mitral stenosis and derivatives: part i: hemodynamics e-mail:...

Cardiology

the Sounds

Howard J Sachs MDwww12DaysinMarchcom

E-mail Howard12daysinmarchcom

Mitral Stenosis and DerivativesPart I Hemodynamics

These are gateway conditions

Microbiology Pathology Pathophysiology

Valve Questions

Location (70)

Murmur v Sound (10)

Systolic v Diastolic (50)

Maneuvers (20) LSB

RUSB

Ao

LUSB

PV

LSB

LLSB Apex (5th IC)

Axilla

MV

The Valves

Mitral(apex S1)

Prolapse(midsystolic click maneuvers)

Regurgitation(systolic rarr axilla)

Stenosis(diastolic opening snap)

A

LV

A

LV

Murmurs Sound

Diastolic (soft) Systolic (harsh)

The Valves

Mitral Stenosis

Location apex (5th IC space midclavicular line)Diastolic

Quality Passive fillingAtrial contraction rarr Low pitch (pressure) rumbleKey features Opening snap and A2OS ratio

Key pathology Calcification of the commissures Aschoff bodies (Rheumatic fever)

The Valves

Mitral Stenosis

Location apex (5th IC space midclavicular line)Diastolic

Quality Passive fillingAtrial contraction rarr Low pitch (pressure) rumbleKey features Opening snap and A2OS ratio

Key pathology Calcification of the commissures Aschoff bodies (Rheumatic fever)

122

1309

The Valves

Mitral Stenosis

LA122

1309

Hg here

1309

The Valves

Mitral Stenosis

LA

1309The pressure in the left ventricle remains normal as the stenotic lesion is lsquoupstreamrsquo

Lungs

lt10 mmHg rarr 25 mmHg

PV

RV

Nl 255

PCWP

Mitral Stenosis Hemodynamics I

PA

LA

1309

Lungs

lt10 mmHg rarr 25 mmHg

PV

RV

Nl 255

PCWP

Mitral Stenosis Hemodynamics I

Disconnect between the PCWP and LV

filling pressures

PA

LA

Normal 1309

Cardiac Cycle

Mitral Stenosis Hemodynamics II

Mitral Stenosis Hemodynamics II

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

EDV

Mitral Stenosis Hemodynamics II

120

80

10

EDV

Pressures

Mitral Stenosis Hemodynamics II

120

80

10

EDV

Pressures

Mitral Stenosis Hemodynamics II

120

80

10

EDV

Pressures

Mitral Stenosis Hemodynamics II

120

80

10

EDV

Pressures

Mitral Stenosis Hemodynamics II

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

EDV

Mitral Stenosis Hemodynamics II

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

What happens to the LA mm Hg curve with mitral stenosis

The atrium has to contract and eject blood into the LV

Mitral Stenosis Hemodynamics II

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

LA pressure risesA2OS decreases

Mitral Stenosis Hemodynamics II

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

LA pressure risesA2OS decreases

LA

This Curve is the Language of Mitral Stenosis

Mitral Stenosis Hemodynamics II

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

A2 OS

Mitral Stenosis Hemodynamics II

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

LA pressure rises rarr A2OS decreases

A2 OS

Mitral Stenosis Hemodynamics II

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

A2 OS

A2OS ratio narrows with worsening MSReflects elevating LA pressures Negative Prognosticator

Mitral Stenosis Hemodynamics II

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

A2 OS

What correlates best with severity of MSMurmur grade or A2OS ratio

AV Close

IsovolRelax

IsovolCont

AV Open

Rapideject

Rapidfilling

MV Open

MV Close

120

80

10

Bro if they ask you which point on the graph corresponds to the murmur point here

Mitral Stenosis Hemodynamics III

Pressure

Volume

Hi Vol Low HgEDV

IsovolumetricContraction

IsovolumetricRelaxation

AoOpen

AoClose

Rapid ejection

ESV

MVOpen

Rapid Filling MVClose

EDV

LV Pressure-Volume Loop

Mitral Stenosis Hemodynamics III

Pressure

Volume

IsovolumetricContraction

IsovolumetricRelaxation

AoOpen

AoClose

Rapid ejection

ESV

MVOpen

Rapid Filling MVClose

StrokeVolume

SV = EDV - ESV

EDV

Mitral Stenosis Hemodynamics III

Pressure

Volume

IsovolumetricContraction

IsovolumetricRelaxation

AoOpen

AoClose

Rapid ejection

ESV

MVOpen

Rapid Filling MVClose

StrokeVolume

SV = EDV - ESV

EF = (EDV ndash ESV)EDV

EDV

Mitral Stenosis Hemodynamics III

Pressure

Volume

IsovolumetricContraction

IsovolumetricRelaxation

AoOpen

AoClose

Rapid ejection

ESV

MVOpen

Rapid Filling MVClose

StrokeVolume

EDV

Mitral Valve Stenosis

LocationDiastolicHemodynamics

PCWPCardiac CyclePressure Volume CurveOpening Snap

PathologyMicrobiology (Rheumatic Fever)Complications (A fib and derivatives)

Cardiology

the Sounds

Howard J Sachs MDwww12DaysinMarchcom

E-mail Howard12daysinmarchcom

Mitral Stenosis and DerivativesOpening Chapter