Mitral Stenosis and Mitral Regurgitation
Transcript of Mitral Stenosis and Mitral Regurgitation
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MITRAL STENOSIS AND MITRAL
REGURGITATION
ASYRAF SAFWAN
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MITRAL STENOSIS
Define as a valvular heart disease presented
as narrowing of the orifice of the mitral
valve of the heart.
Causes: rheumatic heart disease
calcification of mitral valve
congenital mitral stenosis
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Pathophysiology
Fibrosis and
calcification of mitral
valve
Narrowing
of orificeRestriction
of blood
flow from
left atrium
Left atrial
pressure
rises
Pulmonary
venous
congestion
Breathlessness, haemoptysis,
cough. Crepitation, pleural
effusion
Left atrial
hepertrophy and
dilatation
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Left atrial hypertrophyand dilatation with
stenotic mitral valve
Increased
heart rate
(exercise and
pregnancy)may
percipitate
symptoms
Atrial
fibrillation(palpitation.
signs of atrial
fbrillation)
due to
progressive
dilataion
Low cardiac output
(fatique)
Left atrial
thrombosis and
systemic
thromboembolism
(stroke, ischemiclimbs)
Pulmonary
hypertension
(SOB, fatique,
chest pain.
Loud S2, RV
heave)
Right heart
hypertrophy and
dilation
Right heart failure
(ascites, ankleoeedema, raised JVP)
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Signs
Loud S1, tapping apex beat, opening snap,after S1 moving to S2 in severe case.
Low pitched mid diastolic murmur sometimeswith thrill
Coexisting mitral regurgitation can cause middiastolic murmur.
Tricuspid regurgitation in RV dilatation cancause systolic murmur in RV and waves in JVP.
There might be coexisting mitral regurgitation.Pic manouver:
left lateralusing bell
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Investigation
ECG:
Chest x ray
Echocardiogram Doppler echocardiography:pressure gradient
across mitral valve, pulmonary arterypressure, left ventricular function
Cardiac catheterization: assessment ofcoexisting coronary heart disease and mitralregurgitation
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RAD, tall R wave in V1-2 are all diagnostic features of RVH. Biphasic P wave with a
prominent negative component in V1 is good for left atrial enlargement. The P wave
is somewhat prominent in lead II suggesting right atrial enlargement as well.
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Normal cardiac size,
but the left atrial
appendage is
prominent Main
pulmonary arterysegment is just
outside the left
border, indicating
pulmonary
hypertension.
Enlargement of leftpulmonary artery and
right pulmonary
artery are just
modest. The
horizontal fissure is
visible, indicatingcollection of edema
fluid in the fissure.
The aortic knuckle
(Ao) is also seen well..
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Mitral stenosis with left atrial dilatation. This figure shows a thickened
mital valve arrow
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Management
Minor symptoms: medical treatment
Definitive treatment: balloon valvuloplasty, mitral
valvotomy and mitral valve replacement.
Medically: anticoagulant
antiarrhytmia
diuretics
antibiotics from infective
endocarditis
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Mitral ballon valvuloplasty
Fulfill criteria to undergo this procedure
Significant symptoms, isolated mitral stenosis,
no/trivial mitral regurgitation, mobile and non-
calcified valves, LA contain no thrombus.
They need to be given antibiotic to prevent IE.
There is possibility of restenosis.
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Mitral Regurgitation
Defined as disorder of the heart in which the mitralvalve does not close properly when the heart pumps outblood.
Aetiology: rheumatic heart disease
mitral valve prolapsedilatation of the left ventricles and mitral valve
rings (cardiomyopathy, Coronary Artery Disease)
damage to cusp and chordae (IE, rhematic heartdisease)
damage to papillary muscle
MI
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Mitral regurgitation acute
chronic
Acute pulmonaryoedema (Breathlessness,
haemoptysis, cough.
Crepitation, effusion)
Increased left atrial
pressure
Ventricular
hypertrophy
Atrial hypertrophy
P
ulmonary hypertension
Right ventricular
hypertrophyRight sided heart
failure
Displaced apex
beat
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Signs
Pansystolic murmur that radiates to axilla with
or without thrill
Soft S1 and may or may not be loud S3
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Investigation
Tall R waves in V4 and V5 with down sloping ST segment depression
and T wave inversion are suggestive of left ventricular hypertrophy
(LVH) with strain pattern.
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Left atrial hypertrophyP wave
duration > 0.12s in
frontal plane (usually
lead II)
Notched P wave in
limb leads with the
inter-peak
duration > 0.04s
Terminal P negativity
in lead V1 (i.e., "P-
terminal force")
duration >0.04s,
depth >1 mm.
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Parasternal long axis view.
Left atrium is dilated (compare with aorta).
Left ventricle is dilated (the dots on the left side are in centimeters).
Moderate posterior directed mitral regurgitation jet seen.
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CXR: Enlarged left atrium, enlarged left
venticle, pulmonary venous congestion,pulmonary oedema
Echo: detects and quantifies regurgitation
Cardiac catheterisation: Dilated LA, dialted LV,mitral regurgitation, pulmonary hypertension,
coexisting coronary heart disease
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Management
Medical treatment: Diuretics
Vasodilators eg ACE
inhibitorsDigoxin as
antiarrhythmics
Anticoagulantsantibiotics as prophylaxis
from IE
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Surgical management: mitral valve repair
(annuloplasty ring)mitral valve
replacement
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common cause of severe mitral regurgitationis caused by damage to chordae tendinae.
When the cordae are damaged, one or moreof the leaflets that make up the mitral valve
prolapse. Then, repair the leaflet by using a new
support system (new chords made ofGoreTex) or by removing the weakened part
of the leaflet and closing it up. Then annuloplasty ring is implanted round the
valve to provide additional support which actsas a frame for the valve and has a similar roleto a door frame in supporting a door.
Annuloplasty Ring