mohammed alosaimi 25/4/2009 this lecture was conducted during the nephrology unit grand ground by...

Mohammed AlOsaimi 25/4/2009

This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine and Nephrology Consultant. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

Mitral StenosisMitral Stenosis

ACC/AHA 2006 Guidelines for theManagement of Patients With Valvular Heart Disease


Presented By:Dr. Mohammed AlOsaimi

Medical Student2009

A 75 year old woman with loud first A 75 year old woman with loud first heart sound and mid-diastolic heart sound and mid-diastolic murmurmurmur

Chronic dyspneaFatigueRecent orthopneapalpitationPedal edema


Mitral StenosisMitral Stenosis

EtiologyNatural history SymptomsPhysical ExamSeverityTiming of Surgery


Mitral Stenosis: EtiologyMitral Stenosis: EtiologyPrimarily a result of rheumatic fever

(~ 99% of MV’s @ surgery show rheumatic damage )

Scarring & fusion of valve apparatusRarely congenitalPure or predominant MS occurs in

approximately 40% of all patients with rheumatic heart disease

Two-thirds of all patients with MS are female.


Mitral Stenosis: Natural HistoryMitral Stenosis: Natural HistoryProgressive, lifelong disease, Usually slow & stable in the early years.Progressive acceleration in the later years20-40 year latency from rheumatic fever

to symptom onset.Additional 10 years before disabling

symptoms


Mitral Stenosis:Mitral Stenosis:PathophysiologyPathophysiology

Normal valve area: 4-6 cm2

Mild mitral stenosis: ◦MVA 1.5-2.5 cm2

◦Minimal symptomsMod mitral stenosis

◦MVA 1.0-1.5 cm2 usually does not produce symptoms at rest

Severe mitral stenosis◦MVA < 1.0 cm2


Mitral Stenosis:Mitral Stenosis:PathophysiologyPathophysiology

Right Heart Failure:

Hepatic Congestion

JVD

Tricuspid Regurgitation

RA Enlargement

Pulmonary HTN

Pulmonary Congestion

Atrial Fib

LA Thrombi

LA Enlargement

LA Pressure

RV Pressure Overload

RVH

RV Failure LV Filling


Mitral Stenosis: SymptomsMitral Stenosis: Symptoms Breathlessness Fatigue Oedema, ascites Palpitation Haemoptysis Cough Chest pain mitral facies or malar flush Symptoms of thromboembolic complications (e.g. stroke,

ischaemic limb)

Worsened by conditions that cardiac output.◦ Exertion,fever, anemia, tachycardia,, pregnancy,

thyrotoxicosis


Signs of Mitral StenosisSigns of Mitral Stenosis

Palpation:Small volume pulseTapping apex-palpable

S1Palpable S2

Atrial fibrillation Signs of raised pulmonary

capillary pressure◦ Crepitations, pulmonary

oedema, effusions Signs of pulmonary

hypertension◦ RV heave, loud P2

Auscultation:Loud S1S2 to OS interval inversely

proportional to severityDiastolic rumble: length

proportional to severity In severe MS with low flow-

S1, OS & rumble may be inaudible


Mitral Stenosis: Physical ExamMitral Stenosis: Physical Exam

First heart sound (S1) is loud and snappingOpening snap (OS)Low pitch diastolic rumble at the apexPre-systolic accentuation (esp. if in sinus

rhythm)


S1 S2 OS S1

Mitral Stenosis: ComplicationsMitral Stenosis: ComplicationsAtrial dysrrhythmiasSystemic embolization (10-25%)

◦Risk of embolization is related to, age, presence of atrial fibrillation, previous embolic events

Congestive heart failure Pulmonary infarcts (result of severe CHF)Hemoptysis

◦Massive: 20 to ruptured bronchial veins (pulmonary HTN)

◦Streaking/pink froth: pulmonary edema, or infectionEndocarditisPulmonary infections


Mitral Stenosis: InvestigationsMitral Stenosis: Investigations

CXRECGEcho


Mitral Stenosis: ECGMitral Stenosis: ECG

LAERVHPremature contractions Atrial flutter and/or fibrillation

◦ freq. in pts with mod-severe MS for several years

◦A fib develops in 30% to 40% of patient w/symptoms


A 75 year old woman with loud first A 75 year old woman with loud first heart sound and mid-diastolic murmerheart sound and mid-diastolic murmer


Mitral Stenosis: Role of Mitral Stenosis: Role of EchocardiographyEchocardiography

Diagnosis of Mitral StenosisAssessment of hemodynamic severity

◦mean gradient, mitral valve area, pulmonary artery pressure

Assessment of right ventricular size and function.Assessment of valve morphology to determinesuitability for percutaneous mitral balloon

valvuloplastyDiagnosis and assessment of concomitant valvular

lesionsReevaluation of patients with known MS with

changing symptoms or signs.F/U of asymptomatic patients with mod-severe MS


Mitral Stenosis:TherapyMitral Stenosis:TherapyMedical

◦Diuretics for LHF/RHF◦Anticoagulation: In A Fib◦Endocarditis prophylaxis◦Digitalis/Beta blockers/CCB: Rate control in A

Fib

Balloon valvuloplasty◦Effective long term improvement


CRITERIA FOR MITRAL CRITERIA FOR MITRAL VALVULOPLASTYVALVULOPLASTY

Significant symptomsIsolated mitral stenosisNo (or trivial) mitral regurgitationMobile, non-calcified valve/subvalve

apparatus on echoLeft atrium free of thrombus


Mitral Stenosis:TherapyMitral Stenosis:Therapy

Surgical◦Mitral valvotomy◦Mitral Valve Replacement

Mechanical Bioprosthetic


Recommendations for Mitral Valve Recommendations for Mitral Valve Repair for Mitral StenosisRepair for Mitral Stenosis

ACC/AHA Class I◦ Patients with NYHA functional Class III-IV symptoms,

moderate or severe MS and valve morphology favorable for repair if percutaneous mitral balloon valvotomy is not available

◦ Patients with NYHA functional Class III-IV symptoms, moderate or severe MS and valve morphology favorable for repair if a left atrial thrombus is present despite anticoagulation

◦ Patients with NYHA functional Class III-IV symptoms, moderate or severe MS and calcified valve


Recommendations for Mitral Valve Recommendations for Mitral Valve Repair for Mitral StenosisRepair for Mitral Stenosis

ACC/AHA Class IIB◦Patients in NYHA functional Class I, moderate or severe MS and valve morphology favorable for repair who have had recurrent episodes of embolic events on adequate anticoagulation.

ACC/AHA Class III◦Patients with NYHA functional Class I-IV symptoms and mild MS.

*The committee recognizes that there may be a variability in the measurement of mitral valve area and that the mean trans-mitral gradient, pulmonary artery wedge pressure, and pulmonary artery pressure at rest or during exercise should also be considered.


ACC//AHA Guiidelliines 2006ACC//AHA Guiidelliines 2006 Class I:: Conditions for which there is evidence for and/or general

agreement that the procedure or treatment is beneficial,, useful,, and effective..

Class II:: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment..

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy

Class IIb: Usefulness/efficacy is less well established by evidence/opinion

Class III:: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and

in some cases may be harmful..


mohammed alosaimi 25/4/2009 this lecture was conducted during the nephrology unit grand ground by...

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