MITRAL STENOSIS

Dr. Muhammad Alauddin Sarwar

Medical Officer ,
Sindh Government Qatar Hospital,
Karachi, Pakistan
 Normal
Anatomy
 MITRAL STENOSIS

• Etiology
• Symptoms
• Physical Exam
• Severity
• Natural history
• Timing of Surgery
 Mitral Stenosis: Etiology

• Primarily a result of rheumatic fever (~ 99% of MV’s @

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
Right Heart Failure:  Pulmonary HTN
Hepatic Congestion Pulmonary Congestion
RA LA
Tricuspid Regurgitation LA Thrombi
RA Enlargement Atrial Fib
LA Enlargement
 LA Pressure
Mitral Stenosis

RV Pressure Overload
RV RVH LV
RV Failure LV Filling
 Mitral Stenosis: Symptoms
• A-fib
• Fatigue • Systemic embolism
• Palpitations • Pulmonary infection
• Cough • Hemoptysis
• Right sided failure
• SOB – Hepatic Congestion
• Left sided failure – Edema
– Orthopnea • Worsened by conditions
that  cardiac output.
– PND
– Exertion, fever, anemia,
• Palpitation tachycardia, A-fib, I/V fluid
overload, intercourse,
pregnancy, thyrotoxicosis
 Recognizing Mitral Stenosis
Palpation: Auscultation:
• Small volume pulse • Loud S1- as loud as S2 in
• Tapping apex-palpable aortic area
S1 • A2 to OS interval inversely
• +/- palpable opening proportional to severity
snap (OS) • Diastolic rumble: length
• RV lift proportional to severity
• Palpable S2 • In severe MS with low flow-
S1, OS & rumble may be
ECG: inaudible
• 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 P
severity S
S
– mean gradient, mitral valve A
area, pulmonary artery
pressure
• Assessment of right ventricular
size and function.
• Assessment of valve morphology
P
to determine suitability for S
percutaneous mitral balloon L
valvuloplasty (PMBV) A

• Diagnosis and assessment of

concomitant valvular lesions
 Mitral Stenosis: Complications
• Atrial dysrrhythmias
• Systemic embolization (10-25%)
– Risk of embolization is related
to, age, presence of atrial
fibrillation, previous embolic
events
• Congestive heart failure
• Pulmonary infarcts (result of severe CHF) Animation

• Hemoptysis
– Massive: secondary to ruptured bronchial veins (pulm HTN)
– Streaking/pink froth: pulmonary edema, or infection
• Endocarditis
• Pulmonary infections
 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