Mitral Stenosis
Jan 15, 2016
Mitral Stenosis
Etiology
• Most cases of mitral stenosis are due to rheumatic fever
• The rheumatic process causes immobility and thickening of the mitral valve leaflets, with fusion of the commissures.
• Leaflet calcification and subvalvular fusion occur in the late stages of the disease.
PathophysiologyObstruction
Increased left atrial pressure Maintains LV Cardiac Output
Increased pulmonary venous and capillary pressures Exertional dyspnea
Reflex pulmonary arteriolarconstriction
Decreasing the amount of blood flowing through the lungs which lessens the likelihood of pulmonaryedemaPulmonary Hypertension
Right Ventricular Hypertrophy
RV Failure
Pathophysiology
• Atrial contraction is an important component of LV filling
• Loss of atrial contraction when atrial fibrillation develops results in about a 20% reduction in cardiac output
• The left ventricle is spared from both pressure and volume overwork in the pathophysiology of mitral valve obstruction
History
• Dyspnea, cough, and wheezing
• Hemoptysis
• Chest pain
• Thromboembolism
Physical Examination
• PMI of the LV is usually quiet
• Significant pulmonary hypertension may result in a left parasternal systolic lift indicating marked RV hypertrophy
Physical Examination
• Jugular Venous Pulse – a prominent a wave with pulmonary hypertension
• The arterial pulse is usually normal
Physical Examination
• S1 is accentuated due to the elevated LA pressure which does not allow the leaflets to float to a closed position
• S2 – the P2 component will become accentuated with pulmonary hypertension
S1 A2 P2S1 A2 P2
Physical Examination
• The Opening Snap• Occurs with the
abrupt cessation of movement of the mitral valve apparatus into the LV during early diastole
• Heard best at the apex and left sternal border
S1 S2 OS
Physical Examination
• The Murmur• A low pitched
rumbling diastolic murmur immediately following the OS
• Heard best at the apex
S1 S2 OS S1
Systole Diastole
Radiology
EKG
Echocardiography
Echocardiography
Cardiac Catheterization
Medical Management of Mitral Stenosis
• Subacute Bacterial Endocarditis Prophylaxis
• Diuretics
• Treatment of Arrhythmias– Digoxin– Anti-arrhythmic drugs
• Anticoagulation
When To Consider Surgical Management of Mitral Stenosis
• Usually there is a 15-20 year delay between an episode of rheumatic fever and the development of symptoms of MS
• The general indication for surgical intervention in chronic mitral stenosis is the presence of significant symptoms in spite of medical management
• Timing of intervention is based on numerous factors such as age of the patient, functional status, severity of the stenosis, and type of intervention
Interventional Management of Mitral Stenosis
• There are three general types of operative approaches in the treatment of mitral stenosis– Open Valvotomy - palliative therapy– Mitral Valve replacement– Balloon Valvuloplasty – palliative therapy
Balloon Valvuloplasty
Balloon Valvuloplasty
Mitral Regurgitation