MITRAL STENOSIS

Andi Fikryah Muliana Ashariana

C111 13 071

Supervisor: Dr. dr. Idar Mappangara, Sp.PD, Sp.JP,

FIHA, FINASIM
Patien Identity
 Name : Mr. MA
 Age : 46 years old
 Address : Takalar
 MR : 823356
 Date of Admission: 20 November 2011
History Taking
 Chief complaint : Shortness of breath
 Present Illness History :

Shortness of breath experienced since approximately 3 weeks before

admitted to the hospital. Shortness of breath disappeared and felt
more and more severe. Shortness when the activity exists, shortness
when lying so patient prefer to lie on the pillow. The history of
awekening at night because of shortness present. No chest pain.
Edema in both legs and ascites in the abdomen are present. There is
no Fever, nausea (+) and vomitting (+). Defecation and urinating :
normal. Previously, admitted to RS Harapan with the same complain
and diagnosed with Right Heart Failure on Severe Mitral Stenosis
ecausa Rheumatich Heart Disease.
 Past illness history:
 History of hypotension (+), DM (-), Dislipidemia (-)
 History of Rheumatoid Heart Disease

 Family history:
 There is family history with heart disease
• Lifestyle history:
 History of Smoking (+)
 History of Alcohol (+)
Physical Examination
 General Status
 Moderate illness /good nutritional status/ compos mentis
 Weight : 63 kg
 Height : 170 cm
 BMI : 21,7 kg/m2
 Vital Status
 Blood pressure :100/60 mmHg
 Heart rate : 86 bpm
 Respiratory rate : 28 rpm
 Temperature : 36,9 oC
 Eyes : anemic (-) icteric (-)
 Neck : JVP R+3 cmH2O,
 Lung :
 Inspection : symmetry left=right
 Palpation : mass (-), no tenderness, normal vocal
fremitus
 Percussion : sonor
 Auscultation: broncovesicular, ronchi +/+, wheezing -/-
 Cor :
 Inspection : no ictus cordis
 Palpation : ictus cordis not palpable, thrill (-)
 Percussion:
 Upper border 2nd ICS sinistra
 Right border 4th ICS linea parasternalis dextra
 Left border 5th ICS linea midclavicularis sinistra
 Auscultation : heart sound S1, S2 irregular, diastolic
murmur 2/4
 Abdomen :
 Inspection : distended
 Auscultation : peristaltic (+), normal
 Palpation : Shifting dullness(+),
 Percussion : tympani to dull

 Extremities :
 The muscle tone : Normal
 Edema bilateral (+)
 ELECTROCARDIOGRAPHY
(20 /11/ 2017)

 Rhythm : sinus
 Heart Rate : 110 bpm
 Regularity : ireguler
 Axis : normo axis
 P wave : 0.08 seconds
(normal)
 PR interval : 0.28 seconds
(increased)
 QRS rate : duration 0,08
second
 QRS wave : R progession
normal
Conclusion : Atrial fibrilasi rapid  ST segment : ST Depresion V2
ventrikular response, Normoaxis,  T wave : Normal
Atrioventrikuler block Right bundle
branch block
LABORATORY FINDINGS
(21/11/2017)

Test Result Normal Value

WBC 4.48 x 103/uL 4.00-10.0

RBC 3.25 x 106/uL 4.00-6.00
HGB 14,1 g/dL 12.0-16.0
HCT 40.2 % 37.0-48.0
PLT 179 x 103/mm3 150-400
Na 131 mmol/l 136-145
K 4.6 mmol/l 3,5-5,1
Cl 95 mmol/l 97-111
GDS 81 mg/dl 140
LABORATORY FINDINGS
Test Result Normal Value

Ureum 22 mg/dl 10-50

Test Result Normal value
Creatinine 2,15 mg/dl 140 mg/dl
135 mg/dl L : >1,3 P: < 1,1
GDS
SGOT 22 mg/dl96 U/L 10-50 mg/dl < 38
Ureum
SGPT 51 U/L
0,937 mg/dl M(<1,3);F(<1,1)< 41
Creatinin
mg/dl
PT 19.3 detik 10-14
SGOT 18 U/l <38 U/l
APTT 37.0 detik <41 U/l 22-30
SGPT 14 U/l
INR 1.81
Kolesterol total 149 mg/dl 200
Bil.Total 8.23 mg/dl L: >55 P : >65
52 mg/dl
<1.1 mg/dl
Kolesterol HDL
Bil. Direk 5.98 mg/dl < 130
82 mg/dl <0.30 mg/dl
Kolesterol LDL
Albumin 4.1 gr/dl 3.5-5.0 gr/dl
ECHOCARDIOGRAPHY
21/11/2017
• Severe mitral stenosis,
• Good left ventricular
systolic function, EF
56%
• Mild Tricuspid
Regurgitation
• Mild aorta regurgitation
• Pulmonale hypertension
severe
• Left atrium, Right
atrium, Right ventricle
dilatation (LVD shaped)
Diagnosis
 Congestive Heart Failure ecausa Severe Mitral Stenosis
 Pulmonary Hipertension
Therapy
1. O2 3 liter/minutes/nasal kanul
2. Furosemide 5mg/ 24 hours/ syringe pump
3. Spironolactone 25 mg/24 hours/oral
4. Digoxin 0,25 mg/24 hours/oral
5. Simarc 2 mg/24 hours/oral
DISCUSSION
Discussion

Mitral stenosis (MS) is characterized by obstruction to left

ventricular inflow at the level of mitral valve due to structural
abnormality of the mitral valve apparatus.
Etiology
 The most common cause is Rheumatic Fever
 Congenital mitral stenosis
 Less common cause: malignant carcinoid disease, SLE, RA,
mucopolysaccharidoses of the Hunter-Hurler phenotype,
Febry disease, whipple disease.
Pathophysiology
Clinical Features

 Symptoms of mitral stenosis usually manifest during the third

or fourth decade of life and nearly half of patients do not
recall a history of acute rheumatic fever.
 Patients are generally asymptomatic at rest during the early
stage of the disease.
 Palpitation
 Hemoptysis may occur and is usually not fatal
 DOE, PND, fatigue
 Mitral facies (pinkish-purple patches on the cheeks) indicate
chronic severe mitral stenosis
 Jugular vein distension may be seen
 Atrial fibrilation
 Often a right ventricular lift is palpable in the left parasternal
region in the patient with pulmonary hipertension
 The auscultatory findings characteristic of mitral stenosis are
a loud first heart sound, an opening snap, and a diastolic
rumble
Severity
Severity Symptoms
Mild Asymptomatic or mild DOE
Moderate Mild-moderate DOE, orthopnea, PND,
hemoptysis
Severe Dyspnea at rest, possible pulmonary oedem
Very severe Severe fatigue, cyanosis
Supporting
 ECG
 Laboratory
 Rontgen
 Echocardiography
Management

The goal of medical treatment of MS is:

 to reduce recurrence of rheumatic fever
 provide prophylaxis for infective endocarditis
 Reduce symptoms of pulmonary congestion
 Control the ventricular rate if atrial fibrillation
 Prevent thromboembolic complication
 MEDICAL
• Diuretics
• Anti coagulants (IPAH)
• Digoxin
• Oxygen
SURGICAL THERAPY
• Mitral valvotomy
• Mitral valve replacement
Thankyou