Mitral valve pathophysiology
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mitral valve- pathophysiology of mitral stenosis and mitral regurgitation. hemodynamics and etiology
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Mitral valve pathophysiology
- 2. MITRAL VALVE LESIONS • PURE MITRAL STENOSIS • PURE MITRAL REGURGITATION • COMBINED LESION with DOMINANT MS • COMBINED LESION with DOMINANT MR
- 4. DEFINITION - MITRAL STENOSIS “Narrowing of mitral valve orifice resulting in impedence of filling of left ventricle in diastole”
- 5. ETIOLOGY OF MITRAL STENOSIS Rheumatic fever Congenital Carcinoid Heart disease SLE Rheumatoid arthritis Extensive mitral annulus calcification
- 7. HAMMOCK MV OR ARCADE MV
- 8. PARACHUTE MV
- 11. HISTOPATHOLOGY RF focal inflammatory lesions AND PANCARDITIS “Aschoff” bodies - swollen eosinophilic collagen “Anitschkow” cells - swollen macrophages
- 12. HISTOPATHOLOGY ANITSCHKOW CELLS ASCHOFF GIANT CELLS (HALLMARK LESION)
- 13. RHD – chronic Organized acute inflammation (fibrosis) Leaflet thickening Commissure fusion (stenosis) (“buttonhole” or “fishmouth” stenoses ) Chordal thickening/fusion Aschoff bodies replaced with fibrous scar Calcification and fibrous scarring
- 14. HISTOPATH contd…
- 20. Pathophysiology Impaired blood flow through mitral valve Elevated LA pressure Passively elevated pulmonary venous pressure Reactive pulmonary HTN (protection from lung congestion) Fixed pulmonary HTN (organic intimal & medial changes)
- 21. Pathophysiology … Pulmonary HTN Right ventricular hypertrophy & dilatation Tricuspid regurgitation (mostly functional) Right heart failure
- 22. PATHOPHYSIOLOGY
- 23. MV IN MITRAL STENOSIS ACUTE PHASE INFLAMMATION AND EDEMA FIBRIN DEPOSITS CHRONIC PHASE (HEALING PHASE) LEAFLET THICKENING MAXIMAL AT EDGES SYMMETRICAL COMMISSURAL FUSION CHORDAL SHORTENING/FUSION PAPILLARY MUSCLE FUSION CALCIFICATION&SCARRING→NON PLIABLE,STIFF LEAFLETS / SVD
- 24. Right Panel: Sutten G, Anderson RH, et al. Slide atlas of cardiology. London: Medi-Cine Ltd., c1978:Slide 2. Copyright© American College of Cardiology. 5mmHg
- 25. Right Panel: Sutten G, Anderson RH, et al. Slide atlas of cardiology. London: Medi-Cine Ltd., c1978:Slide 3. Copyright© American College of Cardiology. 22mmHg
- 26. Mitral Stenosis and LA 1. LA DILATATION 2. FIBROSIS OF THE ATRIAL WALL 3. DISORGANIZATION MUSCLE BUNDLES SUBSTRATE FOR ATRIAL FIBRILLATION BLOOD STASIS LARGE LA LOSS OF CONTRACTILITY CLOT
- 28. Mitral Stenosis and LA contd….. • ELEVATED MEAN LA PRESSURE PRODUCT OF MS SEVERITY COMPLIANT - PRESSURES DILUTED NONCOMPLIANT - PUL. CONGESTION
- 29. Mitral Stenosis and LV • 85% - LVEDV,EJECTION INDICES ARE NORMAL • REGIONAL HYPOKINESIS • LV STIFFENING (SEPTAL DISPLACEMENT) • LONG STANDING MS-CHRONIC REDUCTION IN PRELOAD AND ELEVATED AFTERLOAD EF%
- 30. PULMONARY ARTERY HYPERTENSION • This pulmonary hypertension in MS has THREE components: 1. Passive transmission of LA pressure 2. Reactive pulmonary artery hypertension 3. Potentially Fixed resistance, secondary to morphologic changes in the pulmonary vasculature
- 31. Reproduced with permission from Baim DS, Grossman W, eds. Grossman’s Cardiac Catheterization, Angiography, and Intervention. 6th ed. Lippincott Williams & Wilkins, 2000:761.
- 33. PULM. VASCULARITY – OLIGEMIA/ HYPEREMIA PULMONARY HAEMOSIDEROSIS (MOTTLING) PULMONARY ARTERIAL HYPERTENSION PERIPHERAL PRUNING CALCIFICATION OF CENTRAL PULMNARY ARTERY
- 34. Mitral stenosis - Symptoms MC:FATIGUE AND DECREASED EXERCISE INTOLERANCE Dyspnea Orthopnea PND (atypical) Hemoptysis Palpitations Hoarseness (Ortner syndrome) Chest pain (atypical) THROMBOEMBOLISM,IE - relatively rare
- 35. Mitral stenosis Late symptoms PHT, TR, right CHF: Easy fatigability Hepatic congestion Ascites Lower limb edema
- 36. PHYSICAL EXAMINATION Mitral facies - purple discoloration Small volume peripheral pulse JVP a - Raised atrial pressure a, v - Right heart failure cv - Severe TR Tapping apical impulse (palpable S1) Palpable S2 - severe PHT Left parasternal lift - RVH
- 37. Physical examination… S1 - pliable valve Opening snap pliable valve Mid-diastolic rumbling murmur Presystolic accentuation Severity inflicted by murmur duration (rather than intensity)
- 38. Physical examination … Short A2-OS (<60 ms) - favors severe MS Additional Determinants of A2-OS LA pressure Closing pressure of aortic valve (systemic HTN) Differential diagnosis: S2 SPLIT,A2-S3,KNOCK,PLOP
- 40. Severity stratification by C/F : MS Phy. Findings Mild MS Mod. MS Severe MS Art. Pulses N N / AF vol., AF JVP N N ; large V waves(if TR) Apical impulse N, palpable S1 & OS RV lift, palpableS1&OS, apical dias. thrill, LV impulse RV lift, palpableS1&OS, apical dias. thrill, LV impulse Heart sounds S1, OS S1,OS,P2 S1,OS,P2 Diastolic murmur EDM/ PreSM PDM thrill Loud PDM + apical thrill
- 41. If you're not confused, you're not paying attention.
- 43. ETIOLOGY OF ACUTE MR MITRAL ANNULUS DISORDERS MITRAL LEAFLET DISORDERS RUPTURE OF CHORDAE PAPILLARY MUSCLE DISORDERS PROSTHETIC VALVE DISORDERS
- 44. MITRAL ANNULUS DISORDERS INFECTIVE ENDOCARDITIS TRAUMA PARAVALVULAR LEAK
- 45. MITRAL LEAFLET DISORDERS INFECTIVE ENDOCARDITIS TRAUMA TUMOURS MYXOMATOUS DEGENERATION SLE
- 46. RUPTURE OF CHORDAE ACUTE RHEUMATIC FEVER MYXOMATOUS DEGENERATION INFECTIVE ENDOCARDITIS IATROGENIC TRAUMA
- 47. PAPILLARY MUSCLE DISORDERS CAD INFILTRATIVE DISEASE ACUTE GLOBAL LV DYSFUNCTION TRAUMA
- 48. PROSTHETIC VALVE CUSP PERFORATION (IE) CUSP DEGENERATION MECHANICAL FAILURE
- 49. ETIOLOGY OF CHRONIC MR • INFLAMMATORY RHD SLE SCLERODERMA • DEGENERATIVE MVP CONN TISSUSE DISORDERS ANNULAR CALCIFICATION • INFECTIVE • STRUCTURAL CHORDAE/PAPILLARY MUSCLE DILATATION OF ANNULUS HOCM PARAVALVULAR LEAK
- 51. TYPE I
- 52. TYPE II
- 53. TYPE III
- 54. STAGES OF MR ACUTE MR CHRONIC COMPENSATED MR CHRONIC NONCOMPENSATED MR
- 56. ACUTE MR SEVERE VOLUME OVERLOAD NON-COMPLIANT LV/LA INCREASED FILLING PRESSURE PULMONARY EDEMA
- 58. CHRONIC MR
- 59. MR AND LV- LV COMPENSATION ACUTE FRANK-STARLING PRINCIPLE CHRONIC LAW OF LAPLACE “MR BEGETS MORE MR”
- 60. LV IN ACUTE MR INCREASE IN PRELOAD DECREASE IN AFTERLOAD INCREASE IN EJECTION FRACTION INCREASED TOTAL STROKE VOLUME
- 61. LV IN CHRONIC MR
- 63. WHY EJECTION INDICES IMPORTANT IN MR?
- 64. • EJECTION PHASE INDICES : EJECTION FRACTION, FRACTIONAL FIBRE SHORTENING, VELOCITY OF CIRCUMFERENTIAL FIBRE SHORTENING INVERSELY RELATED TO AFTERLOAD • LOW-NORMAL RANGE OF INDICES IMPAIRED MYOCARDIAL FUNCTION ANY PT WITH EF OF 40-45% IMPLIES SEV LV DYSFUNCTION
- 65. WHY END SYSTOLIC VOLUME/DM - CHOSEN IN INDICATIONS FOR SURGERY AND PROGNOSTIGATION?
- 66. END SYSTOLIC VOLUME/DM REDUCED IN ACUTE MR NORMAL IN COMPENSATED CHRONIC MR INCREASED IN DECOMPENSATED CHRONIC MR INDEX FOR EVALUATING LV FUNCTION PREDICTOR OF FUNCTION AND SURVIVAL FOLLOWING MV SURGERY
- 67. LA COMPLIANCE • NORMAL or REDUCED COMPLIANCE PROMINENT V WAVE SYMPTOMS OF PULMONARY CONGESTION • MARKEDLY INCREASED COMPLIANCE THIN WALLED AF COMMON SYMPTOMS OF LOWCARDIAC OUTPUT • MODERATELY INCREASED COMPLIANCE MOST COMMON VARIABLE SIZED LA/LA PRESSURE AF
- 69. ISCHEMIC MR
- 71. SYMPTOMS OF MR MOSTLY ASYMPTOMATIC CHRONIC WEAKNESS & FATIGUE –MOST COMMON • DYSPNEA/ORTHOPNEA/PND • PALPITATIONS • ATYPICAL CHESTPAIN • HEMOPTYSIS & SYSTEMIC EMBOLIZATION- LESS COMMON • ACUTE MR - > RIGHT SIDED HEART FAILURE • CHRONIC MR - > LEFT SIDED HEART FAILURE
- 72. PHYSICAL EXAMINATION No characteristic facies Small volume brisk/jerky pulse (small waterhammer) JVP a - Decreased RV compliance a, v - Right heart failure v - Severe TR/ LAP In acute MR Hyperdynamic apical impulse ( , Thrill+ ) Parasternal lift( dilated LA,RVH) Palpable S2 - severe PHT
- 73. Physical examination… S1 , Loud S1 in MVP S2 –Wide split,loud P2, S3+ Holosystolic murmur Severity inflicted by murmur INTENSITY Radiates to axiila/back/base
- 75. MR contd…