13- Mitral valve stenosis. Diagnosis of mitral valve insufficiency.

what is the etiology of mitral stenosis

• rheumatic fever

• non rheumatic

  • congenital valve deformity

  • degenerative calcification

what is the pathomechanism of MS

• decreased MVA → LA pressure increase → LA dilation

  • a fib

  • pulmonary HT

  • LA thrombus formation

• slow progression- asymptomatic for decades

what happens in untreated MS

• irreversible PH

• RV dysfunction

• low CO

what are the symptoms of MS

• dyspnea

• haemoptysis

• cerebral embolization

what are “mitral facies”

• bilateral cyanotic or dusky pink discolouration over the upper cheek

  • due to arteriovenous anastomoses and vascular stasis

describe the murmur in MS

• mi diastolic murmur

• opening snap after S2

  • forceful opening of mitral valve

• low pitched mid diastolic rumbling murmur- best heard at apex

• presystolic accentuation

  • if in sinu srhythm

• S1- short, sharp, accentuated

• functional pulmonary regurgitation

  • Graham- steel murmur- pulmonary HT

what is seen on a CXR in MS

• small heart, enlarged atria

• calcified mitral valve

• PHT, pulmonary oedema

what is seen on an ECG in MS

• a fib

• P mitrale- bifib

• RV hypertrophy

  • right axis eviation, tall R wave in V1

what is seen on an echo in MS

• mitral valve area <1.5cm^2

what is the treatment of asymptomatic MS

• high risk of HD decompensation

  • APSP >50mmHg, needs major cardiac surgery, desire for pregnancy

• high risk for thromboembolism

  • history of systemic embolisation, LA thrombus, SEC, a fib

what is the treatment of symptomatic MS

• percutaneous transvenous mitral commissurotomy

• surgery

what is the etiology of mitral regurgitation

• leaflet abnormality

  • anatomical abnormality ( organic)

• subvalvular apparatus

• LV/ LA/ annulus dilation

  • structurally normal abnormality (functional)

• other- eg haemodynamic cause

what is the course of development of MR

• chronic

• acute

what are the causes of leaflet abnormalities in MR

• endocarditis

  • acute + organic

  • fenestration, prosthetic valve PVL

• rheumatic

  • chronic, organic

• degenerative, mitral valve prolapse

  • organic

what are the causes of subvalvular apparatus in MR

• chordal rupture

  • acute + organic

  • haemodynamic, ischemic

• papillary muscle rupture

  • acute + organic

  • AMI

• papillary muscle remodelling/ dysfunction

  • chronic + functional

  • IHD

what are the causes of LV/ LA/ annulus dilation in MR

• primary/ secondary DCM

  • chronic + functional

• A fib, atrial remodeling

  • chronic + functional

what are the leading causes of MR

• IHD

• MV proapse

• cardiomyopathies

define acute mitral regurgitation

• no time for adaptation

• LV, LA dilation → acute pulmonary oedema, cardiogenic shock

what are the causes of acute MR

• endocarditis

• chordal/ PM rupture

what is the mechanism of chronic MR

• LV volume load (increased preload) → LV eccentric hypertrophy, LV dilation

• until LA pressure normal + CO normal= asymptomatic

• decreased LV compliance→ increased LVEDP, LAP- backward failure

• decreased LV contractility → decreased CO, forward failure

  • these 2 ⇒ symptoms

• untreated cases= pulmonary pressure increase → RV failure

how can you diagnose MR

• murmur

• ECG

• CXR

• Echo

what is the MR murmur

• S1 usually absent, soft

• S2- wide splitting in severe MR

• high pitched soft blowing holosystolic murmur

• p.m- apex, radiation to axilla

what is seen on an ECG in MR

• left axis deviation

• P mitrale

what is seen on a CXR in MR

• cardiac enlargement LA + LV

• pulmonary oedema

what can an echo tell us about MR

• grade of MR

• etiology + mechanism of MR

• degree of LV and LA dilation

• LV function

• pulmonary hypertension

• can show central or not central jet

  • if non central then its due to ischemic heart disease that causes restriction on posterior valve movement

what are the signs of severe MR in an echo

• ERO >0.4cm^2

• regurgitation volume >60ml

• regurgitation fraction >50%

what are the treatment options for organic MR

• mitral valve repair

  • surgical

  • percutaneous-

    • mitraclip

    • cardioband

    • neochord

• mitral valve replacement

  • xenograft

  • mechanical valve

what are the percutanous solutions of MR

• mitraclip- transcatheter, edge to edge repair

• cardioband- transcath. mitral annuloplasty

• neochord- transapical implantation of artificial chords

• transcatheter mitral valve implantation

  • TENDTNE device transapical

  • SATURN device transapical

what are the treatment options in functaional MR

• surgery

• HF treatment

• percutaneous repair

what are the indications for intervention

• symptoms

• LV EF <60%

• L ESD >40mm

• pulmonary HT- APSP >50mmHg

• LAVi >60ml/m^2

• new onset of atrial fibrillatio