mitral stenosis and mitral regurgitation

8/8/2019 Mitral Stenosis and Mitral Regurgitation

1/21

MITRAL STENOSIS AND MITRAL

REGURGITATION

ASYRAF SAFWAN


2/21

MITRAL STENOSIS

Define as a valvular heart disease presented

as narrowing of the orifice of the mitral

valve of the heart.

Causes: rheumatic heart disease

calcification of mitral valve

congenital mitral stenosis


3/21

Pathophysiology

Fibrosis and

calcification of mitral

valve

Narrowing

of orificeRestriction

of blood

flow from

left atrium

Left atrial

pressure

rises

Pulmonary

venous

congestion

Breathlessness, haemoptysis,

cough. Crepitation, pleural

effusion

Left atrial

hepertrophy and

dilatation


4/21

Left atrial hypertrophyand dilatation with

stenotic mitral valve

Increased

heart rate

(exercise and

pregnancy)may

percipitate

symptoms

Atrial

fibrillation(palpitation.

signs of atrial

fbrillation)

due to

progressive

dilataion

Low cardiac output

(fatique)

Left atrial

thrombosis and

systemic

thromboembolism

(stroke, ischemiclimbs)

Pulmonary

hypertension

(SOB, fatique,

chest pain.

Loud S2, RV

heave)

Right heart

hypertrophy and

dilation

Right heart failure

(ascites, ankleoeedema, raised JVP)


5/21

Signs

Loud S1, tapping apex beat, opening snap,after S1 moving to S2 in severe case.

Low pitched mid diastolic murmur sometimeswith thrill

Coexisting mitral regurgitation can cause middiastolic murmur.

Tricuspid regurgitation in RV dilatation cancause systolic murmur in RV and waves in JVP.

There might be coexisting mitral regurgitation.Pic manouver:

left lateralusing bell


6/21

Investigation

ECG:

Chest x ray

Echocardiogram Doppler echocardiography:pressure gradient

across mitral valve, pulmonary arterypressure, left ventricular function

Cardiac catheterization: assessment ofcoexisting coronary heart disease and mitralregurgitation


7/21

RAD, tall R wave in V1-2 are all diagnostic features of RVH. Biphasic P wave with a

prominent negative component in V1 is good for left atrial enlargement. The P wave

is somewhat prominent in lead II suggesting right atrial enlargement as well.


8/21

Normal cardiac size,

but the left atrial

appendage is

prominent Main

pulmonary arterysegment is just

outside the left

border, indicating

pulmonary

hypertension.

Enlargement of leftpulmonary artery and

right pulmonary

artery are just

modest. The

horizontal fissure is

visible, indicatingcollection of edema

fluid in the fissure.

The aortic knuckle

(Ao) is also seen well..


9/21

Mitral stenosis with left atrial dilatation. This figure shows a thickened

mital valve arrow


10/21

Management

Minor symptoms: medical treatment

Definitive treatment: balloon valvuloplasty, mitral

valvotomy and mitral valve replacement.

Medically: anticoagulant

antiarrhytmia

diuretics

antibiotics from infective

endocarditis


11/21

Mitral ballon valvuloplasty

Fulfill criteria to undergo this procedure

Significant symptoms, isolated mitral stenosis,

no/trivial mitral regurgitation, mobile and non-

calcified valves, LA contain no thrombus.

They need to be given antibiotic to prevent IE.

There is possibility of restenosis.


12/21

Mitral Regurgitation

Defined as disorder of the heart in which the mitralvalve does not close properly when the heart pumps outblood.

Aetiology: rheumatic heart disease

mitral valve prolapsedilatation of the left ventricles and mitral valve

rings (cardiomyopathy, Coronary Artery Disease)

damage to cusp and chordae (IE, rhematic heartdisease)

damage to papillary muscle

MI


13/21

Mitral regurgitation acute

chronic

Acute pulmonaryoedema (Breathlessness,

haemoptysis, cough.

Crepitation, effusion)

Increased left atrial

pressure

Ventricular

hypertrophy

Atrial hypertrophy

P

ulmonary hypertension

Right ventricular

hypertrophyRight sided heart

failure

Displaced apex

beat


14/21

Signs

Pansystolic murmur that radiates to axilla with

or without thrill

Soft S1 and may or may not be loud S3


15/21

Investigation

Tall R waves in V4 and V5 with down sloping ST segment depression

and T wave inversion are suggestive of left ventricular hypertrophy

(LVH) with strain pattern.


16/21

Left atrial hypertrophyP wave

duration > 0.12s in

frontal plane (usually

lead II)

Notched P wave in

limb leads with the

inter-peak

duration > 0.04s

Terminal P negativity

in lead V1 (i.e., "P-

terminal force")

duration >0.04s,

depth >1 mm.


17/21

Parasternal long axis view.

Left atrium is dilated (compare with aorta).

Left ventricle is dilated (the dots on the left side are in centimeters).

Moderate posterior directed mitral regurgitation jet seen.


18/21

CXR: Enlarged left atrium, enlarged left

venticle, pulmonary venous congestion,pulmonary oedema

Echo: detects and quantifies regurgitation

Cardiac catheterisation: Dilated LA, dialted LV,mitral regurgitation, pulmonary hypertension,

coexisting coronary heart disease


19/21

Management

Medical treatment: Diuretics

Vasodilators eg ACE

inhibitorsDigoxin as

antiarrhythmics

Anticoagulantsantibiotics as prophylaxis

from IE


20/21

Surgical management: mitral valve repair

(annuloplasty ring)mitral valve

replacement


21/21

common cause of severe mitral regurgitationis caused by damage to chordae tendinae.

When the cordae are damaged, one or moreof the leaflets that make up the mitral valve

prolapse. Then, repair the leaflet by using a new

support system (new chords made ofGoreTex) or by removing the weakened part

of the leaflet and closing it up. Then annuloplasty ring is implanted round the

valve to provide additional support which actsas a frame for the valve and has a similar roleto a door frame in supporting a door.

Annuloplasty Ring

mitral stenosis and mitral regurgitation

Documents