Mitral stenosis

diagnosis and management of mitral stenosis

1. MITRAL STENOSIS K. Kavindya M. F ernando JMJ 1

2. Mitral stenosis Mitral valve Consist of fibrous annulus, Anterior & posterior leaflets Chordae tendinae , Papillary muscle JMJ 2

3. 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 JMJ 3

4. Pathophysiology Normal valve area: 4-6 cm 2 Mild mitral stenosis: MVA 1.5-2.5 cm 2 Minimal symptoms Moderate mitral stenosis MVA 1.0-1.5 cm 2 usually does not produce symptoms at rest Severe mitral stenosis MVA < 1.0 cm2 JMJ 4

5. To maintain sufficient cardiac output Left arterial pressure increases Left arterial hypertrophy and dilation Pulmonary veins, pulmonary arterial and R/ heart pressure increases Increase of pulmonary capillary pressure Followed by development of pulmonary oedema Atrial fibrillation with tachycardia Loss of coordinated atrial contraction JMJ 5

6. To maintain sufficient cardiac output This is prevented by (Reactive pulmonary hypertension) Alveolar and capillary thickening Pulmonary arterial vasoconstriction Pulmonary hypertension leads to R/ ventricular hypertrophy, dilation and failure with subsequent tricuspid regurgitation JMJ 6

7. Symptoms Palpitation Systemic emboli JMJ 7 Dyspnoea Pulmonary infections (Recurrent bronchitis) Haemoptysis Cough R/ heart failure Fatigue Abdominal and lower limb swelling Atrial fibrillation Pulmonary Hypertension

8. 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 JMJ 8

9. 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

10. 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 JMJ 10

11. 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 JMJ 11

12. 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 JMJ 12

13. Signs (Palpation) Tapping impulse felt parasternally on left side Palpable 1 st heart sound Combined with left ventricular backward displacement Produced by an enlarging left ventricle Sustained parasternal impulse Due to R ventricular hypertrophy JMJ 13

14. Signs (Auscultation) Loud 1 st 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 JMJ 14

15. 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) JMJ 15

16. How to determine the severity of mitral stenosis Presence of pulmonary hypertension  Recognized by R/ ventricular heave & loud pulmonary component of 2 nd heart sound And signs with R heart failure : Oedema , hepatomegaly Graham Steell murmur JMJ 16

17. How to determine the severity of mitral stenosis Closeness of the opening snap to the 2 nd heart sound ∞ severe MS Length of mid-diastolic murmur ∞ severity As the valve cusps become immobile Loud 1 st heart sound softens Opening snap diasppears When pulmonary hypertension occurs : P2 intensity increase, mid diastolic murmur become quieter JMJ 17

18. Investigations Chest X-ray Electrocardiogram Echocardiogram Cardiac magnetic resonance Cardiac catheterization JMJ 18

19. 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 JMJ 19

20. 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 JMJ 20

21. Investigations –ECG JMJ 21

22. Investigations –ECG JMJ 22

23. 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 thrombus JMJ 23

24. 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 JMJ 24

25. Treatment Operative therapies Trans-septal balloon valvotomy Closed valvotomy Open valvotomy Mitral valve replacement JMJ 25

26. 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 JMJ 26

27. Treatment: Trans-septal balloon valvotomy JMJ 27

28. 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 procedure JMJ 28

29. 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 JMJ 29

30. Treatment: Open valvotomy Often preferred to closed valvotomy Cusps are carefully dissected apart under direct vision Cardiopulmonary bypass is requied JMJ 30

31. 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 JMJ 31

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