Mitral Valve Disease

1. Mitral Valve Disease Prof JD Marx UFS January 2006

2. Anatomy

3. Mitral Stenosis Aetiology • Almost always rheumatic • Heavy calcification in elderly • Congenital MS in infants

4. Pathophysiology • Mitral valve orifice diminished by • progressive fibrosis • calcification valve leaflets • fusion cusps subvalvular apparatus

5. Mitral Valve Orifice • Normal 5 cm² • Moderately severe 2 cm² or less • severe 1 cm² or less • Pulmonary venous congestion • LA dilatation and hypertrophy • LA contraction important LV filling • Diastolic filling period important • Pulmonary hypertension • Atrial fibrillation • Thrombus formation in LA Bloodflow LA to LV restricted

6. Symptoms • Breathlessness (pulmonary congestion) • Fatigue (low cardiac output) • Oedema, ascites (right heart failure) • Palpitation (atrial fibrillation) • Haemoptysis (pulmonary congestion, pulmonary embolism) • Cough (pulmonary congestion) • Chest pain (pulmonary hypertension) • Symptoms of thromboembolic complications (e.g. stroke, ischaemic limb)

9. Signs • Atrial fibrillation • Mitral facies • Auscultation • Loud first heart sound. Opening snap • Mid-diastolic murmur • Signs of raised pulmonary capillary pressure • Crepitations, pulmonary oedema, effusions • Signs of pulmonary hypertension • RV heave, loud P2

10. Investigations • ECG • Left atrial hypertrophy (if not in AF) • Right ventricular hypertrophy • Chest Radiograph • Enlarged left atrium • Signs of pulmonary venous congestion • Echo • Thickened immobile cusps • Reduced valve area • Reduced rate of diastolic filling of LV • Doppler • Pressure gradient across mitral valve • Pulmonary artery pressure • Cardiac catheterisation • Pressure gradient between LA (or pulmonary wedge) and LV

12. Management • Medical management • Patients with minor symptoms • Anti coagulants eg Warfarin • Diuretics for pulmonary congestion • Rate and rhythm control digoxin, -blockers etc • A/B prophylaxis IE

13. Surgical procedures • Mechanical disease • Consider - patient symptomatic • - pulmonary hypertension • - atrial fibrillation • - MVA 1 cm² or less • Mitral balloon valvuloplasty • Open mitral replacement

14. Mitral Regurgitation Aetiology • Chronic rheumatic endocarditis • Infective endocarditis • Mitral valve prolaps and myxomatous degeneration • Mitral valve ring dilatation eg dilating cardiomyopathy • Papillary muscle necrosis / ischaemia

15. Pathophysiology • Chronic mitral regurgitation • Gradual dilatation LA • Little increase in pressure • LV dilates slowly • Late rise in diastolic and LA pressure • Acute mitral regurgitation • Rapid rise in LA pressure (compliance)

16. Clinical Features Symptoms • Dyspnoea (pulmonary venous congestion) • Fatigue (low cardiac output) • Palpitation (AF, increased stroke volume) • Oedema, ascites (right heart failure)

18. Signs • Atrial fibrillation / flutter • Cardiomegaly – displaced hyperdynamic apex beat • Apical pansystolic murmur ± thrill • Soft S1, apical S3 • Signs of pulmonary venous congestion (crepitations, • pulmonary oedema, effusions) • Signs of pulmonary hypertension and right heart failure

19. 12.87

20. Investigations • ECG • Left atrial hypertrophy (if not in AF) • Left ventricular hypertrophy • Chest Radiograph • Enlarged left atrium • Enlarged left ventricle • Pulmonary venous congestion • Pulmonary oedema (if acute) • Echo • Dilated LA, LV • Dynamic LV (unless myocardial dysfunction predominates) • Structural abnormalities of mitral valve (e.g. prolapse) • Doppler • Detects and quantifies regurgitation • Cardiac catheterisation • Dilated LA, dilated LV, mitral regurgitation • Pulmonary hypertension • Coexisting coronary artery disease

21. Management • Medical management • Mild to moderate MR • Diuretics • Vasodilators eg ACE Inhibitors • Digoxin if AF • Anti coagulants if AF • A/B prophylaxis for IE • Surgical management • Patient more symptomatic • Evidence deteriorating LV function and LV dilatation • Mitral valve repair • Mitral valve replacement