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Mitral Stenosis and Mitral Regurgitation
Mitral Stenosis and Mitral Regurgitation
REGURGITATION
ASYRAF SAFWAN
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
Pathophysiology
Fibrosis and
Narrowing Restriction
calcification of mitral
of orifice of blood
valve
flow from
Breathlessness, haemoptysis, left atrium
cough. Crepitation, pleural
effusion
Atrial
fibrillation
(palpitation.
signs of atrial Low cardiac output Left atrial
fbrillation) (fatique) thrombosis and
due to systemic
progressive thromboembolism
dilataion (stroke, ischemic
limbs)
Signs
• Loud S1, tapping apex beat, opening snap, after
S1 moving to S2 in severe case.
• Low pitched mid diastolic murmur sometimes
with thrill
• Coexisting mitral regurgitation can cause mid
diastolic murmur.
• Tricuspid regurgitation in RV dilatation can cause
systolic murmur in RV and waves in JVP.
• There might be coexisting mitral regurgitation.
Pic manouver:
left lateral
using bell
Investigation
• ECG:
• Chest x ray
• Echocardiogram
• Doppler echocardiography:pressure gradient
across mitral valve, pulmonary artery pressure,
left ventricular function
• Cardiac catheterization: assessment of coexisting
coronary heart disease and mitral regurgitation
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.
Normal cardiac size,
but the left atrial
appendage is
prominent Main
pulmonary artery
segment is just
outside the left
border, indicating
pulmonary
hypertension.
Enlargement of left
pulmonary artery and
right pulmonary
artery are just
modest. The
horizontal fissure is
visible, indicating
collection of edema
fluid in the fissure.
The aortic knuckle
(Ao) is also seen well..
Mitral stenosis with left atrial dilatation. This figure shows a thickened
mital valve arrow
Management
• Minor symptoms: medical treatment
• Definitive treatment: balloon valvuloplasty,
mitral valvotomy and mitral valve replacement.
• Medically: anticoagulant
antiarrhytmia
diuretics
antibiotics from infective
endocarditis
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.
Mitral Regurgitation
• Defined as disorder of the heart in which the mitral valve does
not close properly when the heart pumps out blood.
• Aetiology: rheumatic heart disease
mitral valve prolapse
dilatation of the left ventricles and mitral valve rings
(cardiomyopathy, Coronary Artery Disease)
damage to cusp and chordae (IE, rhematic heart
disease)
damage to papillary muscle
MI
Mitral regurgitation acute
chronic
Increased left atrial
pressure
Displaced apex
Ventricular
beat
hypertrophy
Acute pulmonary
oedema (Breathlessness,
Atrial hypertrophy haemoptysis, cough.
Crepitation, effusion)
Pulmonary hypertension
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.
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.
• 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
Management
• Medical treatment: Diuretics
Vasodilators eg ACE
inhibitors
Digoxin as antiarrhythmics
Anticoagulants
antibiotics as prophylaxis
from IE
• Surgical management: mitral valve repair
(annuloplasty ring)
mitral valve
replacement
Annuloplasty Ring
• common cause of severe mitral regurgitation is
caused by damage to chordae tendinae.
• When the cordae are damaged, one or more of the
leaflets that make up the mitral valve prolapse.
• Then, repair the leaflet by using a new support
system (new chords made of GoreTex) 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 acts as a frame
for the valve and has a similar role to a door frame in
supporting a door.