MITRAL STENOSISK. Kavindya M. Fernando

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Mitral stenosis• Mitral valve– Consist of fibrous annulus,– Anterior & posterior leaflets– Chordae tendinae,– Papillary muscle

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Mitral stenosis• Commonest cause :rheumatic heart

disease• Infections with group A beta hemolytic

streptococci• More common in women

• Inflammation leads to commissural fusion and a reduction in mitral valve orifice area

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Pathophysiology• Normal valve area: 4-6 cm2

• Mild mitral stenosis: –MVA 1.5-2.5 cm2

–Minimal symptoms• Moderate mitral stenosis–MVA 1.0-1.5 cm2 usually does not

produce symptoms at rest• Severe mitral stenosis–MVA < 1.0 cm2

To maintain sufficient cardiac output

1. Left arterial pressure increases2. Left arterial hypertrophy and dilation

3. Pulmonary veins, pulmonary arterial and R/ heart pressure increases

4. Increase of pulmonary capillary pressure 5. Followed by development of

– pulmonary oedema– Atrial fibrillation with tachycardia– Loss of coordinated atrial contraction

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To maintain sufficient cardiac output

6. This is prevented by (Reactive pulmonary hypertension)– Alveolar and capillary thickening– Pulmonary arterial vasoconstriction

7. Pulmonary hypertension leads to– R/ ventricular hypertrophy, dilation and

failure with subsequent tricuspid regurgitation

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Symptoms

• Palpitation• Systemic emboli

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• Dyspnoea• Pulmonary

infections (Recurrent bronchitis)

• Haemoptysis• Cough• R/ heart failure• Fatigue• Abdominal and

lower limb swelling

Atrial fibrillation Pulmonary Hypertension

Signs• Face : Mitral fascies• Pulse : atrial fibrillation• RV : Heaving, sustained• Apex: Localized, tapping• Sounds: Loud S1, Loud P2 (if

pulmonary hypertension), opening snap• Murmurs: Mid diastolic rumble at

apex

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Mitral Stenosis: Physical Exam

• First heart sound (S1) is accentuated & snapping• Opening snap (OS) after aortic valve closure• Low pitch diastolic rumble at the apex• Pre-systolic accentuation (esp. if in sinus rhythm)

S1 S2 OS S1

Signs (Face)• Severe mitral stenosis with pulmonary

hypertension• Mitral fascies / malar rash

• Bilateral• Cyanotic or dusky pink

discolouration• Over the upper cheeks• Due to atriovenous anastomosis &• Vascular stasis

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Signs (Pulse)• Small volume pulse• Usually regular in early stages,• If the patient is in sinus rhythem

• In severe disease, may develop atrial fibrillation

• Irregularly irregular pulse

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Signs (Jugular Veins)• If R heart failure develops

• obvious distension of jugular veins

• If pulmonary hypertension or tricuspid stenosis is present

• ‘a’ Wave will be prominent

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Signs (Palpation)• Tapping impulse felt parasternally on

left side• Palpable 1st heart sound • Combined with left ventricular backward

displacement• Produced by an enlarging left ventricle

• Sustained parasternal impulse• Due to R ventricular hypertrophy

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Signs (Auscultation)• Loud 1st heart sound

– If the mitral valve is pliable– It will not occur in calcified mitral stenosis

• Opening snap– Valve suddenly opens with the force of the increased

L arterial pressure

• Low pitched ‘rumbling’ mid diastolic murmur– Best heard with bell held lightly– At the apex with the patient lying on the left side

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Signs (Auscultation)• If the patient is in sinus rhythm–Murmur becomes louder at the end of

diastole– As a result of atrial contraction

– (Pre- systolic accentuation)

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How to determine the severity of mitral stenosis

• Presence of pulmonary hypertension

– Recognized by R/ ventricular heave & loud pulmonary component of 2nd heart sound

– And signs with R heart failure : Oedema, hepatomegaly

– Graham Steell murmurJMJ 16

How to determine the severity of mitral stenosis

• Closeness of the opening snap to the 2nd heart sound ∞ severe MS

• Length of mid-diastolic murmur ∞ severity

• As the valve cusps become immobile– Loud 1st heart sound softens– Opening snap diasppears– When pulmonary hypertension occurs : P2 intensity

increase, mid diastolic murmur become quieter

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Investigations• Chest X-ray• Electrocardiogram

• Echocardiogram• Cardiac magnetic resonance• Cardiac catheterization

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Investigations –X-ray• Small heart with an enlarged L/ atrium

• Pulmonary venous hypertension

• Calcified mitral valve– on penetrated or lateral view

• Signs of pulmonary oedema or pulmonary hypertension

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Investigations –ECG• Sinus rhythm in ECG shows a bifid P wave– Owing to delayed L/atrial activation

• Atrial fibrillation may be present

• ECG features of R/ventricular hypertrophy– Right axis deviation– Perhaps tall R wave in lead V1

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Investigations –ECG

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Investigations –ECG

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Investigations –Echocardiogram• Transthoracic echocardiography– To determine L/ R/ atrial and ventricular

size– The sevirity of MS

• Transoesophageal Echocardiography (TOE)– To detect the presence of L/ atrial

thrombusJMJ 23

Treatment• Need no treatment other than prompt therapy of

attacks of bronchitis

• Early symptoms like dyspnea - diuretics

• Onset of atrial fibrillation :digoxin, anticoagulants (to prevent atrial thrombus and systemic embolism)

• If pulmonary hypertension or symptoms of pulmonary congestion : surgical therapy

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Treatment• Operative therapies– Trans-septal balloon valvotomy– Closed valvotomy– Open valvotomy–Mitral valve replacement

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Treatment: Trans-septal balloon valvotomy

• Catheter introduced into R atriam via femoral vein• Under local anasthesia

• Inter atrial septum is punctured

• Catheter enter into left atrium then to mitral valve

• Balloon is inflated, briefly to split the valve commissures

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Treatment: Trans-septal balloon valvotomy

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Treatment: Trans-septal balloon valvotomy

• Complications– Regurgitation may result

• Contraindications– Heavy calcification–More than mild mitral regurgitation &

thrombus in the L/atrium

• TOE is done before this procedureJMJ 28

Treatment: Closed valvotomy

• For the patients with – mobile, – non calcified and – non regurgitant mitral valves

• Fused cusps forced apart by a dilator (introduced through the apex of L/ ventricle)

• Cardiopulmonary bypass is not needed for this operation

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Treatment: Open valvotomy

• Often preferred to closed valvotomy

• Cusps are carefully dissected apart under direct vision

• Cardiopulmonary bypass is requied

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Treatment: Mitral valve replacement

• It is necessary if– Mitral regurgitation is present– Badly diseased or badly calcified stenotic

valve, – Moderate or severe mitral stenosis &

thrombus in L atrium despite anticoagulation

• Artificial valve >20 yrs• Anticoagulants are necessary

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