mitral stenosis nicvd lecture

7/27/2019 mitral stenosis nicvd lecture

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MITRAL STENOSIS

MUSTAFIZUL AZIZ

Assistant professor

NICVD


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INTRODUCTION

Mitral stenosis, an obstruction

to blood flow between LA and LV is

caused by abnormal mitral valvefunction.

60% patients with MS donot give H/Orheumatic fever.

50& of patients with acute carditisdo not eventually have valvular heartdiseases.


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SEQUELE OF

RHEUMATIC FEVER

75% of ARF subsides within 6weeks.

90% within 2 months

Less 5% persist more than 6months


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FREQUENCIES OF

VALVULAR INVOLVEMENTMV 50%

MV &AV 40%

MV AV

&TV

5%

AV alone 3%

ALL

OTHER

COMBINATION

2%


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CAUSE

Rheumatic carditis (in virtually

all patients)

Congenital MS(rare-Lutembachers syndrome

Massive mitral valve annular

calcification.


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OTHER CAUSES OF

OBSTRUCTION TO LA OUT

FLOW

LA myxoma Massive LA ball valve thrombus.

Cortriatrium.


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PATHOLOGY


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Mitral Stenosis Shortened diastole(Tachycardia)

Loss of AV Synchrony

(AFib, heart block)

Pulmonary Venous Flow

(Volume loading)

Mitral Valve Gradient

LVEDP

Left Atrial Pressure

Left AtrialEnlargement

Pulmonary VenousPressure

Atrial

ArrhythmiasPulmonary

Edema

Pulmonary Arterial

Hypertension

RVH and RV Hypertension

TR and RVE

Symptoms


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CLINICAL FEATURE


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Symptoms


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SIGN

Mitral facies.

Orthopnic.

Pulse-normal/ lowvolume/tachycardia/AF.

BP-Normal

JVP-Normal/raised-prominent a wavein sinus rhythm/prominent v wave

inTR /absent a wave in AF


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Precordium

Tapping Apex beat

Diastolic thrill at the apex

A parasternal lift. Palpable P2.

S1loud S2 may be loud.

MDM, opening snap,presystolic

accentuation.

Pansystolic murmur graham Steelmurmur


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SEVERITY OF MS

CLINICAL

Full length diastolic murmur.

Short A2-os interval.

A2os may be longer in severe

MS if there is associated

moderate to severe AR

Pulmonary hypertension.


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SEVERITY OF MS

ECHOCARDIOGRAM

MVA plenimitry(normal 4-6 cm2)

Mild -1.5-2.5cm2

moderate 1.00-1.5cm2

severe


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On M-mode by EF slope(normal

70-150mm/s.

MILD-25-35mm/s

Moderate-15-25mm/s

Severe-15mm/s


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Pressure half time(doppler

study)

Mild -60-100ms

Moderate-100-200ms

Severe-200ms


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Transmitral pressure gradient

(Doppler study)

Normal up to 10 mmHg

Mild -10- 15mmHg

Moderate-15-20mmHg

Severe->20mmHg


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Pulmonary arterial pressure

(Doppler study)

Normal-70mmHg


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WILKINS SCORE

GRADE

MobilitySubvalvular

thickening

Thickening Calcification

1 Highlymobile

valve,only

leaflet tip

restricted

Minimal

thickening

just below MV

leaflet

leaflet

near

normal(4-

5mm)

A single area

of increased

brightness

2 Leaflet mid&base portions

have normal

mobility

Chordal

structure up

to 1/3rd of

length

5-

8mm(margi

n)

Scattered area

of brightness

confined to

margin

3 Move forwardmainly from

base

Up to distal1/3rd Entireleaflet(5-

8mm)

Brightnessextending into

mid portion

leaflet

4 No/minimal

forward

movement

Extensive

thickening&

shortening-all cordae

>8-10mm Brightness

throughout

leaflet


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SOME QUESTIONS

Why S1 is loud

Short note on OS

Why OS

Causes of MDM

Presystolic accentuation.

Chest pain in MS

Indication of CAG in MS


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INVESTIGATION


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NATURAL HISTORY

10 survival of patient with MS

without symptom is 84%

MS with mild symptom 10 yearsurvival is 34%to42%

MS with moderate to severe

symptom 20 year survival is


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TREATMENT


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MEDICAL TREATMENT

Antibiotic prophylaxis(rheumatic &IE)

Restrict activities.

ArrhythmiaPrevent or control

Atrial fibrillation-control ventricular rate,anticoagulation, restore sinus rhythm

Treatment of heart failure

Treatment of other complication (LAthrombus,systemic emboli).


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Treatment of LA thrombus

OMC &removal of thrombus

Otherwise anticoacoagulation

by I/V heparin with aim of

endotheliolized


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WARFARIN USED INAF

Systemic emboli

LA thrombus

Pulmonary emboli

LV systolic dysfunction.


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INTERVENTIONAL-PTMC/CBC


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Sellers Grading of MS

Sellers grade I:

Cmmisural fusion, leaflet

thickening

No sub-valvular involvement,

No calcification.

Echo display diastolic

dooming.


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Sellars Grade-II Commisural fusion, leaflet

thickening

Mild to moderate sub-valvularinvolvement, minimalcalcification.

Echo- Funneling of mitral orifice

Treatment: OMC


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Sellers grade III:

Commisural fusion, leaflet

thickening

Significant sub-valvular

involvement, Significant

calcification.

EchoDisorganized valve.

CBC PROCEDURE OF


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CBC PROCEDURE OF

CHOICE-WHY

Hospital mortality in the last 10year is close to 0

Success rate is 95%

MVA increases to an average1-9-2cm2.

Reduction in MVG,LA ,PA

pressure7increase CO 60% improve NYHA class


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HOW WILL YOU ASSESS

SUCCESS PTMC

During procedure

After procedure


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SIGN OF MS AFTER

PTMC/CMC/OMC OSpersist

Loudness of S1persist.

Murmur Disappear/reduces

intensity

Presystolic accentuation never

present.


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Restenosis after PTMC

Incidence: 2-60% Restenosis due to fibrosis after injury,

calcification and rarely recurrence of rheumaticfever.

Recurrence of symptoms usually not due torestenosis which may be due to

1. Inadequate 1st operation

2. Increased severity of MR(Operative /IE)

3.Progerrion of aortic valvular disease.

4.Development of CAD.


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CONTRAINDICATION TO

PTMC

Related to valve

MR that is truly 3+4+

Thrombus in LA

Unfavorable valve

morphology,commissural Ca

MS mild.

Related to centre


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Need for open heart surgery

Procedural difficulties

Severe TR

Huge RA

Distorted /displaced IAS

Venous problem.


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OMC

CLASS-IBalloon valvotomy is not available

All indication to PTMC but there is LAthrombus despite anticoagulation

Patients in NYHA III-IV, moderate to severeMS & anon pliable or calcified valve withthe decision to proceed either repair or

replacement made at the time ofoperation.


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MVR

Patients who are not candidate

for PTMC or repair


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MS IN PREGNANCY

The increased CO tachycardia, fluid

retention may double PG across the MV

Symptom become apparent 20th week,mayaggravated further.

Maternal death is rare when there careful

attention to the management of CCF.


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PTMC valve surgery is appropriate before

conception.

If MS is first recognized & symptom develop

standard medical therapy is appropriate.

If symptom not controlled PTMC/CMC can be

done in 2nd trimaster.

Foetal loss >30%. AF is main concern


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mitral stenosis nicvd lecture

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