MITRAL STENOSIS

MUSTAFIZUL AZIZ Assistant professor NICVD

INTRODUCTION
Mitral stenosis, an obstruction to blood flow between LA and LV is caused by abnormal mitral valve function. 60% patients with MS donot give H/O rheumatic fever. 50& of patients with acute carditis do not eventually have valvular heart diseases.

SEQUELE OF RHEUMATIC FEVER

75% of ARF subsides within 6 weeks. 90% within 2 months Less 5% persist more than 6 months

FREQUENCIES OF VALVULAR INVOLVEMENT

MV 50% ALL 2% OTHER COMBIN ATION

MV &AV 40% MV AV &TV 5%

AV alone 3%

CAUSE
Rheumatic carditis (in virtually all patients) Congenital MS(rareLutembachers syndrome Massive mitral valve annular calcification.

OTHER CAUSES OF OBSTRUCTION TO LA OUT FLOW

LA myxoma Massive LA ball valve thrombus. Cortriatrium.

PATHOLOGY

Mitral Stenosis

Mitral Valve Gradient

Shortened diastole (Tachycardia) Loss of AV Synchrony (AFib, heart block) Pulmonary Venous Flow (Volume loading)

LVEDP

Left Atrial Pressure

Left Atrial Enlargement

Pulmonary Venous Pressure

Atrial Arrhythmias

Pulmonary Edema Pulmonary Arterial Hypertension RVH and RV Hypertension TR and RVE

Symptoms

CLINICAL FEATURE

Symptoms

SIGN
Mitral facies. Orthopnic. Pulse-normal/ low volume/tachycardia/AF. BP-Normal JVP-Normal/raised-prominent a wave in sinus rhythm/prominent v wave inTR /absent a wave in AF

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 Steel murmur

SEVERITY OF MS
CLINICAL Full length diastolic murmur. Short A2-os interval. A2 os may be longer in severe MS if there is associated moderate to severe AR Pulmonary hypertension.

SEVERITY OF MS
ECHOCARDIOGRAM MVA plenimitry(normal 4-6 cm2) Mild -1.5-2.5cm2 moderate 1.00-1.5cm2 severe <1.00cm2

 On M-mode by EF slope(normal 70-150mm/s.

MILD-25-35mm/s Moderate-15-25mm/s Severe-15mm/s

 Pressure half time(doppler study) Mild -60-100ms Moderate-100-200ms Severe-200ms

 Transmitral pressure gradient (Doppler study) Normal up to 10 mmHg Mild -10- 15mmHg Moderate-15-20mmHg Severe->20mmHg

 Pulmonary arterial pressure (Doppler study) Normal-<30mmHg Mild-30-40mmHg Moderate-40-70mmHg Severe->70mmHg

WILKINS SCORE
GRADE

Mobility
Highly mobile valve,only leaflet tip restricted
Leaflet mid &base portions have normal mobility

Subvalvular thickening
Minimal thickening just below MV leaflet Chordal structure up to 1/3rd of length

Thickening Calcification

leaflet near normal(45mm)

A single area of increased brightness

2
3

5Scattered area 8mm(margi of brightness n) confined to margin

Entire leaflet(58mm) >8-10mm Brightness extending into mid portion leaflet Brightness throughout leaflet

Move forward Up to distal mainly from 1/3rd base No/minimal forward movement Extensive thickening& shortening-

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

INVESTIGATION

NATURAL HISTORY
10 survival of patient with MS without symptom is 84% MS with mild symptom 10 year survival is 34%to42% MS with moderate to severe symptom 20 year survival is <10%

TREATMENT

MEDICAL TREATMENT
Antibiotic prophylaxis(rheumatic &IE) Restrict activities. Arrhythmia Prevent or control Atrial fibrillation-control ventricular rate, anticoagulation, restore sinus rhythm Treatment of heart failure Treatment of other complication (LA thrombus,systemic emboli).

Treatment of LA thrombus OMC &removal of thrombus Otherwise anticoacoagulation by I/V heparin with aim of endotheliolized

 WARFARIN USED IN
AF Systemic emboli LA thrombus Pulmonary emboli LV systolic dysfunction.

INTERVENTIONAL-PTMC/CBC

Sellers Grading of MS
Sellers grade I: Cmmisural fusion, leaflet thickening No sub-valvular involvement, No calcification. Echo display diastolic dooming.

Sellers Grading of MS
Sellars Grade-II
Commisural fusion, leaflet thickening Mild to moderate sub-valvular involvement, minimal calcification. Echo- Funneling of mitral orifice Treatment: OMC

Sellers Grading of MS
Sellers grade III:
Commisural fusion, leaflet thickening Significant sub-valvular involvement, Significant calcification. Echo Disorganized valve.

CBC PROCEDURE OF CHOICE-WHY

Hospital mortality in the last 10 year is close to 0 Success rate is 95% MVA increases to an average19-2cm2. Reduction in MVG,LA ,PA pressure7increase CO 60% improve NYHA class

HOW WILL YOU ASSESS SUCCESS PTMC

During procedure After procedure

SIGN OF MS AFTER PTMC/CMC/OMC

OS persist Loudness of S1persist. Murmur Disappear/reduces intensity Presystolic accentuation never present.

Restenosis after PTMC

Incidence: 2-60% Restenosis due to fibrosis after injury, calcification and rarely recurrence of rheumatic fever. Recurrence of symptoms usually not due to restenosis 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.

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

 Need for open heart surgery Procedural difficulties Severe TR Huge RA Distorted /displaced IAS Venous problem.

OMC
CLASS-I
Balloon valvotomy is not available All indication to PTMC but there is LA thrombus despite anticoagulation Patients in NYHA III-IV, moderate to severe MS & anon pliable or calcified valve with the decision to proceed either repair or replacement made at the time of operation.

MVR
Patients who are not candidate for PTMC or repair

MS IN PREGNANCY
The increased CO tachycardia, fluid retention may double PG across the MV Symptom become apparent 20th week,may aggravated further. Maternal death is rare when there careful attention to the management of CCF.

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