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Hakim Alkatiri
Mitral Stenosis
Mitral Stenosis
Causes
•rheumatic fever
•congenital abnormality, calcification, myxoma
Natural history
•RF age 12
•murmur 1st heard 20 yrs later
•symptoms in 3-4th decade
Mitral Stenosis - Clinical features
Severity MVA (cm²) LAP (mm Hg) CO
Mild >2.0 <10-12 NL
Moderate 1.1-2.0 ~10-17 NL
Severe <1.0 >18
Very Severe <0.8 >20-25
Severity Symptoms
Mild Asymptomatic or mild DOE
Moderate Mild-mod DOE; orthopnea, PND, hemoptysis
Inspection
Malar flush
Peripheral cyanosis (severe MS)
Jugular venous distension (right ventricular failure)
Palpation
Parasternal right ventricular impulse
Palpable pulmonary arterial impulse
Palpable S1, P2, and occasionally, the diastolic rumble
Auscultation
Increased intensity of the first heart sound
Opening snap
Low-pitched diastolic rumbling murmur
Mitral Stenosis - Treatment
Medical
•Diuretic - pulmonary congestion
•Prevent embolism - cause of 19% deaths, with
LA size and age
anticoagulate all with PAF/AF, SR in older age
•Control atrial fibrillation
Mitral Stenosis - Treatment
Balloon Mitral Valvuloplasty
Mitral Stenosis - Treatment
Balloon Mitral Valvuloplasty
•100% MVA, final area ~2cm2
•Failure rate 1-15%
•Mortality 0-3%
•Severe MR 2-10%
•Restenosis ~40% at 7years
•Contraindications - thrombus, MR, Ca++, other
disease
Mitral Stenosis - Treatment
Mitral Valve Replacement
•Open mitral valvotomy
•Mitral valve replacement
Mitral Regurgitation - Aetiology
•Primary
Annulus annular calcification
Leaflet myxomatous degeneration
rheumatic deformity
infectious perforation
Chordae myxomatous degeneration
spontaneous rupture
rheumatic shortening
infectious destruction
Papillary infarction
ischemic lengthening
•Functional
LV dilatation and PM displacement
CXR
Mitral Regurgitation - Pathophysiology
Mitral Regurgitation - Clinical findings
Acute dyspnoea, orthopnoea
no cardiomegaly, short murmur, S3
Chronic variable symptoms
cardiomegaly, murmur, P2 loud, S3
Quantification
•echocardiography, angiography
•serial studies, LV function
Mitral Regurgitation - Outcome in
Chronic MR
Acute
•Diuretics LV filling P, p oedema
•Vasodilators forward SV
•IABP
Chronic
No known effective therapy
•Vasodilators - theoretical risks
•Treat complications
Mitral Regurgitation - Surgery
Options
•Valve repair
•MVR with chordal preservation
•MVR with destruction MV apparatus
Outcome
•Mortality 80-94% v 40-60% at 5-10years
•Valve function
•Ventricular function
Mitral Regurgitation - Indications for surgery
No randomised trials!!
1. Symptomatic with normal LV function
•prognosis worse once NYHA class II symptoms
•2-4% population
•females:males 2:1
•diagnosis from echocardiography
•subcategory according to leaflet abnormality
•SBE prophylaxis; normal + MR or abnormal leaflets
Aortic Stenosis - Aetiology
Doppler AVA
AI severity
2-3+ 0-1+
Root
Annuloaoroectasia
Marfans
Dissection
Syphillis
Ankylosing spondylitis
Leaflet
Endocarditis
Bicuspid valve
Rheumatic heart disease
Aortic Regurgitation - Pathophysiology
Normal
Acute Aortic Regurgitation - Clinical features
Treatment
•Medical therapy ineffective
•AVR if symptoms/signs LVF
Chronic Aortic Regurgitation - Clinical features
Medical - afterload
Nifedipine 20mg bd delayed surgery by 2-3 yrs
Duplicated with small ACEI trials
Surgery - AVR prior to irreversible LV dysfunction
1. Asymptomatic
•LVEF<55%, LVESD>55mm, LVESV 60ml/m2
2. Symptomatic
•NYHA class II