RESEARCH ON MITRAL STENOSIS MADE BY DOCTOR FATIMA

What is Mitral stenosis ? And how can you understand it?

1. MITRAL STENOSIS Presented by: Dr Fatima Khan

2. Introduction : Normal mitral valve orifice 4-6 sq.cm Symptoms present if MS area <2.5 sq.cm Critical MS-area < 1 sq.cm

3. Etiology : Rheumatic – upto 99% Congenital Calcification of mitral valve leaflets Lute m bacher’s syndrome ( MS with ASD) Infective endocarditis Systemic diseases- carcinoid SLE RA mucopolysaccharide s

4. Pathophysiology : Normal Mitral Valve Function : 4 to 6 square centimetres Mitral valve opens during diastole Blood flows from left atrium to left ventricle Equal pressures during diastole Left ventricular filling: Early diastole: passive filling Late diastole: atrial kick

5. Mitral orifice area < 2 cm² Increased pressure gradient across mitral valve Left atrial pressure rises (up to 25 mmHg) Pressure transmitted to pulmonary vasculature Pulmonary hypertension Left Atrial Enlargement Chronic elevated left atrial pressure Increased risk of atrial fibrillation Atrial kick lost if atrial fibrillation develops Decreased left ventricular filling Decreased Cardiac Output Sudden development of congestive heart failure

6. Symptoms : Asymptomatic – detected on routine examination Exertional dyspnea/ PND Hemoptysis Chest pain (angina like) Fatigue ( decreased CO) Palpitations Edema, Ascites, Hepatomegaly

7. Clinical Signs : Mitral facies – cyanotic patch on cheek Peripheral cyanosis in severe MS Low volume pulse Tapping apex beat Left parasternal heave (RVH) Loud S1 Opening snap Mid diastolic murmur - low pitched, low frequency, rumbling quality,best heard in left lateral posi tion, on expiration

8. Evaluation : ECG changes in MS: LA enlargement ( P mitrale) RVH RV strain’s pattern RBBB/ RV dominance pattern Atrial fibrillation

9. 2. Chest Xray changes in MS: During early stages : normal heart size, straightening of the left border of the cardiac silhouette, prominent main pulmonary arteries, dilatation of the upper pulmonary veins, and displacement of the esophagus by an enlarged left atrium . During severe chronic stage : enlargement of all the chambers, pulmonary arteries, and pulmonary veins 3. Echocardiography in MS: for assessing mitral stenosis etiology, morphology, severity, and treatment intervention .

10. A score upto 8 is considered ideal for BMV/ PTMC

11. 4. Exercise echocardiogram: performed using an upright treadmill or supine bicycle with Doppler recording of transmitral and tricuspid valve velocities. This measures the transmitral gradient and pulmonary artery systolic pressure at rest and with exercise. 5. Cardiac Catheterization: should be performed to assess the severity of mitral stenosis when noninvasive tests are inconclusive or when there is a discrepancy between noninvasive tests and clinical findings regarding the severity of mitral stenosis .

12. Classification of Severity of Mitral Valve Stenosis ACC/AHA 2020 valve guidelines

13. Management : Medical Therapy Percutaneous Mitral Balloon Valvuloplasty Surgical therapy MEDICAL THERAPY: focused on Prophylaxis of Rheumatic fever : prophylaxis with Benzathine penicillin is the primary prevention treatment in patients with streptococcal pharyngitis. Prophylaxis of Infective Endocarditis : to high-risk patients before dental procedures involving gingival tissue manipulation or perforation of the oral mucosa .

14. 3. Treatment of AF : control the rate using AV node blocking agents such as beta-blockers, calcium channel blockers, and/or digitalis. In an unstable patient, perform direct current cardioversion. 4. Decreasing thromboembolic risk : Warfarin is the anticoagulation of choice with target INR 2.5

15. Balloon Valvuloplasty (PMBV) : indicated in symptomatic patients (New York Heart Association functional class greater than II) or asymptomatic patients with pulmonary hypertension with moderate or severe stenosis and favorable valve morphology in the absence of left atrial thrombus or moderate to severe mitral regurgitation. Mitral valve replacement surgery : indicated in patients with symptomatic moderate or severe mitral stenosis when percutaneous mitral balloon valvuloplasty is contraindicated or unfavorable valve morphology.