Mitral valve pathophysiology

mitral valve- pathophysiology of mitral stenosis and mitral regurgitation. hemodynamics and etiology

1. PATHOPHYSIOLOGY OF MITRAL VALVE DISEASE

2. MITRAL VALVE LESIONS PURE MITRAL STENOSIS PURE MITRAL REGURGITATION COMBINED LESION with DOMINANT MS COMBINED LESION with DOMINANT MR

3. MITRAL STENOSIS

4. DEFINITION - MITRAL STENOSIS “ Narrowing of mitral valve orifice resulting in impedence of filling of left ventricle in diastole ”

5. ETIOLOGY OF MITRAL STENOSIS Rheumatic fever Congenital Carcinoid Heart disease SLE Rheumatoid arthritis Extensive mitral annulus calcification

6. CONGENITAL MS

7. HAMMOCK MV OR ARCADE MV

8. PARACHUTE MV

9. SUPRAMITRAL RING (SMR)

10. DOUBLE ORIFICE MV

11. HISTOPATHOLOGY RF  focal inflammatory lesions AND PANCARDITIS “ Aschoff ” bodies - swollen eosinophilic collagen “ Anitschkow ” cells - swollen macrophages

12. HISTOPATHOLOGY ANITSCHKOW CELLS ASCHOFF GIANT CELLS ( HALLMARK LESION )

13. RHD – chronic Organized acute inflammation (fibrosis) Leaflet thickening Commissure fusion ( stenosis ) (“ buttonhole ” or “ fishmouth ” stenoses ) Chordal thickening/fusion Aschoff bodies replaced with fibrous scar Calcification and fibrous scarring

14. HISTOPATH contd …

15. FIBRIN DEPOSITS GROSS PATHOLOGY

16. AML PML ALC PMC SEVERE SVD

17. THICKENED LEAFLETS Ca++ DEPOSITS THICKENED/FUSED CHORDAE

18. GIANT LEFT ATRIUM APPENDAGE SEVERE MS

19. Pathophysiology Impaired blood flow through mitral valve Elevated LA pressure Passively elevated pulmonary venous pressure Reactive pulmonary HTN (protection from lung congestion) Fixed pulmonary HTN (organic intimal & medial changes)

20. Pathophysiology … Pulmonary HTN Right ventricular hypertrophy & dilatation Tricuspid regurgitation (mostly functional) Right heart failure

21. PATHOPHYSIOLOGY

22. MV IN MITRAL STENOSIS “ SITE OF IMPEDENCE TO BLOODFLOW”

23. Right Panel: Sutten G, Anderson RH, et al. Slide atlas of cardiology. London: Medi-Cine Ltd., c1978:Slide 2. Copyright© American College of Cardiology . 5mmHg

24. Right Panel: Sutten G, Anderson RH, et al. Slide atlas of cardiology. London: Medi-Cine Ltd., c1978:Slide 3. Copyright© American College of Cardiology. 22mmHg

25. Mitral Stenosis and LA LA DILATATION FIBROSIS OF THE ATRIAL WALL DISORGANIZATION MUSCLE BUNDLES SUBSTRATE FOR ATRIAL FIBRILLATION CLOT

26. Mitral Stenosis and LA contd ….. ELEVATED MEAN LA PRESSURE PRODUCT OF MS SEVERITY COMPLIANT - PRESSURES DILUTED NONCOMPLIANT - PUL. CONGESTION LA COMPLIANCE

27. Mitral Stenosis and LV 85% - LVEDV,EJECTION INDICES ARE NORMAL REGIONAL HYPOKINESIS LV STIFFENING (SEPTAL DISPLACEMENT) LONG STANDING MS-CHRONIC REDUCTION IN PRELOAD AND ELEVATED AFTERLOAD EF%

28. PULMONARY ARTERY HYPERTENSION This pulmonary hypertension in MS has THREE components: Passive transmission of LA pressure Reactive pulmonary artery hypertension Potentially Fixed resistance, secondary to morphologic changes in the pulmonary vasculature

29. Reproduced with permission from Baim DS, Grossman W, eds. Grossman’s Cardiac Catheterization, Angiography, and Intervention. 6th ed. Lippincott Williams & Wilkins, 2000:761.

30. PULM. VASCULARITY – OLIGEMIA/ HYPEREMIA PULMONARY HAEMOSIDEROSIS (MOTTLING) PULMONARY ARTERIAL HYPERTENSION PERIPHERAL PRUNING CALCIFICATION OF CENTRAL PULMNARY ARTERY

31. Mitral stenosis - Symptoms MC:FATIGUE AND DECREASED EXERCISE INTOLERANCE Dyspnea Orthopnea PND (atypical) Hemoptysis Palpitations Hoarseness ( Ortner syndrome ) Chest pain ( atypical ) THROMBOEMBOLISM,IE - relatively rare

32. Mitral stenosis Late symptoms PHT, TR, right CHF: Easy fatigability Hepatic congestion Ascites Lower limb edema

33. PHYSICAL EXAMINATION Mitral facies - purple discoloration Small volume peripheral pulse JVP a - Raised atrial pressure a, v - Right heart failure cv  - Severe TR Tapping apical impulse (palpable S1) Palpable S2 - severe PHT Left parasternal lift - RVH

34. Physical examination… S1  - pliable valve Opening snap pliable valve Mid-diastolic rumbling murmur Presystolic accentuation Severity inflicted by murmur duration (rather than intensity)

35. Physical examination … Short A2-OS (<60 ms) - favors severe MS Additional Determinants of A2-OS LA pressure Closing pressure of aortic valve (systemic HTN) Differential diagnosis : S2 SPLIT,A2-S3,KNOCK,PLOP

36. Severity stratification by C/F : MS Phy . Findings Mild MS Mod. MS Severe MS Art. Pulses N N / AF vol., AF JVP N N ; large V waves(if TR) Apical impulse N, palpable S1 & OS RV lift, palpableS1&OS, apical dias. thrill, LV impulse  RV lift, palpableS1&OS, apical dias. thrill, LV impulse  Heart sounds S1, OS S1,OS,P2 S1,OS,P2 Diastolic murmur EDM/ PreSM PDM  thrill Loud PDM + apical thrill

37. If you're not confused, you're not paying attention .

38. MITRAL REGURGITATION

39. ETIOLOGY OF ACUTE MR

40. MITRAL ANNULUS DISORDERS

41. MITRAL LEAFLET DISORDERS

42. RUPTURE OF CHORDAE

43. PAPILLARY MUSCLE DISORDERS

44. PROSTHETIC VALVE

45. ETIOLOGY OF CHRONIC MR INFLAMMATORY RHD SLE SCLERODERMA DEGENERATIVE MVP CONN TISSUSE DISORDERS ANNULAR CALCIFICATION INFECTIVE STRUCTURAL CHORDAE/PAPILLARY MUSCLE DILATATION OF ANNULUS HOCM PARAVALVULAR LEAK

46. CARPENTIERS FUNCTIONAL CLASSIFICATION

47. TYPE I

48. TYPE II

49. TYPE III

50. STAGES OF MR

51. BLASÉ etal.NEJM;337:1997 . PATHOPHYSIOLOGY

52. PATHOPHYSIOLOGY contd … BLASÉ etal.NEJM;337:1997 .

53. CHRONIC MR

54. MR AND LV- LV COMPENSATION “MR BEGETS MORE MR”

55. LV IN ACUTE MR

56. LV IN CHRONIC MR

57. WHY EJECTION INDICES IMPORTANT IN MR?

58. EJECTION PHASE INDICES : EJECTION FRACTION, FRACTIONAL FIBRE SHORTENING, VELOCITY OF CIRCUMFERENTIAL FIBRE SHORTENING INVERSELY RELATED TO AFTERLOAD LOW-NORMAL RANGE OF INDICES IMPAIRED MYOCARDIAL FUNCTION ANY PT WITH EF OF 40-45% IMPLIES SEV LV DYSFUNCTION

59. WHY END SYSTOLIC VOLUME/DM - CHOSEN IN INDICATIONS FOR SURGERY AND PROGNOSTIGATION?

60. END SYSTOLIC VOLUME/DM INDEX FOR EVALUATING LV FUNCTION PREDICTOR OF FUNCTION AND SURVIVAL FOLLOWING MV SURGERY

61. LA COMPLIANCE NORMAL or REDUCED COMPLIANCE PROMINENT V WAVE SYMPTOMS OF PULMONARY CONGESTION MARKEDLY INCREASED COMPLIANCE THIN WALLED AF COMMON SYMPTOMS OF LOWCARDIAC OUTPUT MODERATELY INCREASED COMPLIANCE MOST COMMON VARIABLE SIZED LA/LA PRESSURE AF

62. MITRAL VALVE PROLAPSE

63. ISCHEMIC MR

64. AORTO MITRAL ANGLE

65. SYMPTOMS OF MR MOSTLY ASYMPTOMATIC CHRONIC WEAKNESS & FATIGUE –MOST COMMON DYSPNEA/ORTHOPNEA/PND PALPITATIONS ATYPICAL CHESTPAIN HEMOPTYSIS & SYSTEMIC EMBOLIZATION- LESS COMMON ACUTE MR - > RIGHT SIDED HEART FAILURE CHRONIC MR - > LEFT SIDED HEART FAILURE

66. PHYSICAL EXAMINATION No characteristic facies Small volume brisk/jerky pulse (small waterhammer ) JVP a - Decreased RV compliance a, v - Right heart failure v - Severe TR/ LAP In acute MR Hyperdynamic apical impulse ( , Thrill+ ) Parasternal lift( dilated LA,RVH) Palpable S2 - severe PHT

67. Physical examination… S1 , Loud S1 in MVP S2 –Wide split,loud P2, S3+ Holosystolic murmur Severity inflicted by murmur INTENSITY Radiates to axiila /back/base

68. MR contd …