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MD Professor of Medicine Medical College Hospital Thiruvananthapuram 1 Definition : Definition Mitral Valve Stenosis is a narrowing of the mitral valve orifice area to less than 2.5cm2 and thus resulting in an obstruction to the flow of blood from LA to LV 2 Anatomy & physiology : Anatomy & physiology Mitral Stenosis 3 Anatomy : Anatomy The mitral valve is the inlet valve to LV. There are two mitral valve leaflets, namely the anterior and posterior, which are attached to an outer fibrous ring 4 Normal Physiology : Normal Physiology In normal cardiac physiology, the mitral valve opens during left ventricular diastole to allow flow of blood, from left atrium to the left ventricle 5 Mitral Blood Flow : Mitral Blood Flow During diastole, blood flows from LA to LV because during this phase of the cardiac cycle the pressure in the LV is lower than that in LA 6 Mitral Valve - Video : Mitral Valve - Video This video demonstrates the anatomy of mitral valve, papillary muscles and chordae tendinae and also describes the basic physiology 7 Pathophysiology : Pathophysiology In presence of mitral valve stenosis the valve orifice is narrowed reducing the flow of blood from the left atrium to the left ventricle 8 Incidence : Incidence Pure Mitral Stenosis in combination with other lesions occurs in approximately 40% of all patients with rheumatic valvular heart disease 9 Combined Lesions : Combined Lesions In other patients with RHD, lesser degrees of MS may accompany mitral regurgitation (MR) and or aortic valve disease (AS or AR) 10 Current Status : Current Status With reductions in incidence of acute rheumatic fever, worldwide occurrence of Mitral Stenosis has declined over past few decades 11 Our Scenario : Our Scenario However, it remains a major problem in developing nations, especially in tropical and semitropical climates of the world, like India 12 Morbidity and Mortality : Morbidity and Mortality If symptoms are absent or minimal, the 10-year survival rate of untreated patients with MS is 80%. Once symptoms develop, the mortality 13 etiology : etiology Mitral Stenosis 14 Rheumatic Fever : Rheumatic Fever Rheumatic fever occurs, in genetically susceptible individuals, as an uncommon complication of group A hemolytic streptococcal infection of throat 15 Streptococcal Infection : Streptococcal Infection Not all cases of streptococcal pharyngitis lead to rheumatic fever. In fact, only 2-3% of patients with untreated pharyngitis develop it 16 Etiology : Etiology Most cases of Mitral Valve Stenosis are secondary to rheumatic fever and the consequent rheumatic heart disease later in life 17 Pathogenesis & pathology : Pathogenesis & pathology Mitral Stenosis 18 Mitral Valve Apparatus : Mitral Valve Apparatus The normal mitral valve is composed of an annulus and two leaflets attached to two papillary muscles by means of chordae tendineae 19 Pathogenesis : Pathogenesis Lesions of mitral valve begin as deposits of fibrin and red blood cells that form small verrucae along the borders of valve leaflets 20 Pathogenesis : Pathogenesis Patients then develop over years fibrosis of mitral ring, contracture of leaflets, chordae and papillary muscles and commissural adhesions binding the valve leaflets 21 Fish Mouth Valve : Fish Mouth Valve These changes, in turn, lead to narrowing at the apex of the funnel-shaped ("fish-mouth") valve, when the mitral valve is seen from above 22 Non-specific Changes : Non-specific Changes Though the initial insult to the mitral valve is rheumatic in origin, later changes are nonspecific resulting from trauma to the valve caused by altered flow patterns 23 Symptomatic Mitral Stenosis : Symptomatic Mitral Stenosis By 2nd or 3rd decade, calcium deposits further constrict the effective orifice of the already damaged mitral valve and symptoms begin to appear. 24 Calcification of Mitral Valve : Calcification of Mitral Valve Calcification of the stenotic mitral valve immobilizes the leaflets. It also results in thrombus formation and then arterial embolization may arise out of it 25 Significant MS : Significant MS Normal Mitral Valve orifice cross-sectional area is 4-6 cm2. When it is reduced to less than 2.0 cm2, hemodynamically significant Mitral Stenosis occurs 26 The Aperture in MS : The Aperture in MS At 1 cm2, obstruction to blood flow becomes severe. The short axis view in echocardiogram of this patient showed the mitral valve of which area was 0.67cm2 27 Hemodynamics : Hemodynamics Mitral Stenosis 28 Left Atrial Pressure : Left Atrial Pressure The normal left atrial pressure is 8 to 10mm of Hg. It is indirectly measured by the Pulmonary Artery wedge pressure by right heart catheterization 29 Left Atrial Pressure in MS : Left Atrial Pressure in MS The valve does not open completely, and so to transport the same amount of blood, the LA needs a higher pressure than normal 30 Pathogenesis of Pulmonary Edema : Pathogenesis of Pulmonary Edema An increase in blood flow across the stenotic mitral valve as in pregnancy, exercise emotional stress and fever leads to increase in LAP & PAP 31 Effect of Tachycardia : Effect of Tachycardia An increase in heart rate shortens diastole proportionately more than systole and diminishes the time available for flow across the stenosed valve 32 Tachycardia due to AF : Tachycardia due to AF At any given level of cardiac output, tachycardia augments the trans-valvular pressure gradient and elevates the left atrial pressure further 33 Left Ventricular Pressure : Left Ventricular Pressure The Left Ventricular diastolic pressure and ejection fraction (EF) are normal in isolated Mitral Stenosis. Hence left ventricle is seldom affected by pure MS 34 Cardiac Output : Cardiac Output In patients with moderate Mitral Stenosis (orifice 1.0 cm2–1.5 cm2), the cardiac output is normal at rest; but rises only subnormally during moderate exertion 35 Pulmonary hypertension : Pulmonary hypertension Mitral stenosis 36 Pulmonary Artery Pressure : Pulmonary Artery Pressure The clinical and hemodynamic features of rheumatic Mitral Stenosis are influenced importantly by the level of the Pulmonary Artery Pressure 37 Pulmonary Artery Pressure : Pulmonary Artery Pressure The elevated pulmonary venous and pulmonary arterial pressures reduce pulmonary compliance, contributing to exertional dyspnoea in severe MS 38 Pulmonary Artery Hypertension : Pulmonary Artery Hypertension Pulmonary Artery Hypertension develops eventually in all patients with rheumatic mitral Stenosis and it is due to at least three different mechanisms 39 Pulmonary Vasoconstriction : Pulmonary Vasoconstriction In PAH, pulmonary arteries constrict, resulting in increased resistance to pulmonary blood flow and increased pulmonary blood pressure 40 Hypertrophy : Hypertrophy Hypertrophy of the medial layer of the pulmonary arteries occurs as a result of proliferation of pulmonary vascular smooth muscle cells 41 Intimal Fibrosis : Intimal Fibrosis This causes the pulmonary arteries to become stiff and to thicken. As the vessels narrow, they can become completely obliterated 42 Right ventricular hypertrophy : Right ventricular hypertrophy Mitral Stenosis 43 Right Ventricular Hypertrophy : Right Ventricular Hypertrophy Increased vascular resistance associated with PAH forces the right ventricle of the heart to work harder leading to right ventricular hypertrophy 44 Right Ventricular Hypertrophy : Right Ventricular Hypertrophy Right ventricular Hypertrophy in mitral stenosis produces thickening of the walls of the chamber and indicates the presence of significant PAH 45 Right Ventricular Hypertrophy : Right Ventricular Hypertrophy When cardiac muscle of the right ventricle gets hypertrophied the thickness of the muscle increases even more than that of the left ventricle 46 Right Ventricular Dilatation : Right Ventricular Dilatation The right ventricle which is initially hypertrophied then starts failing and thus gets enlarged. This enlargement is in a upward and left ward 47 Secondary Tricuspid Regurgitation : Secondary Tricuspid Regurgitation As right ventricular chamber enlarges, the tricuspid valve ring gets dilated and results in significant tricuspid valve regurgitation 48 Pulmonary Regurgitation (PR) : Pulmonary Regurgitation (PR) Later pulmonary regurgitation develops when there is significant PAH. It produces an early diastolic murmur in the pulmonary area 49 Right-sided Heart Failure : Right-sided Heart Failure Finally the patient develops right sided heart failure with raised JVP, tender hepatomegaly and bilateral pitting pedal or sacral edema 50 Atrial fibrillation : Atrial fibrillation Mitral Stenosis 51 Atrial Fibrillation : Atrial Fibrillation Approximately 30-40% of patients with MS eventually develop atrial fibrillation. AF may cause several hemodynamic upsets in MS 52 Effects of Atrial Fibrillation : Effects of Atrial Fibrillation Loss of the atrial kick to the LV filling results in further diminution of already compromised CO. in ventricular rate leads to further reduction in EDV 53 Congestive Heart failure : Congestive Heart failure Mitral Stenosis 54 The Vicious Cycle of CHF : The Vicious Cycle of CHF An increase in blood flow across the stenotic mitral valve by a reduction in diastolic filling time due to increased heart rate, perpetuates the cycle 55 Summary of Hemodynamics : Summary of Hemodynamics The various hemodynamic consequences of Mitral Rheumatic Stenosis are demonstrated in the chart including the mechanism of CHF 56 complications : complications Mitral Stenosis 57 Respiratory Infections : Respiratory Infections Pulmonary infections, i.e., bronchitis, bronchopneumonia, and lobar pneumonia, commonly complicate untreated Mitral Stenosis 58 Left Atrial Thrombus : Left Atrial Thrombus Thrombi may form in the left atria, particularly in the enlarged atrial appendages and these may get dislodged resulting in embolism 59 Left Atrial Thrombus : Left Atrial Thrombus In patients with atrial fibrillation (AF), complicating mitral stenosis, thrombi arise more frequently and get embolized from the dilated left atrium 60 Systemic Embolization : Systemic Embolization Systemic embolization, the incidence of which is 10–20% occurs more frequently in patients with AF, in older patients, and in those with a reduced CO 61 Pulmonary Emboli : Pulmonary Emboli Recurrent pulmonary emboli sometimes with pulmonary infarction, are an important cause of morbidity and mortality late in the course of MS 62 Endocarditis : Endocarditis Infective Endocarditis is rare in isolated Mitral Stenosis. How ever development of mitral valve regurgitation significantly increases the chance 63 Symptomatology : Symptomatology Mitral Stenosis 64 Symptoms of Mitral Stenosis : Symptoms of Mitral Stenosis Patients may remain asymptomatic for a long period of time in spite of significant valve narrowing. Eventually all patients become symptomatic 65 Progressive Exertional Dyspnoea : Progressive Exertional Dyspnoea Progressive exertional dyspnoea is the classical presenting symptom of mitral stenosis occurring in majority of patients over a period of time 66 Paroxysmal Nocturnal Dyspnoea : Paroxysmal Nocturnal Dyspnoea Here the patient wakes up from bed during the later part of the night gasping for breath and finds that an open window gives comfort 67 Orthopnea : Orthopnea Orthopnoea is breathlessness occurring only while lying down. This is due to several mechanisms like elevation of diaphragm & increased venous return 68 Resting Dyspnoea : Resting Dyspnoea Resting dyspnoea occurs during late stage of Mitral valve Stenosis. It indicates presence of significant mitral stenosis 69 Hemoptysis : Hemoptysis Hemoptysis in Mitral Stenosis results from rupture of pulmonary-bronchial venous connections secondary to pulmonary venous hypertension 70 Hemoptysis : Hemoptysis It occurs most frequently in patients who have elevated LA pressures without markedly elevated pulmonary vascular resistance 71 Dysphagia : Dysphagia Dysphagia may occur from compression of the esophagus by an enlarged left atrium and the left ventricle if associated with mitral regurgitation or AS 72 Other Symptoms : Other Symptoms Several other symptoms may become the initial presenting feature of Mitral Stenosis. Some of these are totally atypical symptoms 73 Cardiac Cachexia : Cardiac Cachexia It occurs in presence of severe mitral stenosis as a result of significantly reduced cardiac output and decrease in perfusion of peripheral tissues 74 Pulse : Pulse Mitral Stenosis 75 Examination of Pulse : Examination of Pulse Examination of Pulse in MS may be normal or it may reveal a low volume pulse called as pulsus parvus indicating a reduction in cardiac output 76 Pulse Irregularity : Pulse Irregularity The most important finding to be detected in the pulse in association is the presence of an irregularly irregular rhythm due to atrial fibrillation 77 Apex Pulse Deficit : Apex Pulse Deficit The apex pulse deficit is checked simultaneously and if the AP deficit is more than 10 per minute, it considered as positive proof of Atrial fibrillation 78 Blood Pressure : Blood Pressure Blood pressure recording in Mitral Stenosis usually reveals a normal value unless there is severe mitral stenosis in which case there is low BP 79 Jugular venous pressure : Jugular venous pressure Mitral Stenosis 80 Jugular Venous Pressure : Jugular Venous Pressure The pressure is assessed by measuring the upward distance from the ankle of Louis to the upper level of the jugular venous pulsations in neck 81 Jugular Venous Pressure in MS : Jugular Venous Pressure in MS Jugular venous pressure is normal if there is no heart failure. When the patient develops CHF the jugular venous pressure becomes elevated 82 Jugular Venous Pulse : Jugular Venous Pulse Jugular venous pulse when examined in relation to the carotid artery pulsation, reveals a large a wave in the absence of any atrial fibrillation 83 Absent a wave in the JVP : Absent a wave in the JVP In presence of atrial fibrillation, in association with Mitral stenosis, the ‘a’ wave in the Jugular Venous Pressure disappears and only the ‘v’ wave is visible 84 Inspection & palpation : Inspection & palpation Mitral Stenosis 85 Apex Beat Position : Apex Beat Position The apex beat is usually felt in normal position in isolated mitral stenosis. But if there is associated mitral regurgitation or Aortic Valve Disease it varies 86 Normally Placed Apex (PMI) in MS : Normally Placed Apex (PMI) in MS The apex beat position does not change in patients with MS because, hypertrophy produced in the Right ventricle does not displace the heart 87 Left Para-sternal Heave : Left Para-sternal Heave In patients with significant mitral stenosis a left parasternal heave is usually palpable indicating the presence of right ventricular Hypertrophy 88 auscultation : auscultation Mitral stenosi 89 Auscultation of the Apex : Auscultation of the Apex In suspected MS the apex of the patient is carefully auscultated in the supine position looking for any alteration in the heart sounds or any murmur 90 Normal Auscultation of Mitral Area : Normal Auscultation of Mitral Area The normal auscultation of the mitral area reveals the 1st and 2nd heart sounds only, without any additional sounds or murmurs 91 Left Lateral Decubitus Position : Left Lateral Decubitus Position Now the mitral area is carefully auscultated with the patient turned to the left lateral decubitus position with the bell and the breath held in expiration 92 Loud First Sound : Loud First Sound A loud S1 occurs in Mitral stenosis because the stenosed valve is kept fully open at the end of diastole because of a higher pressure gradient 93 Accentuated First Heart Sound : Accentuated First Heart Sound Loud S1 is due to an abrupt closure of a stenotic but still pliable valve. Intensity of S1 is directly proportional to the LA-LV pressure gradient at the end of diastole 94 The Opening Snap : The Opening Snap The opening of the MV in normally does not produce any sound, but in presence of significant pressure gradient in MS, the valve opens with a snap 95 A2-OS Interval : A2-OS Interval In mild MS, LA pressure is only mildly increased; the valve opens at a normal interval after the S2; as severity of MS increases shorter is the A2 to OS gap 96 Mid-diastolic Murmur : Mid-diastolic Murmur It begins at the time of opening of mitral valve and increases following atrial contraction as long as the patient is in NSR. It is low frequency and rumbling May May Heard best Best heard Increases May No change 97 Mitral Stenosis Murmur : Mitral Stenosis Murmur In this audio which has three parts one can hear a long mitral diastolic murmur, a short MDM with an OS and a severe Mitral Stenosis murmur 98 Accentuated P2 : Accentuated P2 P2 increases in intensity in direct proportion to elevation of pulmonary artery pressure. Later an early diastolic Graham Steel murmur of PR may appear 99 Differential diagnosis : Differential diagnosis Mitral Stenosis 100 Left Atrial Myxoma : Left Atrial Myxoma It can produce a ‘tumor plop’ on auscultation and change in intensity of the murmur with position of the patient and a characteristic echo mass in the Lt Atrium 101 Ball Valve Thrombus : Ball Valve Thrombus Often associated with rheumatic MS, ball valve thrombus has a potential for fatal systemic emboli or occlusion of the mitral valve resulting in sudden death 102 Unusual causes of MS : Unusual causes of MS Other causes of acquired Mitral Stenosis include Carcinoid syndrome, Systemic Lupus, Rheumatoid Arthritis, Amyloidosis and Mucopolysaccharidoses 103 investigations : investigations Mitral stenosis 104 ECG Findings in MS : ECG Findings in MS ECG is often within reference ranges in patients with mild MS. In those with moderate MS, ECG tracing shows LA enlargement by P Mitrale, RVH, and AF 105 Broad and Notched P wave : Broad and Notched P wave The P wave in lead II is classically broad and notched with an M pattern. Width of the P wave is more than 3mm. Also the 2nd component of P wave is taller 106 Left Atrial Enlargement in ECG : Left Atrial Enlargement in ECG The normal p wave is due to an overlap of electrical potentials of the right and left atrium. When left atrium gets enlarged the shadow is displaced to the right Right atrial Potential Left atrial Potential P Mitrale P Normal P Normal P Mitrale 107 ECG Change in RVH : ECG Change in RVH Right ventricular Hypertrophy can be identified in the ECG recording with a tall R wave in lead V1 and a deep S wave in lead V6 along with RAD 108 Chest X-Ray PA view : Chest X-Ray PA view The chest X-RAy provides an excellent idea regarding the various hemodynamic and patho-physiological changes in rheumatic mitral stenosis 109 Shadow in Shadow : Shadow in Shadow Left atrium causes double outline (right arrow) and is somewhat grossly dilated. Left atrial appendage is also dilated, causing a prominence of the left border 110 Pulmonary Venous Hypertension : Pulmonary Venous Hypertension Arrow points to a dilated upper lobe vein. A branch of a dilated upper lobe artery lies medial to it. There is therefore upper lobe blood diversion 111 Kerley “B” Lines : Kerley “B” Lines Short horizontal line shadows or septal (Kerley "B") lines seen above the costo-phrenic recesses, indicates interstitial oedema of the septa 112 Straight Left Border : Straight Left Border The heart shadow is more than half of the chest diameter and it has a straight left border. There is peri-hilar hazy shadows with visible bronchi 113 CXR in MS with PAH : CXR in MS with PAH Heart is enlarged and its otherwise straight left margin has a bulge over the left hilum. The main branches of pulmonary artery, still large at the hilum, taper rapidly 114 X-Ray of PAH : X-Ray of PAH Severe pulmonary artery hypertension is seen as an enlargement of the main pulmonary artery segment, as well as the right pulmonary artery 115 Chest X-Ray in Combined Lesion : Chest X-Ray in Combined Lesion When MS is associated with MR or AR the cardiac size enlarges and the apex is shifted down and out and the left ventricular margin is seen bulging out 116 Normal M Mode ECHO : Normal M Mode ECHO It shows the excursions of the mitral valve as a M W pattern, E (early opening) and F (mid-diastolic closure), C (closure of MV) and D (end systole) 117 M Mode Echocardiography : M Mode Echocardiography It used to be the easy and primary investigation to diagnose MS. Leaflet tips are bright (calcified) and thickened The EF slope is decreased 118 M Mode Echo findings : M Mode Echo findings The excursions of normal mitral valve produces the classical M pattern in M Mode Echo. In MS the valve is thickened immobile with a reduction in EF slope 119 Echocardiography : Echocardiography Gives direct anatomic data including visualization of morphology and motility of valve leaflets and measurement of valve orifice dimensions, LAE & RVH 120 2D Echocardiography : 2D Echocardiography It provides hemodynamic and physiologic data including the pressure gradient across stenotic mitral valve, presence and severity of MS as well as MR 121 Parasternal Long Axis View : Parasternal Long Axis View The para-sternal long axis view shows the features of the mitral valve including the orifice, thickening of the leaflets and the relative motion of the leaflets 122 3 D Echocardiography : 3 D Echocardiography This sequence of echocardiographic pictures show the two dimensional, followed by three dimensional videos of the normal valve movements 123 Trans-Esophageal Echo : Trans-Esophageal Echo It is recommended when TTE is incomplete, especially if left atrial thrombus is suspected and in the operating room and catheterization laboratory 124 Cardiac Catheterization : Cardiac Catheterization It is used to obtain direct measurement of the pressure gradient across the mitral valve as well as pulmonary artery wedge pressure 125 Rheumatic Reactivation : Rheumatic Reactivation ASO is nonspecific, unless the patient is experiencing an acute attack of recurrent rheumatic fever, in which case, C-reactive protein, ESR and ASO are also high 126 Medical Management : Medical Management Mitral Stenosis 127 Salt Restriction : Salt Restriction Salt intake should be restricted to 3-5 gm per day and excessive fluid intake minimized to avoid exacerbating signs and symptoms of congestive heart failure 128 Activity : Activity Patients should avoid strenuous exertion. Increased heart rate may result in decreased diastolic filling, thereby decreasing CO. AF may further impair CO 129 Digoxin : Digoxin Digoxin is used to slow (AV) node conduction and decrease ventricular rate response. Resistant AF may require electrical cardioversion or surgery 130 Treatment of AF : Treatment of AF AF require medical treatment aimed at restoration and maintenance of sinus rhythm. If it is not possible, decrease the ventricular response to atrial contraction 131 Anticoagulation : Anticoagulation Warfarin titrated to an INR of 2-3 should be given for at least 1 year to patients with MS who have suffered from embolization and permanently if AF 132 Surgical management : Surgical management Mitral Stenosis 133 Indications for Valvuloplasty : Indications for Valvuloplasty A) Suitable anatomy, No LA clot, ≤ mild MR. B) Symptomatic pts (NYHA class II-IV) & MVA>1.5 cm2 C) Asymptomatic patients with MVA <1.5 cm2 134 Contraindications for Valvuloplasty : Contraindications for Valvuloplasty The major contraindications for mitral valvuloplasty are calcification of the mitral valve, moderate mitral regurgitation and left atrial thrombus formation 135 Mitral Valvuloplasty : Mitral Valvuloplasty A right heart catheter is passed through a temporary hole made in the atrial septum and the tip passed through the mitral valve and catheter balloon inflated 136 Commissurotomy : Commissurotomy Surgery is indicated when the valve is not amenable to balloon valvuloplasty with incision of fused mitral valve commissures and shaving of thickened mitral leaflets 137 Mitral Restenosis : Mitral Restenosis After mitral valvuloplasty for severe MS, restenosis occurs by fibrosis along the annulus. These patients may later require MVR with a prosthetic valve 138 Mitral Stenosis+Regurgitation : Mitral Stenosis+Regurgitation MS and MR are said to co-exist when the valve is neither able to open fully nor able to close fully resulting in obstruction as well as incompetence 139 Mitral valve Replacement : Mitral valve Replacement MVR is reserved for patients in whom mitral valvotomy is considered unlikely to achieve a satisfactory result because of calcification or Mitral Regurgitation 140 Follow Up : Follow Up Asymptomatic patients with MS require yearly follow-up to monitor for disease progression including examination, ECG, CXR and Echo for soft thrombus 141 Prevention : Prevention Preventing recurrent attacks of rheumatic fever is absolutely essential, because otherwise it can lead to further aggravation of Mitral Stenosis 142 Slide 143: 143 Slide 144: Thank You for the Patient Listening 144 You do not have the permission to view this presentation. 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