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7/27/2019 mitral stenosis nicvd lecture
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MITRAL STENOSIS
MUSTAFIZUL AZIZ
Assistant professor
NICVD
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INTRODUCTION
Mitral stenosis, an obstruction
to blood flow between LA and LV is
caused by abnormal mitral valvefunction.
60% patients with MS donot give H/Orheumatic fever.
50& of patients with acute carditisdo not eventually have valvular heartdiseases.
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SEQUELE OF
RHEUMATIC FEVER
75% of ARF subsides within 6weeks.
90% within 2 months
Less 5% persist more than 6months
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FREQUENCIES OF
VALVULAR INVOLVEMENTMV 50%
MV &AV 40%
MV AV
&TV
5%
AV alone 3%
ALL
OTHER
COMBINATION
2%
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CAUSE
Rheumatic carditis (in virtually
all patients)
Congenital MS(rare-Lutembachers syndrome
Massive mitral valve annular
calcification.
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OTHER CAUSES OF
OBSTRUCTION TO LA OUT
FLOW
LA myxoma Massive LA ball valve thrombus.
Cortriatrium.
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PATHOLOGY
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Mitral Stenosis Shortened diastole(Tachycardia)
Loss of AV Synchrony
(AFib, heart block)
Pulmonary Venous Flow
(Volume loading)
Mitral Valve Gradient
LVEDP
Left Atrial Pressure
Left AtrialEnlargement
Pulmonary VenousPressure
Atrial
ArrhythmiasPulmonary
Edema
Pulmonary Arterial
Hypertension
RVH and RV Hypertension
TR and RVE
Symptoms
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CLINICAL FEATURE
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Symptoms
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SIGN
Mitral facies.
Orthopnic.
Pulse-normal/ lowvolume/tachycardia/AF.
BP-Normal
JVP-Normal/raised-prominent a wavein sinus rhythm/prominent v wave
inTR /absent a wave in AF
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Precordium
Tapping Apex beat
Diastolic thrill at the apex
A parasternal lift. Palpable P2.
S1loud S2 may be loud.
MDM, opening snap,presystolic
accentuation.
Pansystolic murmur graham Steelmurmur
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SEVERITY OF MS
CLINICAL
Full length diastolic murmur.
Short A2-os interval.
A2os may be longer in severe
MS if there is associated
moderate to severe AR
Pulmonary hypertension.
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SEVERITY OF MS
ECHOCARDIOGRAM
MVA plenimitry(normal 4-6 cm2)
Mild -1.5-2.5cm2
moderate 1.00-1.5cm2
severe
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On M-mode by EF slope(normal
70-150mm/s.
MILD-25-35mm/s
Moderate-15-25mm/s
Severe-15mm/s
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Pressure half time(doppler
study)
Mild -60-100ms
Moderate-100-200ms
Severe-200ms
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Transmitral pressure gradient
(Doppler study)
Normal up to 10 mmHg
Mild -10- 15mmHg
Moderate-15-20mmHg
Severe->20mmHg
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Pulmonary arterial pressure
(Doppler study)
Normal-70mmHg
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WILKINS SCORE
GRADE
MobilitySubvalvular
thickening
Thickening Calcification
1 Highlymobile
valve,only
leaflet tip
restricted
Minimal
thickening
just below MV
leaflet
leaflet
near
normal(4-
5mm)
A single area
of increased
brightness
2 Leaflet mid&base portions
have normal
mobility
Chordal
structure up
to 1/3rd of
length
5-
8mm(margi
n)
Scattered area
of brightness
confined to
margin
3 Move forwardmainly from
base
Up to distal1/3rd Entireleaflet(5-
8mm)
Brightnessextending into
mid portion
leaflet
4 No/minimal
forward
movement
Extensive
thickening&
shortening-all cordae
>8-10mm Brightness
throughout
leaflet
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SOME QUESTIONS
Why S1 is loud
Short note on OS
Why OS
Causes of MDM
Presystolic accentuation.
Chest pain in MS
Indication of CAG in MS
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INVESTIGATION
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NATURAL HISTORY
10 survival of patient with MS
without symptom is 84%
MS with mild symptom 10 yearsurvival is 34%to42%
MS with moderate to severe
symptom 20 year survival is
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TREATMENT
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MEDICAL TREATMENT
Antibiotic prophylaxis(rheumatic &IE)
Restrict activities.
ArrhythmiaPrevent or control
Atrial fibrillation-control ventricular rate,anticoagulation, restore sinus rhythm
Treatment of heart failure
Treatment of other complication (LAthrombus,systemic emboli).
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Treatment of LA thrombus
OMC &removal of thrombus
Otherwise anticoacoagulation
by I/V heparin with aim of
endotheliolized
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WARFARIN USED INAF
Systemic emboli
LA thrombus
Pulmonary emboli
LV systolic dysfunction.
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INTERVENTIONAL-PTMC/CBC
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Sellers Grading of MS
Sellers grade I:
Cmmisural fusion, leaflet
thickening
No sub-valvular involvement,
No calcification.
Echo display diastolic
dooming.
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Sellers Grading of MS
Sellars Grade-II Commisural fusion, leaflet
thickening
Mild to moderate sub-valvularinvolvement, minimalcalcification.
Echo- Funneling of mitral orifice
Treatment: OMC
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Sellers Grading of MS
Sellers grade III:
Commisural fusion, leaflet
thickening
Significant sub-valvular
involvement, Significant
calcification.
EchoDisorganized valve.
CBC PROCEDURE OF
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CBC PROCEDURE OF
CHOICE-WHY
Hospital mortality in the last 10year is close to 0
Success rate is 95%
MVA increases to an average1-9-2cm2.
Reduction in MVG,LA ,PA
pressure7increase CO 60% improve NYHA class
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HOW WILL YOU ASSESS
SUCCESS PTMC
During procedure
After procedure
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SIGN OF MS AFTER
PTMC/CMC/OMC OSpersist
Loudness of S1persist.
Murmur Disappear/reduces
intensity
Presystolic accentuation never
present.
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Restenosis after PTMC
Incidence: 2-60% Restenosis due to fibrosis after injury,
calcification and rarely recurrence of rheumaticfever.
Recurrence of symptoms usually not due torestenosis which may be due to
1. Inadequate 1st operation
2. Increased severity of MR(Operative /IE)
3.Progerrion of aortic valvular disease.
4.Development of CAD.
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CONTRAINDICATION TO
PTMC
Related to valve
MR that is truly 3+4+
Thrombus in LA
Unfavorable valve
morphology,commissural Ca
MS mild.
Related to centre
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Need for open heart surgery
Procedural difficulties
Severe TR
Huge RA
Distorted /displaced IAS
Venous problem.
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OMC
CLASS-IBalloon valvotomy is not available
All indication to PTMC but there is LAthrombus despite anticoagulation
Patients in NYHA III-IV, moderate to severeMS & anon pliable or calcified valve withthe decision to proceed either repair or
replacement made at the time ofoperation.
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MVR
Patients who are not candidate
for PTMC or repair
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MS IN PREGNANCY
The increased CO tachycardia, fluid
retention may double PG across the MV
Symptom become apparent 20th week,mayaggravated further.
Maternal death is rare when there careful
attention to the management of CCF.
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PTMC valve surgery is appropriate before
conception.
If MS is first recognized & symptom develop
standard medical therapy is appropriate.
If symptom not controlled PTMC/CMC can be
done in 2nd trimaster.
Foetal loss >30%. AF is main concern
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