants

Mitral reg rgitation


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Mitral regurgitation

Indications for mechanical reliefProgressive cardiac enlargement.


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