• Rheumatic heart disease (Group A beta haemolytic streptococcus)
• Others : congenital, calcification/fibrosis in elderly, carcinoid tumour metastasizing to lung

• Degenerative disease
• Functional (LV dilatation)
• Annular calcification
• Rheumatic fever
• Infective Endocarditis
• Mitral valve prolapse
• Ruptured chordae tendineae
• Papillary muscle dysfunction/rupture
• Connective tissue disease: Marfan’s syndrome, Ehler’s Danlos
• Rheumatic autoimmune disease e.g. SLE
• Cardiomyopathy
• Congenital
• Drugs

• Mitral valve regurgitation > left atrial dilatation (but in acute, left atrium does not allow much dilatation, there will be rise in left atria pressure >> pulmonary oedema)
• Stroke volume ↓ due to regurgitation, thus LV hypertrophy to increase stroke volume and hence CO
• As time goes by , R sided HF

• No symptoms until orifices <2cm²
  • Due to pulmonary hypertension: dyspnoea, haemoptysis, recurrent bronchitis
• Eventually right HF: fatigue, leg swelling
  • Due to large left atrial, favours AF: palpitations , systemic emboli

• Due to pulmonary oedema or left heart failure: dyspnoea, orthopnoea, fatigue and lethargy
• Due to the stoke volume: palpitations
• Subacute infective endocarditis

• Face : Mitral facies / malar flush (due to ↓CO)
• Pulse : AF
• RV : heaving, sustained
• Apex: localised, tapping
• HS: Loud S1, loud P2(pulmonary HTN), opening snap
• Murmurs: mid diastolic murmur rumbling at apex

• Pulse : sinus rhythm or AF
• Apex : forceful, displaced, systolic thrill
• Sounds: Soft S1, split S2, loud P2 . maybe a mid-systolic click (sudden prolapse of the valve)
• Murmurs : pansystolic , radiating to axilla

• Small heart with enlarged left atrium
• Calcified mitral valve
• Sign of pulmonary oedema

2.     ECG

• AF
• Bifid P wave/P mitrale
• Right axis deviation/ tall R waves in lead V1 (Right ventricle hypertrophy)

3.     Echocardiogram

4.     Cardiac catherisation (indicated in):

• Previous valvotomy, sign of other valve disease, angina, severe pulmonary hypertension, calcified mitral valve

• Left atrial and left ventricular enlargement
• Increased cardiac thoracic ratio
• Valve calcification

2.      ECG

• Bifid P wave
• Left ventricular hypertrophy (tall R wave in leads 1, V6 and deep S wave is V1 and V2)
• AF might be present

3.     Echocardiogram + Doppler

4.     Cardiac catherization

• AF: digoxin and anticoagulation
• Pulmonary oedema : diuretics

Surgical: ( 4 options)

• Trans-septal balloon valvotomy (pliable, non-calcified valve)
• Closed valvotomy
• Open valvotomy
• Mitral valve replacement

(if 1.mitral regurg also present; 2. Badly diseased or calcified stenotic valve 3. Moderate or severe mitral stenosis and thrombus in the left atrium despite anticoagulation)

• Prophylaxis against IE
• If fast AF : rate control + anticoagulated
• Pulmonary oedema / HF; diuretics
• ACE inhibitor

Surgical :

• For deteriorating symptoms
• Aim to repair or replace valve be4 LV irreversibly impaired (early intervention!)

Percutaneous mitral valve repair (Mitraclip)

• New
• Appropriate for patient unsuitable for cardiac surgery