Mitral stenosis for post graduates

MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP,FASE
Professor and Head of Cardiology
Colonel Malek Medical College , Manikganj
.drtoufiq19711@yahoo.com13/8/2019

What is RHD?
ARF
episodes
make
valve(s)
inflamed.
The valve is
left damaged
and scarred.
May cause
leakage then
later,
blockage, or
both.
Leaking valves:
heart chambers
get stretched.
Blocked valves:
heart muscle
struggles hard
to move blood
forwards
Heart failure
starts to
develop. The
patient may
develop
symptoms
including
breathlessness.
Heart
medications
are needed.
Eventually,
valve surgery
may be
needed.
Example age timeline (years)
5 10 161513
Natural history of disease if adequate
secondary prevention is not given
continued
Natural history of disease if adequate secondary prevention is not given
Mitral Stenosis

First
surgical
step may
be valve
repair
Next surgical
step may be
valve
replacement.
If a metal valve
is used, or the
heart develops
fibrillation,
then the
person needs
warfarin
treatment
Too much
warfarin can
cause
haemorrhage.
Not enough
can cause
stroke. Either
of these can be
fatal.
Valves which
are scarred or
operated on a
prone to
infection
(endocarditis).
This can also
be fatal.
Further RHD progress
Example age timeline (years)
16 21 302821
Natural history of disease if adequate secondary prevention is not given
Further progress of RHD
Mitral Stenosis

Mitral valve is affected in over 90% of cases of RHD
Mitral regurgitation most commonly found in children & adolescents
Mitral stenosis represents longer term chronic disease, commonly in adults
Most common complication of mitral stenosis is atrial fibrillation
Aortic valve next most commonly affected
Often occurs with disease of the mitral valve.
Stenosis tends to develop as a long term complication of aortic
regurgitation
Tricuspid and pulmonary valves are much less commonly affected
Usually affected in very severe RHD when all valves are affected
Which valves are affected?Which valves are affected?
Mitral Stenosis

• Symptoms of RHD may not develop for many years
– A murmur but no symptoms suggests mild or moderate disease
Patients may not realize they need medical help; may think symptoms are normal
– Symptoms usually suggest more severe disease
• Symptoms depend upon the type and severity of disease e.g.
– Breathlessness with exertion or when lying down flat
– Waking at night feeling breathless
– Tiredness
– Leg swelling (peripheral oedema)
– Palpitations if atrial fibrillation or other rhythm problem develops
• Sudden onset of symptoms may occur
– New ARF episode with carditis
– pregnancy / labour
– rupture of valve cord
Signs and symptoms
Mitral Stenosis

• No. RHD is more likely if:
– Heart is affected in ARF (carditis)
– ARF is severe
– ARF occurs at a young age
– Recurrent ARF episodes occur
• However, you can’t accurately predict who will go on to
develop recurrent ARF and RHD
– hence EVERYONE who has had ARF, even if there was
no carditis, needs secondary prophylaxis with long-
term penicillin.
Does ARF always led to RHD?Does ARF always led to RHD?
Mitral Stenosis

• Atrial fibrillation
– Common in RHD
– Causes irregular heart rate /
palpitations, blackouts etc, causes
blood clots in atrium which can then
cause stroke
• Stroke
– Ischaemic stroke (blood clot)
• Due to not enough warfarin, when
atrial fibrillation or metal valve are
present
• Also can complicate infective
endocarditis
– Hemorrhagic stroke (bleed into
brain)
• Due to too much warfarin
Complications of RHD
• Heart failure
– Symptoms: shortness of breath,
swelling in the legs, cough, fatigue,
weakness
• Infective endocarditis
– bacterial infection of heart valve –
targets damaged valves
– Bacteria get into blood via mouth
(especially when dental hygiene is
poor), open skin etc
– People at high risk receive
endocarditis prophylaxis prior to
surgical procedures
– Dental health and hygiene reduces
risk of endocarditis
Mitral Stenosis

Mitral Valve Structure
8/13/2019
Col. Malek Medical College, Manikganj
drtoufiq19711@yahoo.com
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Mitral Stenosis

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Mitral Stenosis

Causes of Mitral Stenosis
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Mitral Stenosis

Pathology
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Mitral Stenosis

Clinical Presentation
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Mitral Stenosis

Physical Examination Findings
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Mitral Stenosis

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Mitral Stenosis

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Mitral Stenosis

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Laboratory Examination Findings
Mitral Stenosis

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Mitral Stenosis

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Mitral Stenosis

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Mitral Stenosis

1. Register with RHD program
2. Establish or continue secondary prophylaxis
3. Disease education and self-management support
4. Regular clinical review and echocardiogram
5. Regular dental care
6. Management of cardiac symptoms
7. Infective endocarditis prevention
8. Family planning
9. Well-planned surgery
10. Management of pregnancy
Ten-point management plan
Mitral Stenosis

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Treatment
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Treatment
Mitral Stenosis

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Treatment Mitral Stenosis

Selecting surgery type for mitral valve
Percutaneous
balloon
valvuloplasty
(for mitral
stenosis)
Valve repair
(for mitral
regurgitation)
If replacement
can’t be avoided,
tissue valve
preferred
If metal valve +
warfarin are
essential, ensure
education including
contraception
Mitral Stenosis

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Treatment Mitral Stenosis

Tertiary prevention of RHD
Prevention of morbidity and mortality by:
• Prevention of acute rheumatic fever recurrence
• - 3-4 weekly Benzathine Penicillin G
• Modification of environment
• Heart failure management
• Valve repair
• Valve replacement
• Heart failure medication
• Anticoagulation management
• Dilated left atrium
• Atrial fibrillation
• Mechanical valve
• Arrhythmia management
• Ablation
• Medication – digoxin
• Anticoagulation
• Endocarditis prevention
• Prevention of pregnancy related complications
Mitral Stenosis

Why does RHD get worse in pregnancy?
• Normal pregnancy:
– 30-50% increase in blood volume
– Increase in heart rate by 10-15 beats per minute
• therefore ‘hyperdynamic circulation’; major extra
cardiac work needed.
– Labour – further major increase in cardiac work
needed
• If heart capacity is reduced due to RHD, then
breathlessness and heart failure can occur
Mitral Stenosis

Pregnancy:
Careful planning, careful management
• Contraception to allow for careful planning
• Education: risks for mother / risk for baby
• Advice / decision on anticoagulation
Warfarin - tablets Clexane injection Heparin infusion
Safest for mother Safest for baby Not an option to stay on
infusion for 40 weeks
Miscarriage, late foetal loss -30%
Embryopathy- birth defects – 8%
-greatest risk 6-12 weeks
20% risk of valve blockage
Peri-partum haemorrhage
Option1:
1. Clexane 0- 13 weeks
2. Warfarin 14-36 weeks
3. Then Clexane
Option 2:
1. Warfarin until 36 weeks
2. Then Clexane

Note: Diltiazem and ACEI (e.g. ramipril) contraindicated in pregnancy
Contraception
e.g. OCP,
Implanon
Temporary valve
repair if surgery
indicated
Optimise medical
management
Once pregnant:
refer to high-risk
O&G clinic.
Serial echos
Avoid over-exertion;
salt/fluid overload
Keep going with
secondary
prophylaxis
Check vaccinations
up to date
Replace warfarin
with LMWH in
weeks 6-12 and
after week 36
Complex – see
guidelines
Anticoagulated:
timed labour
induction or
elective caesar
Non-
anticoagulated:
can try normal
delivery
Careful monitoring
in labour
Endocarditis
prophylaxis when
indicated
2 days post-
partum, resume
warfarin
Avoiding
pregnancy
Trying for
pregnancy
Pregnant
Overview of RHD management in pregnancy
Labour
Mitral Stenosis

Case report 1
• A 17 years old lady presented with shortness of
breath on exertion, increasing in intensity for last 2
months. On examination she is dysnoeic, pulse-
105/min, regular, BP-Normal, RR-28/min, diastolic
thrill in apex, S1 loud P2-loud, mid-diastolic murmur
in apical area best heard in left lateral position, breath
held in expiration. ECG-sinus tachycardia, CXR-P/A
view-straightening of left border, double right border,
Echocardiogram-Moderate mitral stenosis with mild
pulmonary hypertension. Patient being treated with
medical treatment and she is doing well.
8/13/2019
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Mitral Stenosis

Case report 2
110/min, regular, BP-Normal, RR-30/min, diastolic
thrill in apex, S1 loud P2-loud, mid-diastolic murmur
in apical area best heard in left lateral position, breath
held in expiration. ECG-sinus tachycardia, CXR-P/A
view-straightening of left border, double right border,
Echocardiogram-severe mitral stenosis with
moderate pulmonary hypertension with Wilkins echo
score-6. Patient underwent PTMC and she is doing
well.
8/13/2019
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Mitral Stenosis

Case report 3
• A 39 years old lady presented with shortness of breath
on exertion for last 10 years, increasing in intensity for
last 3 months. She was treated with anti-asthmatic
drugs. On examination she is dysnoeic, pulse-130/min,
irregular, BP-110/80 mm Hg, RR-31/min, diastolic thrill
in apex, S1 soft P2-loud, mid-diastolic murmur in
apical area best heard in left lateral position, breath
held in expiration. ECG- Atrial Fibrillation, CXR-P/A
view-Cardiomegaly, straightening of left border,
double right border, Echocardiogram-severe mitral
stenosis with mild MR with moderate pulmonary
hypertension with Wilkins echo score-8. Patient
underwent PTMC and she is doing well.
8/13/2019
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Mitral Stenosis

Case report 4
on exertion for last 10 months, increasing in intensity
for last 1 months. She had h/o CMC 15 years back . On
examination she is dysnoeic, pulse-110/min, irregular,
BP-100/75 mm Hg, RR-28/min, diastolic thrill in apex,
S1 soft P2-loud, mid-diastolic murmur in apical area
best heard in left lateral position, breath held in
expiration. ECG- Atrial Fibrillation, CXR-P/A view-
Cardiomegaly, straightening of left border, double right
border, Echocardiogram-severe mitral stenosis with
severe MR with severe pulmonary hypertension with
Wilkins echo score-12. Patient underwent MVR and
she is doing well.
8/13/2019
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Mitral Stenosis

Case report 5
on exertion for last 8 months, increasing in intensity for
last 1.5 months. She had h/o CMC 20 years back, H/O
PTMC 10 years back . On examination she is dysnoeic,
pulse-118/min, irregular, BP-90/70 mm Hg, RR-32/min,
diastolic thrill in apex, S1 soft P2-loud, mid-diastolic
murmur in apical area best heard in left lateral position,
breath held in expiration and pansystolic murmur in
apical area with radiation to left axilla. ECG- Atrial
Fibrillation, CXR-P/A view-Cardiomegaly, straightening
of left border, double right border, Echocardiogram-
severe mitral stenosis with severe MR with severe
pulmonary hypertension with Wilkins echo score-13.
Patient underwent MVR and she is doing well.
8/13/2019
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Mitral Stenosis

Case report 6
• A 53 years old gentleman presented with shortness
of breath on exertion for last 2 years , increasing in
intensity for last 3 months. On examination she is
dysnoeic, pulse-128/min, irregular, BP-100/30 mm
Hg, RR-32/min, diastolic thrill in apex, mid-diastolic
murmur in apical area, early diastolic murmur in left
lower sternal area and systolic murmur in aortic
area. ECG- Atrial Fibrillation, CXR-P/A view-
Cardiomegaly, Echocardiogram-severe mitral
stenosis with Moderate AS with severe AR with
moderate pulmonary hypertension. Patient
underwent DVR and she is doing well.
8/13/2019
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Mitral Stenosis

Case report 7
• A 42 years old lady presented with sudden weakness on right
side of the body with shortness of breath on exertion for last
6 years. She was treated with anti-asthmatic drugs. On
examination she is dysnoeic, pulse-130/min, irregular, BP-
110/80 mm Hg, RR-31/min, diastolic thrill in apex, S1 soft P2-
loud, mid-diastolic murmur in apical area best heard in left
lateral position, breath held in expiration, Right sided
hemiplegia. ECG- Atrial Fibrillation, CXR-P/A view-
Cardiomegaly, straightening of left border, double right
border, Echocardiogram-severe mitral stenosis with mild MR
with moderate pulmonary hypertension with Wilkins echo
score-8. CT scan of Brain showed infarction in left parietal
region. Patient underwent PTMC and she referred to
neurologist and physiatrist for care of hemiplegia .
8/13/2019
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Mitral Stenosis

Case report 8
105/min, regular, BP-Normal, RR-28/min, systolic
thrill in apex, S1 soft P2-loud, pansystolic murmur
in apical area with radiation to left axilla. ECG-
sinus tachycardia, CXR-P/A view-cardiomegaly ;
Echocardiogram-Severe mitral regurgitation with
moderate pulmonary hypertension. Patient being
treated with MVR and she is doing well.
8/13/2019
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Mitral Stenosis

Case report 9
breath on exertion. On examination she is
dysnoeic, pulse-115/min, regular, BP-Normal, RR-
31/min, systolic thrill in apex, S1 soft, P2-loud,
pansystolic murmur in apical area with radiation to
left axilla. ECG-sinus tachycardia, CXR-P/A view-
cardiomegaly ; Echocardiogram-Severe mitral
regurgitation with moderate pulmonary
hypertension. Patient being treated with Mitral
valve repair and she is doing well.
8/13/2019
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Mitral Stenosis

Case report 10
breath on exertion, swelling of abdomen and legs. She
was being treated with anti asthmatic drugs. On
examination she is dysnoeic, pulse-110/min, regular,
BP-Normal, RR-30/min, diastolic thrill in apex, S1 loud
P2-loud, mid-diastolic murmur in apical area best
heard in left lateral position, breath held in expiration,
ascites in abdomen and hepatomegaly. JVP-raised.
ECG-sinus tachycardia, CXR-P/A view-straightening of
left border, double right border, Echocardiogram-
severe mitral stenosis with severe pulmonary
hypertension with Wilkins echo score-8. She was
diagnosed as CCF with Pulmonary Hypertension due
to MS. Patient treated conservatively and later on
underwent PTMC and she is doing well now .
8/13/2019
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Mitral Stenosis

Case report 11
• A 54 years old lady presented with swelling of
abdomen and legs and shortness of breath on
minimal exertion. On examination she is dysnoeic,
pulse-130/min, irregular, BP-Normal, RR-33/min,
diastolic thrill in apex, S1 soft P2-loud, mid-diastolic
murmur in apical area best heard in left lateral
position, breath held in expiration, ascites in
abdomen and hepatomegaly. JVP-raised. ECG-sinus
tachycardia, CXR- cardiomegaly, Echocardiogram-
Valvular cardiomyopathy(EF-25%, dilated LA and LV)
with severe mitral stenosis with severe pulmonary
hypertension with Wilkins echo score-14. Patient
treated conservatively and she is doing well now .
8/13/2019
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Mitral Stenosis

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Mitral stenosis for post graduates

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