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Mitral stenosis Mitral regurgitation
Causes
  • Rheumatic heart disease (Group A beta haemolytic streptococcus)
  • Others : congenital, calcification/fibrosis in elderly, carcinoid tumour metastasizing to lung
Pathophysiology To maintain CO, left atrial pressure↑>> left atrial hypertrophy and dilatation >> pulmonary venous, arterial and right heart pressure ↑ >> pulmonary oedema >> pulmonary HTN >> right ventricular hypertrophy, dilatation failure and subsequent tricuspid regurgitation
  • 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
Symptoms
  • 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
Signs
  • 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
Investigation 1.     CXR

  • 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
1.     CXR

  • 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

Treatment Pharmacological:

  • 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)

Pharmacological

  • 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

References

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