MITRAL STENOSIS

MITRAL STENOSIS MITRAL VALVELEFT SIDED

BICUSPID

CHORDAE TENDINAE

MVA - 4 TO 6 sq cm

MVA 2 sq cm -- significant

MILD MS -- 1.5 TO 2.0

MOD. MS -- 1.0 TO 1.5

SEVERE MS -- < 1.0

CRITICAL -- < 0.6ETIOLOGYMOSTLY RHEUMATIC . UNLESS PROVED OTHERWISE !

Rare causes areCONGENITALCALCIFIC as age advancesCOR TRIATRIATUM,CARCINOID SYNDROMESLE, RHUMATOID ARTHRITISINFECTIVE ENDOCARDITIS , LA MYXOMADIFFUSE THICKENING OF THE MITRAL LEAFLETS AND SUBVALVULAR APPARATUS,

COMMISSURAL FUSION,

CALCIFICATION OF THE ANNULUS AND LEAFLETSPATHOPHYSIOLOGYan abnormally elevated left atrioventricular pressure gradient . the hemodynamic hallmark of MS.

PRESSURE GRADIANT ACROSS MVLEFT ATRIAL VOLUME OVERLOADBOTH VOLUME AND PRESSURE OVERLOADPROGRESSIVELY INCREASED LEFT ATRIAL PRESSURELEFT ATRIAL ENLARGEMENT AND HYPERTROPHYDISTORTION OF LA CONDUCTION PATHWAYS ATRIAL FIBRILLATION

Changes in the pulmonary vasculatureLA PRESSURE IS TRANSMITTED TO PULMONARY VEINS-INCREASED PULMONARY VENOUS PRESSUREPULMONARY VENOUS CONGESTION-DUE TO TRANSUDATION OF FLUID INTO INTERSTITIAL SPACEPULMONARY CONGESTION.DECREASED PULMONARY COMPLIANCE - INCREASED WORK OF BREATHINGPULMONARY OEDEMA-WHEN PULMONARY VENOUS PRESSURE EXCEED PLASMA ONCOTIC PRESSUREREACTIVE CHANGES IN THE PULMONARY VASCULAR BEDPULMONARY ARTERIAL HYPERTENSION

RIGHT VENTRICULAR CHANGES.. PULMONARY ARTERIAL HYPERTENSIONRIGHT VENTRICULAR PRESSURE RISES

R V HYPERTROPHYRV DILATATIONRV FAILURE

TRICUSPID REGURGITATION ,PULMONARY REGURGITATION.

LEFT VENTRICULAR CHANGESLV FUNCTION USUALY PRESERVEDDECREASED FILLING

DECREASED VOLUME

DECREASED PRESSURE

THINNING OF LV WALLSYMPTOMS Initial attack of rheumatic carditis

2 decades

Symptoms of mitral stenosis disability in 4th decade of life

2-5 years

deathDyspnea

Large mitral orifices normal flow

mild elevations in LA pressure Cough

Marked increase in LA pressure dysnoea Precipitated by sudden changes in

Heart rateVolume statusCardiac outputAs mitral stenosis progresses

Lesser stress dysnoea

Patients daily activities limited

Orthopnoea and nocturnal dysnoea MECHANISMPulmonary venous pressure increases Fluid driven out

Decreases compliance

Increased work of breathing

dysnoeaACUTE PULMONARY EDEMAPulmonary capillary pressures exceed oncotic pressure

Lymphatic unable to decompress this fluid

Usually preceded by orthopnoea and PND

Can occur suddenly in patients with non critical mitral stenosis

PregnancyOne of the most common precipitants

Increased mitral valve flow due to Increased cardiac outputIncreased heart rateCentral blood volume

Maximal at 25 to 27 weeksHaemoptysis Rupture of pulmonary bronchial venous connections

Elevated LA pressures without markedly elevated pulmonary vascular resistances

Almost never fatal

Recurrent pulmonary emboli

Pulmonary infections

Bronchitis , bronchopneumonia and lobar pneumonia complicate untreated MS esp. in winter

Thrombi and emboliLeft atrial appendage

Systemic embolization more in

Atrial fibrillationOlder patientsReduced cardiac outputLOW EFFORT TOLERANCEEASY FATIGUABILITYSYNCOPEMITRAL FACIESDUE TO LEFT ATRIAL ENLARGEMENTORTNERS SYNDROMEANGINA DUE TO RV ISCHEMIA INSEVERE PULMONARY HTN.

DUE TO DECREASED CARDIAC OUTPUTSigns Mitral facies (pink-purple patches on cheeks).

JVP prominent a wave

Apex tapping apex ( S1)

Right parasternal heave

Diastolic thrill at the cardiac apex24Auscultation First heart sound (S1) is accentuated and snappingOpening snap (OS) after aortic valve closureS2-OS GAP LESS THAN 0.08 S SEVERE D/SLow pitch diastolic rumble at the apexPre-systolic accentuation (esp. if in sinus rhythm)

S1 S2 OS S1 25Hepatomegaly

Ascities

Ankle odema

Pleural effusion ( right sided)INVESTIGATIONSElectrocardiogram LEFT ATRIAL HYPERTROPHY-CAUSES P MITRALE-BIFID APPEARANE OF P WAVE IN LEAD 2,3 AVFSECOND HALF OF THE P WAVE IS NEGATIVE IN V1.ATRIAL FIBRILLATIONRIGHT VENTRICULAR HYPERTROPHY-DOMINANT R WAVE IN V1 V2.RIGHT AXIS DEVIATION.PATIENT ON DIGOXIN-DIGITALIS EFFECTS (ST DEPRESSION WITH A SAGGING,DECREASED T WAVE AMPLITUDE,SHORTENED QT,PROMINENT U WAVE)

Echocardiogram Trans thoracic 2 dimensional echocardiogram with flow doppler (TTE) Trans esophageal echocardiogram (TEE)USED TO ASSESS ANATOMY OF MITRAL VALVE,DEGREE OF LEAFLET THICKENING,CALCIFICATION,CHANGES IN MOBILITY AND EXTENT OF INVOLVEMENT OF SUBVALVULAR APPARATUS,EVALUATION OF CARDIAC CHAMBER DIMENSIONS,LEFT AND RIGHT VENTRICULAR FUNCTION,OTHER VALVULAR D/S AND EXMNTN OF LEFT ATRIAL APPENDAGE FOR PRESENCE OR ABSENCE OF THROMBUS.SEVERITY OF MITRAL STENOSIS IS ASSSSED BY CALCULATION OF MITRAL VALVE AREA AND MEASUREMENT OF TRANSVALVULAR PRESSURE GRADIENT,MITRAL TRANSVALVULAR PRESSURE GRADIENT HIGHER THAN 10 INDICATES SEVERE D/S.SEVERITYMVA(CM2)EDP GRADIENT(mmhg)PAPSYMPTOMSMILD>1.5