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MITRAL STENOSIS

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INCIDENCE

25% ISOLATED 40% MS+MR 38%MULTIVALVES 35%AORTIC 6%TRICUSPID NO PULMONARY 2/3RD FEMALE RF-MS 2 to >20 YRS

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pathology

Thickening at leaflet edges, Fusion of commissures Chordal shortening & fusion Inflammation & edema of leaflets wit

small fibrin thrombi--->scarring ->valve deformity wit obliteration of normal leaflet architecture by fibrosis,neovascularisation,increased collagen &tissue cellularity

Aschoff - myocardium

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When leaflets open in DIASTOLE –flexible leaflets snap into curved shape due restriction of motion at tips-diastoic doming- ant leaflet

Doming less prom- in fibrotic /calcified leaflet

Symmetric fusion of commissure – fish mouth apperance(button hole)

End stage-thickened leaflets-so rigid &adherent-cannot open /shut –soft S1-MS+MR

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MS………

Almost rheumatic Congenital Malignant carcinoid,SLE,rheumatoid

arth,mucopolysaccharadosis,fabry dis,whipple dis,

Methysergide Lutembacher synd-ASD+rheumatic

MS

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D…..D

LT atrial myxoma Bal valve thrombus in LA IE with large vegetations in leaflet

edges Cor triatriatum Functional MS – annular calcification in old age

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WHEN MR RESULTS

When RF results predominantly in contraction &fusion of valvular commissures- MR dominant

Recurrent infections: Disease progression Restenosis after valvuloplasty due to

fibrosis &thickening

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Normal MVA 4-6 sqcm Symptom free until 1.5- 2.5sqcm Moderate 1-1.5sqcm Critical <1sqcm LAP LV DP

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Trans valvular pressure gradient == TVFR 2

LAP -> PULMONARY capillary pressure

2 FR=4 PRESSURE GRADIENT

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LA CHANGES

LAD Fibrosis of atrial muscle Disorganization of atrial muscle bundles All leads to disparate conduction velocity&

inhomogenous refractory period Premature atrial contr-automatic focus

/reentry-AF AF- Severity of MS ,LAD LAP AF->diffuse atrophy of atrial muscle-LAD-

inhomo RP-irreversible AF

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CLINICAL FEATURES -- SYMPTOMS

Dyspnoea- fatigue,decreased exercise tolerence

Decreased VC due to engorged pul vessels & interstitial oedema

Orthopnoea – critical MS PE- precipitated by

stress,infections,fever,preg,AF wit tachycardia

RHF-marked rise of PVR

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Hemoptysis

Sudden& severe-rupture of thin walled dilated broncial veins due to rise of LAP

Mild hemoptysis may be asso wit PND –Blood stained sputum

Pink frothy – rupture of alveolar cappillaries

Pulm infarction

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Chest pain

Not typical symp of MS 15% chest discomfort Due to severe pulmonary HT Concommitant coronary

atherosclerosis Rarely due to coronary emboli

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Compression of LT recurrent LN by LAD

ORTNERS SYND-hoarseness – due to dilated pulm artery

Systemic venous HT,hepatomegaly,oedema,ascites,hydrothorax in severe MS wit PHT

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SIGNS

Mitral facies-pinkish purple patches in cheeks Loud S1 with MDM rumbling Pulse – normal to small volume pulse,

irregular in AF JVP-PROMINENT a wave in SR Absent a wave in AF Tapping S1 – anterior leaflet is pliable Diastolic thrill RV lift with PHT Loud P2 at 2nd ICS

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LOUD S1 –leaflets are flexible OS ECG-LAE (P WAVE duration in lead

II>0.12sec ECG correlate LA volume than LAP RVH – R:S ratio in lead V1 >1 Rt axis deviation

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CXR

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COMPLICATIONS

AF SYSTEMIC EMBOLI IE

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MANAGEMENT

Medical 1.Prevention of recurrent RF 2.Prevention & treatent of complications of MS Monitoring of disease prog to allow

intervention at right time Surgical Percut BMV Closed MV Open MV MVR

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Prevention of recurrent RF Penicillin prophylaxis for GABHS Benzathine penicillin 1.2 million units

IM q 3-4 wks Penicillin 250mg PO bid Erythromycin 250mg PO bid Sulfonamides 1 gm PO od

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Duration of prophylaxis

Depend upon age,known RHD,time since last episode of RF ,no episodes of RF,family h/o RF,endemic areas

Minimum-5 yrs or until age of 18yrs in absence of carditis

10yrs or until age of 25 –mild or healed carditis

Life long – moderate – severe carditis

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2.Prevention of complications 1.AF -early intervention & percut

valvotomy by preventing rise of LAP- by preventing

increased trans mitral valve flow (TMFR) Conditions increasing TMFR – stress ,

pregnancy , hyperthyroidism,exercise. 2.Systemic embolisation prevention –

anticoagulant in pts with AF , LT atrial thrombus in ECHO . Severe MS wit severe LAE even in SR

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3.IE prevention-prophylaxis For dental ,oral,respiratory,oesophageal

procedure High risk – amoxy 2gm IV +genta 1.5mg/kg at

induction then amoxy 1 gm iv /PO after 6 hrs If allergic to penicillin – vancomycin 1gm IV -

120mins +genta 1.5mg/kg IV at induction or clindamycin 300mg iv 10mins then clinda 150mg iv /po 6hrs later

Moderaterisk – same as above except vanco and gentamicin

For GI procedure – same as above

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Treatment of complicationsAF

Immediate (acute)=to restore SR Long term – to control ventricular rate Onset <48 hrs – DC shock at 200 then 360J Flecainide 2mg/kg max 150mg over 30mins IV

>48hrs onset – conversion to SR associated with emboli.

So anticoagulation by I heparin follow by oral warfarin for 3 wks

Digoxin iv loading dose 500mics in 100ml saline over 20 mins rptd at 4 – 8hr interval to total of 1- 1.5 mg

If VR not controlled wit digoxin – B blockers ,CCB Chronic AF – MAZE procedure

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AF …

Digoxin doesn’t convert AF to SR OR prevent further AF

Amiadarone- slows rate , helps sustain SR once regained .

300mg in 5%D iv over 1 hr & follwd by 900mg -23hr

Verapamil- 5-10mg

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Systemic embolisation

Anticoagulant – warfarin to maintain INR 2-3

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IE

NATIVE VALVE ENDOCADITIS – due do srepto viridans/bovis

Penicillin g 12-18MU/24hr iv cont /q4th hrly-4wks or

Ceftrioxone 2gm od iv /im -4wks or Penicillin G+ceftrixone +genta

3mg /kg iv od or q8hrly in divided dose -- 2 wks

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IE - enterococci

Ampicillin 12 gm/24 hr iv or q 4hrly in divided -6wks

Genta 1mg/kg im or iv q 8hrly -6 wks If allergic to penicillin Vancomycin 30mg/kg /day iv or q 12

hrly in divided dose – 6 wks + genta

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Staph -native valve

Methicillin susceptiple –nafcillin /oxacillin 2gm iv q 4hrly -6 wks+genta 1mg /kg iv tds -3 to 5 days

Vanco 30mg /kg /day in bid – 4-6 wks

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Staph – prosthetic valve

MRSA – vanco > 6 wks Rifampin 300mg PO tds >6 WKS GENTA 1MG/KG tds > 6 wks

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Hacek group

Ceftrioxone 2 gm od iv – 4 wks Ampi + sulbactum 12 gm /day iv or

as q 4hrly -4 wks

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Monitoring disease progression

Asymptomatic pts with mild to moderate MS – ECHO 3-5 yrs for mild

1-2 yrs for moderate MS Yrly for severe MS

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Treatment

Severe MS with persistent symp after surgical intervention

Or in whom intervention nit possible diuretis , digoxin Reduced sodium intake Ttt of hemoptysis – reduce PVP Sedation , upright position ,b

blockers, diuretics,

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Surgical

PCBMV(per cut balloon mitral valvotomy) Symptomatic pts mod to severe MS wit mva

<1 SQCM FAVOURABLE valve morphology No or mild MR No e/o LA thrombus Pregnant women Elderly MS wit renal disease, pulm disease, neoplastic Mild MS wit significant PHT

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PCBMV

COMPLICATIONS Cerebral emboli,cardiac

perforation,severe MR,persistent ASD Benefits Favourable hemodynamics,decrease

in TMPG , doubling mitral area, decline in PVR

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CLOSED MV

NO severe MR No Atrial thrombus No severe calcification No severe chordal fusion &

shortening

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Open MV

TOO distorted valves Calcified valves If MR + concommitant annuloplasty

can be done

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MVR

MS wit severe MR Mitral valvotomy not possible Extensive commissural calcification Severe fibrosis, MS with PHT >70 mmhg Complications Valve deterioration Chronic anticogulation

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Anesthetic goals

Avoid tachy Avoid hypo Hypoxia, Hypercarbia Drugs to reduce pul VR- NO,milrinone Hypotension- ionotropes but wit

careful .will increase PVR Increased pvr – NTG/sodium nitro pruss-

but can cause hypotension severe

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Premed – midazolam,scopalamine Induction- thio Opioids - morphine/fentanyl Vecuronium but careful wit opioids-

can go for severe brady Other – pancuronium Use N2O carefully – increase PVR

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Regional

If not in failure – epidural Avoid spinal .

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Who 2002-03 criteria

Primary epi RF -2major+1minor/2minor+preceding strepto

Recurrent attack of RF wit out RHD-2major/1maj+2min+prec infection

Wit RHD-2min+infection Rheu chorea /rhd

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Major – carditis50-60%,poly arthritis60-75,chorea2-30,erythema marginatum,subcut nodules<5

Minor- fever,poly arthralgia,ESR/WBC , prolonged PR interval

Aso rising, positive throat cul,rapid ag test ,recent scarlet fever

1992 revised jones- no wbc (crp),scarlet fever

60% of RF ->rhd