MITRAL STENOSIS

Dr. Muhammad Alauddin Sarwar

Medical Officer ,
Sindh Government Qatar Hospital,
Karachi, Pakistan

Normal
Anatom
y

MITRAL STENOSIS

Etiology
Symptoms
Physical Exam
Severity
Natural history
Timing of
Surgery

Mitral Stenosis: Etiology

Primarily a result of rheumatic fever (~ 99%
of MVs @ surgery show rheumatic
damage )
Scarring & fusion of valve apparatus
Rarely congenital
Pure
or predominant MS
occurs
in
approximately 40% of all patients with
rheumatic heart disease
Two-thirds of all patients with MS are female.

Normal mitral valve

Chordae Tendinae

Ant papillary muscle

Thickening of cusps

Fusion of chordae

Stenotic mitral valve

Mitral Stenosis:
Pathophysiology

Mitral Stenosis:
Pathophysiology
RA

RV

Right Heart
Failure:
Hepatic
Congestion
Tricuspid
Regurgitation
RA Enlargement
RV Pressure
Overload
RVH
RV Failure

Pulmonary HTN
Pulmonary
Congestion
LA Thrombi
Atrial Fib
LA Enlargement
Stenosis
Mitral
LA Pressure

LA

LV
LV Filling

Mitral Stenosis: Symptoms

Fatigue
Palpitations
Cough
SOB
Left sided
failure
Orthopnea
PND

Palpitation

A-fib
Systemic embolism
Pulmonary infection
Hemoptysis
Right sided failure
Hepatic Congestion
Edema

Worsened by
conditions that
cardiac output.
Exertion, fever,
anemia, tachycardia,
A-fib, I/V fluid

Recognizing Mitral
Stenosis
Palpation:

Auscultation:

Small volume pulse

Tapping apexpalpable S1
+/- palpable
opening snap (OS)
RV lift
Palpable S2

Loud S1- as loud as S2

in aortic area
A2 to OS interval
inversely proportional
to severity
Diastolic rumble: length
proportional to
severity
In severe MS with
low flow- S1, OS &
rumble may be

ECG:

NSR/AF, LAE, RVH,

RAD

Mitral Stenosis: Natural

History

Progressive, lifelong disease,

Usually slow & stable in the early years.
Progressive acceleration in the later years
20-40 year latency from rheumatic fever to
symptom onset.
Additional 10 years before disabling symptoms
With physically limiting symptoms
10 yr survival 0-15%
10-20% systemic embolism
30-40% develop AF
With onset of severe pulmonary hypertension
Mean survival < 3 yrs

Mitral Stenosis: Role of

Echocardiography
Diagnosis of Mitral Stenosis
Assessment
of
hemodynamic severity
mean gradient, mitral
valve area, pulmonary
artery pressure
Assessment
of
right
ventricular
size
and
function.
Assessment
of
valve
morphology to determine
suitability for percutaneous
mitral
balloon
valvuloplasty (PMBV)

P
S
S
A

P
S
L
A

Mitral Stenosis:
Complications
Atrial dysrrhythmias

Systemic embolization (1025%)

Risk of embolization is
related
to, age, presence of atrial
fibrillation, previous
embolic events
Pulmonary
infarcts (result of severe CHF) Animation
Congestive heart failure
Hemoptysis
Massive: secondary to ruptured bronchial veins
(pulm HTN)
Streaking/pink froth: pulmonary edema, or
infection
Endocarditis

Mitral Stenosis:Therapy
Medical

Diuretics for LHF/RHF

Digitalis/Beta blockers/CCB for Rate control in A Fib
Anticoagulation: In A Fib
Endocarditis prophylaxis

Balloon valvuloplasty
Effective long term improvement

Step By Step Balloon valvuloplasty (Commissurotomy )

Inoue balloon technique for
mitral balloon valvotomy.

A. After trans-septal
puncture, the deflated
balloon catheter is
advanced across the
inter-atrial septum,
then across the mitral
valve and into the left
ventricle. B. The
balloon is then inflated
stepwise within the
mitral orifice.

Mitral Stenosis:Therapy
Surgical
Mitral commissurotomy
Mitral Valve Replacement
Mechanical
Bioprosthetic

Surgical Commissurotomy

A surgical procedure
to open a stenotic
valve. A stenotic
valve restricts the
flow of blood. A
scalpel incision
widens the valve.

Step by Step Heart Valve

Replacement Animation
( copy the following link and paste it into the address bar of Internet Explorer & hit Enter)

http://www.byrnehealthcare.com/animations/SutterValveReplacement.htm

Contact:
alauddinsarwar@gmail.com
doctoralauddin@yahoo.co.in