Mitral Stenosis

MITRAL STENOSIS

r. Muhammad Alauddin Sarwar edical Officer , ndh Government Qatar Hospital, rachi, Pakistan

Normal Anatom y

MITRAL STENOSIS • • • • • •

Etiology Symptoms Physical Exam Severity Natural history Timing of Surgery

Mitral Stenosis: Etiology • Primarily a result of rheumatic fever (~ 99% of MV’s @ surgery show rheumatic damage ) • Scarring & fusion of valve apparatus • Rarely congenital • Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease • Two-thirds of all patients with MS are female.

Normal mitral valve Chordae Tendinae

Ant papillary muscle

Thickening of cusps

Fusion of chordae

Stenotic mitral valve

Mitral Stenosis: Pathophysiology

Mitral Stenosis: Pathophysiology RA

RV

Right Heart Failure: Hepatic Congestion Tricuspid Regurgitation RA Enlargement RV Pressure Overload RVH RV Failure

↑ Pulmonary HTN Pulmonary Congestion LA Thrombi Atrial Fib LA Enlargement Stenosis Mitral ↑ LA Pressure

LA

LV LV Filling

Mitral Stenosis: Symptoms • • • • •

Fatigue Palpitations Cough SOB Left sided failure – Orthopnea – PND

• Palpitation

• • • • •

A-fib Systemic embolism Pulmonary infection Hemoptysis Right sided failure – Hepatic Congestion – Edema

• Worsened by conditions that ↑ cardiac output. – Exertion, fever, anemia, tachycardia, A-fib, I/V fluid

Recognizing Mitral Stenosis Palpation:

Auscultation:

• Small volume pulse • Tapping apexpalpable S1 • +/- palpable opening snap (OS) • RV lift • Palpable S2

• Loud S1- as loud as S2 in aortic area • A2 to OS interval inversely proportional to severity • Diastolic rumble: length proportional to severity • In severe MS with low flow- S1, OS & rumble may be

ECG: •

NSR/AF, LAE, RVH, RAD

• • • •

Mitral Stenosis: Natural History

Progressive, lifelong disease, Usually slow & stable in the early years. Progressive acceleration in the later years 20-40 year latency from rheumatic fever to symptom onset. • Additional 10 years before disabling symptoms • With physically limiting symptoms 10 yr survival 0-15% 10-20% systemic embolism 30-40% develop AF • With onset of severe pulmonary hypertension Mean survival < 3 yrs

Mitral Stenosis: Role of Echocardiography • Diagnosis of Mitral Stenosis • Assessment of hemodynamic severity – mean gradient, mitral valve area, pulmonary artery pressure • Assessment of right ventricular size and function. • Assessment of valve morphology to determine suitability for percutaneous mitral balloon valvuloplasty (PMBV)

P S S A

P S L A

Mitral Stenosis: Complications Atrial dysrrhythmias

• • Systemic embolization (1025%) – Risk of embolization is related to, age, presence of atrial fibrillation, previous embolic events • Pulmonary infarcts (result of severe CHF)Animation • Congestive heart failure • Hemoptysis – Massive: secondary to ruptured bronchial veins (pulm HTN) – Streaking/pink froth: pulmonary edema, or infection • Endocarditis

Mitral Stenosis:Therapy • Medical – – – –

Diuretics for LHF/RHF Digitalis/Beta blockers/CCB for Rate control in A Fib Anticoagulation: In A Fib Endocarditis prophylaxis

• Balloon valvuloplasty – Effective long term improvement

Step By Step Balloon valvuloplasty (Commissurotomy ) Inoue balloon technique for mitral balloon valvotomy.

A. After trans-septal puncture, the deflated balloon catheter is advanced across the inter-atrial septum, then across the mitral valve and into the left ventricle. B. The balloon is then inflated stepwise within the mitral orifice.

Mitral Stenosis:Therapy • Surgical – Mitral commissurotomy – Mitral Valve Replacement • Mechanical • Bioprosthetic

Surgical Commissurotomy

A surgical procedure to open a stenotic valve. A stenotic valve restricts the flow of blood. A scalpel incision widens the valve.

Step by Step Heart Valve Replacement Animation ( copy the following link and paste it into the address bar of Internet Explorer & hit Enter)

http://www.byrnehealthcare.com/animations/SutterValveReplacement.htm

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