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MITRAL STENOSIS

(MS)
INTRODUCTION

MS is narrowing of mitral valve orifice

Normal mitral valve orifice 4-6 sq.cm

Symptoms present if MS area <2.5 sq.cm

Critical MS- area < 1 sq.cm

F:M = 3:2, best 5-15 years


MITRAL VALVE APPRATUS

Anterior & posterior


leaflets
Mitral annulus
Chordae tendinae (120)
Papillary muscles

MS is usually valvular &


rarely due to the fusion
of sub valvular
components
Etiology

Rheumatic upto 99%


Congenital
Lutenbachers syndrome ( MS with ASD)
Systemic diseases
-carcinoid
-SLE
-RA
-mucopolysaccharides
-healed endocarditis
Pathology in MS

The leaflets are diffusely thickened by fibrous tissue &


Ca++ deposits

The mitral commisures fuse

Chordae tendinae fuse to shorten

The valvular cusps become rigid

Finally leads to narrowing of funnel shaped valve

Calcification/thrombus/embolism can occur


Pathophysiology

Normal mitral valve 4-6 sq.cm

Obstruction of mitral valve- increases left atrio-


ventricular pressure gradient (hallmark of MS)

Increased obstruction (MS)- increased LA


pressure- raise in pul.venous/art./cap. pressure

The severity of obstruction depends upon trans


valvular pressure gradient & HR
Pathophysiology

Increased HR shortens diastole & decreases the


time available for trans mitral flow- elevates
further LA pressure

With MS of 1 sq.cm LA pressure is apprx. 25mm


of Hg required to maintain normal CO

When Pul. Artery pressure> 50mm Hg-


compensatory mechanism occurs- increased
RV & diastole pressure &volume- RVH-RVF

PH is directly proportional to severity of MS


Hemodynamics in MS

MS ( obstruction to LA LV flow)

decreased transmitral flow

increased backward passive pressure

increased Pul.venous HTN

PH (protective phenomenon)

RVH RVF
Pulmonary HTN in MS

Passive backward transmission of the elevated LA


pressure

Pul.arteriolar constriction ( reactive pH)

Organic obliterative changes in the pul. vascular


bed ( decreases VC,TLC)
Symptoms

Asymptomatic detected on routine


examination
Exertional breathlessness/ dyspnea
Hemoptysis
Chest pain (angina like)
Fatigue ( decreased CO)
Repeated LRTI
Palpitations
Symptoms due to complications
Hemoptysis

Severe pul.venous HTN venous hemorrhage


Pulmonary oedema
Pulmonary infarction (pulmonary embolism)
Bronchitis
Resolving pneumonitis
Anti coagulant excess/ toxicity
Chest pain in MS

Seen in 10% of severe MS

Due to
-pH RV O2 demand
-IHD ( CAD)
-acute Pul.infarction ( emboli)
Clinical signs

Inspection
Mitral facies cyanotic patch on
cheek( CO)
Low volume pulse ( CO)
Peripheral cyanosis in severe MS (
CO)
Precordial bulge
Left parasternal pulsations ( RVH)
Epigastric pulsations ( RVH)
Clinical signs

Palpation
Apex beat classical tapping
Left parasternal heave (RVH)
Palpable P2 ( diastolic shock)
Diastolic thrill at apex

Percussion

Cardiomegaly ( RV type)
PA impaired note/ dullness (PA
dilatation)
Clinical signs

Auscultation
Loud S1 ( M1)

MDM low pitched, low frequency, rumbling quality,


best heard in left lateral position with bell of the
stethoscope, on expiration

Presystolic accentuation

Opening snap (OS)

Functional murmurs of PR( Graham steel)/TR


Severity of MS

> 2.5 sq.cm - no symptoms

1.5-2.5 sq.cm - dyspnea on exertion

1 - 1.5 sq.cm - PND

< 1 sq.cm - orthopnea


Severity of MS

Louder the S1

Longer the MDM

Narrower gap of A2 OS interval


DD for Rheumatic MS

Congenital
Left atrial myxoma
Cor triatriatum
Ball valve thrombus
TS
Rheumatic MS

Commonest cause of MS
50% give Rheumatic h/o
Best between 5-15 years
OS is common
Congenital sequelae absent
Juvenile MS

Occur in tropical countries (India)


Occur early in life
Runs a rapid downhill course
Sometimes MS to CCF in 6m 2years
Silent MS

Its tight/ severe MS


Has a huge RV
OS often heard
MDM heard posteriorly & not In front of the chest
wall
Radiological changes in
MS
LA enlargement double density / straightening of
left borders , barium swallow for indentation on
esophagus

Pul.venous HTN prominent upper lobe veins,


kerleys B lines,pul.hemosiderosis

Pul.arterial HTN dilated PA. pleural effusion

Calcification of mitral valve

Calcification of LA
Auscultation type in MS
ECG changes in MS

LA enlargement ( P mitrale)
RVH
RV strains pattern
RBBB/ RV dominance pattern
Atrial fibrillation
Investigations

ECHO cardiography
-for definite diagnosis of MS
-to assess the severity of MS
-to assess the transmitral flow &
complications of MS

Cardiac catherisation
-to assess the hemodynamics of the
heart
Complications of MS

Mechanical Rhythm

Recurrent LRTI - Atrial fibrillaton


Hemoptysis - Atrial flutter
IE - Ectopics
CCF
Thromoembolism
pH
Ortners syndrome
( left rec.laryngeal nerve
compression)
Medical management

Treatment of CCF
Treatment of AF
Prophylaxis of RF
Prophylaxis of IE
Surgery indications

Symptomatic MS
Critical MS
Pulmonary oedema
Low output state
Evidence of systemic embolism
Failed medical line of treatment
Option of surgery in MS

Ballon valvuloplasty (PTMC)


-in moderate MS
-only MS (with mobile valve)
-favorable mitral valve morphology

Mitral valve replacement (MVR)


-MS with MR
-Calcified mitral valve
-failed PTMC