Mitral stenosis and regurgitation sushila

M&S

1. Mitral Regurgitation
Mitral Stenosis

2. Mitral Regurgitation
Mitralregurgitation(MR)involvesbloodflowing
backfromleftventricleintoleftatriumduring
systole.
Oftenthemarginofmitralvalvecannotclose
duringsystole.
Theleafletscannotclosebecauseofthickening
andfibrosisofleafletsandchordaetendinae
resultingintheircontraction.

4. Etiology
Degenerative changes of mitral valve (e.g.mitral
valve prolapse)
Ischemia of left ventricle
Rheumatic heart disease
Myxomatouschanges which enlarges left atrium
and ventricle
Infective endocarditis may cause perforation of
leaflet
Collagen vascular diseases (e.g. systemic lupus
erythematous)
Cardiomyopathy

5. Pathophysiology

6. Clinical Features
Symptoms :
Chronicmitralregurgitationisoften
asymptomatic
Acutemitralregurgitationusually
manifestsasseverecongestiveheart
failure
Fatigue
DyspneaonExertion
Palpitation
Cough

7. Clinical Features
Signs
Pulse:Briskcarotidupstroke,AtrialFibrillation
BloodPressure:Usuallynormal
Apex:Laterallydisplaced,diffuse,illsustained
S1-Normal
S3-Present(severeMR,andincreaseswith
expiration)
Murmur–Pansystolic,Blowingmurmuratthe
apexradiatingtoaxilla(withprolapseofthe
Posteriorleaflet–towardsbase)
Amylnitratedecreasesthemurmur

8. Investigations
E.C.G.
Atrial fibrillation in 60 –75 %, and 50 % in surgically
corrected cases.
Left Ventricular Hypertrophy
Chest X –Ray
Cardiomegaly
Dilated Left Atrium
Echocardiography:
Loss of function of leaflets
Dilated Left Atrium, Left Ventricle and Left Ventricular
Hypertrophy
Rheumatic MR –thickened leaflets
Ischaemic MR -ruptured chordae, regional wall motion
abnormalities, flail leaflets

9. Investigations
Dopplerechocardiographyisusedto
diagnoseandmonitortheprogressionof
mitralregurgitation.
Transesophageal echocardiography
providesthebestimagesofthemitral
valve.

10. Managementissimilartocongestiveheartfailure.
PatientswithMRbenefitfromafterloadreduction
(arterialdilation)bytreatmentwith,
Angiotensinconvertingenzyme(ACE)inhibitors
Hydralazine
RheumaticfeverandInfectiveendocarditis
prophylaxis.
Atrialfibrillationrateiscontrolbyuseofdigoxin
andbetablockers,amiodarone.
Medical Management

11. Surgical Management
Mitral valve reconstruction
Mitral valve replacement
MVRshouldbeperformedbefore
LVfunctiondeterioratesirreversibly.

12. Mitral Stenosis
Mitralstenosisisanobstructionofblood
flowingfromtheleftatriumintotheleft
ventricle.
Oftencausedbyrheumaticendocarditis,
whichprogressivelythickensthemitral
valveleafletsandchordaetendineae.
Theleafletsoftenfusetogether.

13. Mitral Stenosis

14. Etiology
Rheumatic Fever
Congenital
Infective Endocarditis
Connective Tissue Disorders
Massive Annular Calcification
EndocardialFibroelastosis
Prosthetic Valve

15. Pathophysiology

16. Clinical Features
Asymptomatic
Dyspnea, orthopnea and PND ( due to
redistribution of blood to thorax when supine)
Palpitations ( frequent PACs or paroxysmal Atrial
fibrillation / flutter )
Fatigue
Hemoptysis:
a) alveolar capillary rupture
b) chronic bronchitis due to edematous
mucosa
c) pulmonary infarction
d) pulmonary apoplexy-rupture of bronchial
veins
e) anticoagulant use

17. Systemicembolism:in20-30%
Cerebral,mesenteric,aorticbifurcation,
atrialfibrillation,increasingage,previous
historyofthromboembolism,increasingLA
size.
Pulmonary edema:Precipitateby
uncontrolledatrialfibrillation,exercise,chest
infection,pregnancy,anesthesia,emotional
stress
Chestpain:Rightventricularhypertrophy
Dysphagia,Hoarsenessofvoice
Clinical Features

18. Atrial Fibrillation
Embolism
Acute Pulmonary oedema
Pulmonary HTN
Right Ventricular Hypertrophy/ Dilatation
Tricuspid Regurgitation
Heart Failure
Left Ventricular Dysfunction
Chest Pain
Infective Endocarditis
Complications of Mitral
Stenosis

19. Investigations
ECG and cardiac catheterization with angiography
may be used to determine the severity of mitral
stenosis.
Chest X-Ray:
Heart shadow normal in size
Evidence of LA enlargement:-
Straightening of left heart border (LA
appendicular enlargement)
Central radio density
Elevation of left main bronchus

20. Investigations
ECHOCARDIOGRAPHY
Thickened / Calcified Leaflets
Thickening / Shortening / Fusion of chordae
Fusion of the commissures
Calcification of the annulus
Decreased EF slope (Normal 70 to 150 cm/sec)
LA enlargement / thrombus
LV size: normal or small
RV: enlarged

21. Treatment
A)Medical
Rheumaticfeverprophylaxis
Infectiveendocarditisprophylaxis
Restrictionofphysicalactivitywithinone’s
cardiacreserve
Arrhythmias–restoresinusrhythmifpossible
Emboli–anticoagulants
Elevatedpulmonaryvenouspressure–diuretics
Heartfailure–digitalis,diuretics,ACEinhibitors

22. B)Interventional
Indications of PTMC
Pulmonary arterial hypertension
Episodic pulmonary oedema
Persistent or recurrent atrial fibrillation
Thromboembolism
Pregnancy
C)Surgical
Closed mitral commissurotomy(CMC)
Open mitral commissurotomy(OMC)
Mitral valve replacement (MVR)
Treatment

23. IstTrimester:Assessthepatient.Ifsymptomaticdo
echo,ifMSisnotcriticalclosefollowupanduse
diuretics.Ifstenosisiscritical,planforPTMC
(preferred)intheIIndTrimester.
IIIrdTrimester:Hospitaldelivery,supervisedjointly
bycardiologistandobstetrician.Secondstageof
labourmustbeshortandassisteddeliveryis
preferred.Becauseincreasedvalsalvaeffortmay
precipitatepulmonaryoedema.
Management of MS in
Pregnancy

24. Any Query ????