Mitral stenosis

1. MITRAL
STENOSIS

2. MITRAL VALVE : ANATOMY
• Mitral valve connects the left atrium
and left ventricle.
• The normal function of the mitral valve
depends on its 6 components, which are
(1) the left atrial wall,
(2) the annulus,
(3) the leaflets,
(4) the chordae tendineae,
(5) the papillary muscles, and
(6) the left ventricular wall.

3. MITRAL VALVE : ANATOMY

4. MITRAL STENOSIS
• In normal adults, the area of the mitral
valve orifice is 4-6 cm2.
• In mitral stenosis, the area of valve
orifice decreases.
• Minimal MS - >2.5 cm2
• Mild MS - 1.6- 2.5 cm2
• Moderate MS – 1- 1.5 cm2
• Severe MS(tight/critical) - <1 cm2

5. MITRAL STENOSIS:
ETIOLOGY
• Rheumatic fever (most common cause-40%).
• Congenital mitral valve stenosis，
• Cor triatriatum，
• Mitral annular calcification with extension
onto the leaflets，
• Systemic lupus erythematosus，
• Rheumatoid arthritis，
• Left atrial myxoma， and
• Infective endocarditis with large
vegetations.

6. MITRAL STENOSIS:
PATHOGENESIS
• Rheumatic fever is the most common cause of MS.
• In rheumatic MS, chronic inflammation leads to
diffuse thickening of the valve leaflets with
formation of fibrous tissue and/or calcific deposits.
• The mitral commissures fuse, the chordae
tendineae fuse and shorten, the valvular cusps
become rigid.
• These changes, in turn, lead to narrowing at the
apex of the valve.
• Calcification of the stenotic mitral valve
immobilizes the leaflets and narrows the orifice
further.

7. MITRAL STENOSIS-
PATHOPHYSIOLOGY

8. CLINICAL PRESENTATION
• Symptoms d/t pulmonary hypertension-
1. Dyspnoea, orthopnea, PND
2. Recurrent pulmonary infections, i.e., bronchitis,
bronchopneumonia and lobar pneumonia
especially during the winter months.
3. Hemoptysis results from rupture of
pulmonary-bronchial venous connections.
4. Cough
5. Fatigue
6. Lower limb swelling, pain rt hypochondrium.
• Palpitations can develop in case if A.fib
develops

9. PHYSICAL EXAMINATION
• Mitral facies
• Pulse - irregularly irregular if AF is
present.
• Parasternal heave can be there d/t
RVH.
• Tapping type of apex beat (palpable 1st
heart sound) is there, normal in position,
can go outwards if RVH present.
• A diastolic thrill may rarely be present
at the cardiac apex, with the patient in
the left lateral recumbent position.

10. MITRAL
FACIES
pinkish purple
patches on
cheeks, tip of
nose and lips
bilaterally d/t
AV
anastamoses
and vascular
stasis.

11. Jugular veins in MS
-If RV failure develops, jugular veins will
be distended
- If pulmonary hypertension develops,
“a” wave will be prominent.

12. • On auscultation
-S1 will be loud if mitral valve is pliable.
It will be muffled in calcified MS.
-The pulmonic component of the second
heart sound (P2) is often accentuated
with elevated PA pressure.(PHTN)
-Opening snap i.e. mitral valve opens
suddenly with the force of increased
left atrial pressure.
-Low pitched rough rumbling mid
diastolic murmur with pre systolic
accentuation.

13. MURMUR OF MITRAL
STENOSIS
• Low pitched, rumbling, diastolic murmur,
following opening snap heard best at the
apex with the patient in the left lateral
recumbent position.
• Best heard with the bell of stethoscope.

14. • If the patient is in sinus rhythm,
murmur becomes louder at the end of
diastole d/t atrial contraction i.e.
PRESYSTOLIC ACCENTUATION.
• Presystolic accentuation will be absent
in case of AF, Left atrial failure and big
left atrial thrombus.

15. SEVERITY OF MITRAL
STENOSIS????
• The time interval between A2 and OS varies
inversely with the severity of the MS. Normally,
it is 0.05-0.12 s. The smaller the gap, the more
severe is the MS.
• Longer the duration of mid diastolic murmur,
the more severe is the MS.
• As the valve cusps become immobile,
-Loud S1 softens
-opening snap disappears
• When pulmonary hypertension appears,
-P2 gets loud

16. INVESTIGATIONS
• Chest X-ray
• Electrocardiogram
• Echocardiogram
• Cardiac MRI
• Cardiac cathetrisation

17. CHEST X-RAY IN MS
• MITRALISATION of heart straightening of
the left border of heart & is due to(from
above downwards)
1. Small aortic knuckle d/t low CO
2. Convexity d/t dilated pulmonary artery d/t
pulmonary hypertension
3. Left atrial appendages prominence
4. Left border of LV
• Double contour of right border of heart
(shadow within shadow)

19. • Dilated pulmonary aretries at hilum with
peripheral pruning (pulmonary hypertension)
• Bat’s wing appearance from parahilar region
to periphery and Kerly’s B lines indicating
pulmonary edema
• Elevation of left upper lobe bronchus which
becomes horizontal due to LA enlargement
• Calcified mitral valve can be seen on lateral
view.
• Chest Xray (RAO view) with barium filled
esophagus shows sickling of esophagus by
enlarged LA

20. ECG IN MITRAL STENOSIS
• LA enlargement – Wide i.e. >0.12s (3
small sq) and notched P wave with the
interpeak duration of >0.04s (1 small sq)
i.e. P mitrale in lead v1 & II.

21. • P wave may become tall and peaked (>2.5
small sq) in lead II & V1 when severe
pulmonary hypertension or TS
complicates MS and right atrial (RA)
enlargement occurs i.e. P pulmonale

22. • RVH- RAD and tall R wave in lead
V1(>7mm)
• Atrial fibrillation may be present.

23. ECHO IN MITRAL STENOSIS
• To see chamber enlargement , left atrial
thrombus, valve pathology, valve movement,
mitral orifice, diameter.
• In MS there are thickened immobile cusps,
reduced valve area, LA enlargement and
reduced rate of diastolic filling of LV.
• TEE provides superior images and should be
used when TTE is inadequate for guiding
management decisions. TEE is especially
indicated to exclude the presence of LA
thrombus prior to percutaneous mitral
balloon valvotomy (PMBV).

24. CARDIAC CATHETRIZATION
IN MS
• In men older than 40 years of age,
• Women older than 45 years of age and
• Younger patients with coronary risk factors,
especially those with positive noninvasive
stress tests for myocardial ischemia，
Coronary angiography is advisable
preoperatively to identify patients with
critical coronary obstructions that should be
bypassed at the time of operation.

25. D/D OF MITRAL DIASTOLIC
MURMUR
• Carey coombs murmur
• Austin Flint murmur
• Functional mid diastolic murmurs
• Left atrial myxoma
• Tricuspid stenosis
• Ball valve thrombus
• Cor triatriatum

26. COMPLICATIONS OF MS
• Left atrial enlargement, acute left atrial
failure and acute pulmonary edema
• Pulmonary hypertension
• Right ventricular failure
• A fib, A flutter, VPC or APCs
• Embolic manifestations
• Infective endocarditis
• Recurrent broncho-pulmonary infections
• Compression of RLN (Ortner’s syndrome)
• Dysphagia

27. TREATMENT OF MS
• Medical Management
• Surgical Management
1. Valvotomy or Commissurotomy
(closed/open)
2. PMBV (treatment of choice)
3. Mitral valve replacement or prosthesis
(starr-edwards ball valve or bjork
shiley disc valve)

28. MEDICAL MANAGEMENT
• Treatment of CHF
• Antibiotic prophylaxis against infective
endocarditis and rheumatic fever
• Anticoagulation in presence of AF or LA
clot
• Treatment of AF
• Management of complications

29. INDICATIONS OF
VALVOTOMY
• Mitral valve orifice <1-1.5 cm2 i.e. severe MS
with NYHA functional class II-IV
• If mitral orifice area >1.5 cm2 i.e. mild to
moderate MS
a) Recurrent attacks of systemic thrombo-
embolism
b) Severe pulmonary htn with PA systolic
pressure of >50mmHg at rest or >60mmHg with
exercise
• MS with pregnancy if pulmonary congestion
develops despite intensive medical management

30. CONTRAINDICATIONS OF
VALVOTOMY
• Calcified mitral valve
• Presence of MR with MS
• Presence of thrombus in left atrium

31. PERCUTANEOUS
MITRAL BALLOON
VALVOTOMY (PMBV)
PROCEDURE

32. After trans septal puncture，the deflated balloon
catheter is advanced across the interatrial septum，
then across the mitral valve and into the left
ventricle.

33. The balloon is then inflated stepwise within
the mitral orifice.

34. SUCCESSFUL VALVOTOMY:
INDICATORS
• 50% reduction in the mean mitral
gradient
• Doubling of the mitral valve area
• Striking symptomatic and hemodynamic
improvement

35. INDICATIONS OF MITRAL
VALVE REPLACEMENT
• Presence of MR
• Badly diseased or badly calcified
stenotic valve
• Severly distorted valve by previous
trans catheter or operative manipulation
• Moderate or severe MS with thrombus
in LA despite anticoagulation

36. TYPES OF PROSTHESIS
• Metallic prosthesis
1. Caged ball valve (Starr-Edwards)
2. Tilting disc valve (Bjork-shiley)
• Bioprosthesis
1. Porcine Bioprosthesis
2. Pericardial Xenograft

37. Thanks!!!!