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Mitral Stenosis

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• The mitral valve apparatus is a funnel-shaped structure with its apex beat on the left ventricle.
• Mitral Stenosis is the narrowing of the mitral valve of the heart.
• Leads to complications due to the impairment of blood flow
• More commonly seen in females.
• Most Common cause : Rheumatic Heart Disease.

ALTERED ANATOMY IN RHEUMATIC MITRAL STENOSIS

  1. Primary Pathologic Features:
    • Thickened mitral cusps with/without calcification.
    • Fusion of valve commissures.
    • Shortening & fusion of chordae tendineae.
  2. Secondary Pathological Features:
    • Left atrial hypertrophy & dilatation.
    • Left atrial thrombi.
    • Changes in venous & arterial hypertension in pulmonary vasculature.

ETIOLOGY:
• Rheumatic fever.
• Congenital mitral Stenosis
• Systemic Lupus Erythematosus (SLE)
• Malignant carcinoid
• Gout
• Atrial Myxoma
• Infective Endocarditis (rare)
• Rheumatoid Arthritis (rare)


PATHOPHYSIOLOGY:

PATHOPHYSIOLOGY OF MITRAL STENOSIS ***Management of Atrial Fibrillation & RVF is written in bullet points for easier understanding

CLINICAL FEATURES:
• Early presentation of Mitral stenosis include breathlessness on exertion and fatigue.
• As stenosis progresses, patients are dyspnic on rest.
• They have orthopnoea & paroxysmal nocturnal dyspnoea.
• Acute pulmonary oedema may occur.
• Haemoptysis: due to rupture of pulmonary-bronchial connection.
• Edema of lower limbs.
• Thromoembolic events like stroke, limb ischaemia
• Winter bronchitis: Patient with myocardial infarction are prone to recurrent attacks of bronchitis, particularly during winters.

INVESTIGATIONS:

• ECG: May indicate left atrial(LA) enlargement, right ventricular hypertrophy and atrial fibrillation.
• CHEST X-RAY: LA enlargement, pulmonary congestion.
• ECHOCARDIOGRAPHY: Most sensitive & specific non-invasive methods to diagnose valvular disease.

  • May reveal structural abnormalities of the valve.
  • Size of cardiac chambers.
  • Pulmonary artery pressure.
  • Ventricular dysfunction & presence of thrombi.

CARDIAC CATHETERIZATION: Used to assess associated valvular lesions & to detect coronary artery disease.

MANAGEMENT:

  1. Treatment of atrial afibrillation

-Anticoagulants. – Verapamil. -Digoxin. – Beta blockers.

2. Treatment right ventricular failure:

  • Salt restrictions.
  • Diuretics
  • Digoxin.

3. Restriction of physical activity.

4. Prophylaxis should be given to all patients to prevent rheumatic fever.

5. Prophylaxis for Infective Endocarditis should be given prior to the procedure.

SURGICAL MANAGEMENT:

  1. MITRAL VALVECTOMY

Percutaneous Balloon Valvotomy:

  • Indicated when mitral valve is non-calcified &without regurgitation.
  • Procedure involves passing of a catheter across the valve & inflation of the balloon to dilate the orifice.

Open Valvotomy:

  • Carried out in patients where balloon valvotomy is not possible or in cases with restenosis(*means that a section of blocked artery that was opened up with angioplasty or a stent has become narrowed again)
  • In this procedure, the fusion of the valve is loosened, Ca(calcium) deposits and thrombi are removed.

2. MITRAL VALVE REPLACEMENT:
o Mitral Valve is replaced when there is critical mitral stenosis(<1cm² of orifice size)
o And/or there is an associated significant mitral regurgitation.
o Replacement done,when mitral valve is severely distorted & calcified.

COMPLICATIONS:
o Atrial fibrillation
o Pulmonary Hypertension
o Right Ventricular Failure
o Systemic thromboembolism
o Winter Bronchitis
o Ortner’s Syndrome


REFERENCES:

  • Davidson’s Principle and Practise of Medicine
  • Medicine Prep Manual for Undergraduate, K George Mathew(4th Edition)
  • Mayoclinic.org
  • Medlineplus.gov
  • Medmovie.com

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