Cardio-Vascular Disease

Mitral Stenosis & Mitral Regurgitation

Dr. Deepak K. Gupta
 Valvular Heart Diseases
• Mitral stenosis
• Mitral regurgitation
• Aortic stenosis
• Aortic regurgitation
• Tricuspid stenosis
• Tricuspid regurgitation
• Pulmonic stenosis
• Pulmonic regurgitation
 Mitral Stenosis
• Almost always rheumatic in
origin
– although in older people it can be
caused by heavy calcification
– also a rare form of congenital MS
• Mitral valve orifice slowly gets
diminished (5 cm2 - 1 cm2 )
– Progressive fibrosis,
– Calcification of the valve leaflets
– Fusion of the cusps and
subvalvular apparatus.
 Aetiology and Pathophysiology
• The flow of blood from LA to LV is restricted
and left atrial pressure rises,
• Leading to pulmonary venous congestion and
breathlessness.
• There is dilatation and hypertrophy of the LA,
• And left ventricular filling becomes more
dependent on left atrial contraction.
 Aetiology and Pathophysiology
• Situation which increases heart rate or cardiac
output like pregnancy and exercise – poorly
tolerated
– shortens diastole and produces a further rise in left
atrial pressure
• Atrial fibrillation - progressive dilatation of the LA
• Pulmonary oedema - accompanying tachycardia
and loss of atrial contraction
• All these lead to marked haemodynamic
deterioration
 Clinical features: Symptom
• Patients usually remain asymptomatic until the stenosis is <
2 cm2
• Breathlessness - Reduced lung compliance, due to chronic
pulmonary venous congestion
• Fatigue - low cardiac output
– Exercise tolerance typically diminishes very slowly over many
years
• Oedema, ascites (right heart failure)
• Palpitation (atrial fibrillation)
• Haemoptysis (pulmonary congestion, pulmonary embolism)
• Cough (pulmonary congestion)
• Chest pain (pulmonary hypertension)
• Thromboembolic complications (e.g. stroke, ischaemic limb)
 Clinical features: Signs
• Atrial fibrillation
• Mitral facies (calcification)
• Auscultation
– Loud first heart sound (S1),
– Opening snap: may be audible and move closer to S2
with increase in severity
– Mid-diastolic murmur: Turbulent flow produces
characteristic low pitched
– accentuated by exercise
– inaudible if the valve is heavily calcified.
• Crepitations, pulmonary oedema, effusions (raised
pulmonary capillary pressure)
 Investigations
• ECG
– P mitrale or atrial
fibrillation
– Right ventricular
hypertrophy: tall R
waves in V1–V3
• Chest x-ray
– Enlarged LA and
appendage
– Signs of pulmonary
venous congestion
 Investigations
• Echo -
– Thickened immobile cusps
– Reduced valve area
– Reduced rate of diastolic filling of LV
– Enlarged LA
• Doppler echocardiography - definitive evaluation
– Pressure gradient across mitral valve
– Pulmonary artery pressure
– Left ventricular function
• Cardiac catheterisation - assessment of coexisting
conditions.
– Coronary artery disease
– Mitral stenosis and regurgitation
– Pulmonary artery pressure
 Management
• Patients with minor symptoms should be
treated medically
• Surgical Management: patient remains
symptomatic despite medical treatment or if
pulmonary hypertension develops
– Balloon valvuloplasty,
– Mitral valvotomy
– Mitral valve replacement
 Medical Management
• Systemic embolism: anticoagulants
• Atrial fibrillation: ventricular rate control by
digoxin, β-blockers or rate-limiting calcium
antagonists
• Pulmonary congestion: diuretic therapy
• Antibiotic prophylaxis against infective
endocarditis is no longer routinely recommended
 Surgical Management
• Mitral valvuloplasty: treatment of choice if
specific criteria are fulfilled
– Significant symptoms
– Isolated mitral stenosis
– No (or trivial) mitral regurgitation
– Mobile, non-calcified valve/subvalve apparatus on
ech
– LA free of thrombus
Mitral Balloon Valvotomy.A. After transseptal
puncture, the deflated balloon catheter is
advanced across the interatrial septum, then
across the mitral valve and into the left
ventricle. B.-D. The balloon is inflated stepwise
within the mitral orifice
 Surgical Management
• Valvoplasty: closed or open mitral valvotomy
are acceptable alternatives
• Valve replacement: substantial mitral reflux or
if the valve is rigid and calcified
• Regular follow up: at 1–2-yearly intervals
because restenosis may occur
Valve replacement
 Mitral Regurgitation
• Backflow of blood through a defective
heart valve.
• Any one or more of the five functional
components of the mitral valve apparatus
– Leaflets,
– Annulus,
– Chordae tendineae,
– Papillary muscles,
– Subjacent myocardium
 Etiology
• Acute
– Endocarditis
– Papillary muscle rupture (post-MI)
– Trauma
– Chordal rupture/leaflet flail
• Chronic
– Myxomatous (MVP)
– Rheumatic fever
– Endocarditis (healed)
– Mitral annular calcification
– Congenital (cleft, AV canal)
– Hypertrophic obstructive cardiomyopathy (HOCM) with systolic
anterior motion (SAM)
– Ischemic (LV remodeling)
– Dilated cardiomyopathy
– Radiation
 Pathophysiology
• Regurgitation into the LA produces LA
dilatation
• But little increase in left atrial pressure if the
regurgitation is chronic
– as the regurgitant flow is accommodated by the
large left atrium
• Acute mitral regurgitation - normal
compliance of the left atrium does not allow
much dilatation
– left atrial pressure rises.
 Clinical features
• Symptoms depend on how suddenly the
regurgitation develops
• Chronic: symptom complex that is similar to that
of MS
• Acute: usually presents with acute pulmonary
oedema
• Symptom
– Dyspnoea or Orthopnea (pulmonary venous
congestion)
– Fatigue (low cardiac output)
– Palpitation (atrial fibrillation, increased stroke
volume)
– Oedema, ascites (right heart failure)
 Signs
• Atrial fibrillation/flutter
• Cardiomegaly: displaced hyperdynamic apex beat
• Apical pansystolic murmur ± thrill
• Signs of pulmonary venous congestion (crepitations,
pulmonary oedema, effusions)
• Signs of pulmonary hypertension and right heart
failure
• Floppy mitral valve - mid-systolic click
• Prominent third heart sound - sudden rush of blood
back into the dilated left ventricle in early diastole
 Investigations
• ECG
– Left atrial hypertrophy (if not in AF)
– Left ventricular hypertrophy
• Chest x-ray
– Enlarged LA
– Enlarged LV
– Pulmonary venous congestion
– Pulmonary oedema (if acute)
 Investigations
• Echo
– Dilated LA, LV
– Dynamic LV (unless myocardial dysfunction
predominates)
– Structural abnormalities of mitral valve (e.g. prolapse)
• Doppler: Detects and quantifies regurgitation
• Cardiac catheterisation
– Dilated LA, dilated LV, mitral regurgitation
– Pulmonary hypertension
– Coexisting coronary artery disease
 Management
• Mild MR can be treated medically.
– Diuretics
– Vasodilators
– Digoxin if atrial fibrillation is present
– Anticoagulants if atrial fibrillation is present
• Evidence of progressive cardiac enlargement -
early surgical intervention.
– Valvotomy, Valvoplasty and valve replacement.
• Repair the valve and restore mitral valve function
by inserting an annuloplasty ring
– overcome annular dilatation
– bring the valve leaflets closer together
 THANKS……
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