MITRAL STENOSIS Aetiology Rheumatic fever • Fusion of commissures • Thickening of leaflets • Thickening of subvalvular apparatus Degenerative mitral stenosis • Elderly patients • Extensive calcification congenital mitral stenosis • Rare Pathophysiology Stenotic MV causes a diastolic gradient between LA and LV. Increases LA, capillary wedge and pulmonary arterial pressure – more pronounced with high CO and tachycardia. LA enlargement AF Stasis of blood in LA thrombo embolism Clinical Features Progressive dyspnoea pulmonary oedema. Palpitation AF. Systemic embolism. Loud 1st heart sound. Opening snap in early diastole. Mid – diastolic murmur. Signs of PHT. Signs of RHF. Investigations ECG • AF • LA enlargement • RVH Chest Radiography • LA enlargement • Dilatation of pulmonary artery • Interstitial oedema / pulmonary oedema. ECHO (TTE and TOE) • Most important investigation to confirm the diagnosis and guide management. • MS confirmed by 2D Echo showing leaflet thickening and restricted movement. • Severity of MS assessed by transvalve gradient using Doppler technique / trace MVA by planimetry. • Valve anatomy – commissural fusion, leaflet thickening, calcification and subvalvular involvement. cardiac catheterization and haemodynamic studies • Rarely needed. MANAGEMENT Medical Therapy Symptom relief • ß blocker - heart rate, prolong diastole, increase ventricular filling, reduce transmitral gradient. • Diuretics. Anticoagulation • All patients with MS and AF • Patients with sinus rhythm • Previous embolic events. • Thrombus in LA / LAA. • LA > 5 cm. • Target INR 2 – 3. Intervention / Surgery PTMC • Symptomatic patients with severe MS. • Safe procedure when performed by experienced team. • Good immediate and long – term results. • Non – calcified valve. • pregnancy • Contraindications. • Massive bicommissural calcification. • LA /LAA thrombus. • Significant MR. • Severe associated AV disease. Surgery • MVR • Open and closed Mitral valvotomy. • MVR carries a higher risk than PTMC and is associated with long – term prosthesis – related complications. • Generally considered when valves are anatomically unsuitable for balloon dilatation. Percutaneous mitral commissurotomy using an Inoue balloon. Follow – up
Moderate MS with no symptoms.
• Echo every 1 – 2 years / new symptoms.
• Annual Echo after PTMC – risk of restenosis.
MITRAL REGURGITATION Aetiology Rheumatic MR – thickening and retraction of the posterior leaflet. Ischaemic MR – acute or chronic ischaemia. • Acute MR due to papillary muscle ischaemia or rupture complicating AMI (usually inferior) pulmonary oedema. • Chronic Ischaemic MR is more common and associated ventricular remodeling. Degenerative MR. Mitral valve Prolapse and regurgitation. • Leaflets are pliable and elongation or rupture of chordae leads to prolapse of one or both leaflets into LA. Endocarditis causing MR • Leaflet perforation. • Chordal rupture. Functional / secondary Mitral regurgitation. • Dilated cardiomyopathy. • Modification of movement of subvalvular apparatus. MR secondary to inflammatory disease, endomyocardial fibrosis, and HOCM Pathophysiology Acute MR abrupt rise of LA pressure pulmonary oedema. Chronic well tolerated with a moderate rise in LA pressure. Long term MR LV dilatation with irreversible myocardial damage and dysfunction. Clinical Features Asymptomatic for many years Dyspnoea. Pansystolic murmur. Third heart sound – severe MR. . Investigation ECG • LA enlargement. • Rarely AF. Chest Radiography • Enlarged LA / LV. • Pulmonary oedema. Echo • Key examination to confirm diagnosis, quantify regurgitation and assess underlying mechanism. • CW or color Doppler – detect systolic regurgitant flow. • Quantification of regurgitant volume. . • Mechanism and cause of MR – TTE and TOE assessment of leaflet structure, and movement, features of subvalvular apparatus and the dimensions of Mitral annulus. • Consequences of MR – PHT, LA dilation, LV dialatation and dysfunction LV angiography • Semiquantitative assessment of MR. • LV dilatation and EF. Management
Medical Management
• ACEI reduces volume of chronic severe MR
and may palliate LV dysfunction.
• Anticoagulation is mandatory in AF.
Surgery • Severe acute MR requires early surgery. • Chronic MR – timing of surgery. • Symptomatic patients. • Asymptomatic patients with LV dysfunction or LVESD > 45 mm. • Valve repair or MVR. Follow – up