Valvular heart disease Mitral Valve Diseases Dr. Hussam Al-Faleh Med 341 course

Mitral Valve Diseases

Mitral stenosis

Etiology Congenital (rare) Acquired 1. Rheumatic (most common) - Most common valve lesion after RF - Stenosis occurs due to fibrosis/calcification of: a. Commissures b. Cusps c. Chords d. Combination 2. CTD (SLE, RA) 3. Obstructive masses ( Atrial Myxoma, large vegetation)

Diastole Systole Rheumatic Fever Normal Mitral Valve Mitral Stenosis Commisural fusion (fishmouth) Diastole Rheumatic Fever Systole

Tricuspid Regurgitation Right Heart Failure: Hepatic Congestion JVD Tricuspid Regurgitation RA Enlargement  Pulmonary HTN Pulmonary Congestion LA Enlargement Atrial Fib LA Thrombi  LA Pressure RV Pressure Overload RVH RV Failure LV Filling RA LA RV LV

Symptoms Dyspnea - Occurs at rest or exertion - Orthopnea - Can be precipitated by any increase cardiac output (exertion, fever, AF, intercourse , pregnancy, etc..) Hemoptysis Chest pain (uncommon)

Signs Mitral facies (pink-purple patches on cheeks). Central pulse normal or small in volume JVP prominent a wave Apex tapping apex (↑ S1) Right parasternal heave Palpable S2

Auscultation First heart sound (S1) is accentuated and snapping S1 S2 OS S1 First heart sound (S1) is accentuated and snapping Opening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apex Pre-systolic accentuation (esp. if in sinus rhythm)

Investigations ECG A Fib/Flutter, LAD, RVH CXR Echo Assessing severity by estimating the gradient across the MV and measuring the Valve area ( Severe is ≤ 1 cm²)

Management Medical treatment : for Penicillin prophylaxis. 1. Patients with a Rheumatic MV should be considered for Penicillin prophylaxis. 2. Endocarditis prophylaxis. 3. If in Atrial Fibrillation , should receive long term anticoagulation .

Management 4. Digoxin , Beta blockers or Calcium channel blockers to reduce heart rate of patients with Atrial Fibrillation. 5. Symptomatic patients would benefit from Diuretics such as Lasix to reduce left atrial pressure and reduce Dyspnea.

Management Patients with moderate to severe MS and symptoms should have either : 1. Percutaneous balloon Mitral Valvotomy 2. Surgical Valvotomy - Open - Closed 3. Mitral valve replacement - Mechanical prosthesis - Bioprosthesis

Mitral Regurgitation

Etiology Valvular-leaflets Annulus Papillary Muscles Chordae Trauma Myxomatous MV Disease (MV prolapse) Rheumatic Endocarditis Congenital-clefts Chordae Fused/inflammatory Torn/trauma Degenerative IE Annulus Calcification, IE (abcess) Papillary Muscles - CAD (Ischemia, Infarction, Rupture) - HCM - Infiltrative disorders - LV dilatation Trauma

LV wall hypertrophy and dilation (Eccentric Hypertrophy) Pathophysiology LAE, Afib, Pulmonary HTN Mitral Regurgitation Chronic LV volume overload CHF LV wall hypertrophy and dilation (Eccentric Hypertrophy) Decompensation (increased LV wall tension)

Symptoms Dyspnea, Orthopnea, PND Fatigue Pulmonary HTN, right sided failure Hemoptysis

Signs JVP : Normal or elevated Pulse: Apex: Brisk, High volume - Hyperdynamic - laterally displaced - palpable S3 +/- thrill - late parasternal lift 2 to LA filling

Auscultation S1 S2 S1 - Fixed MR - Pansystolic - Loudest apex to axilla

MVP S1 Click S2 S1 Mitral valve prolapse

Investigations ECG LAE, A fib, LVH, RVH CXR  LV,  LA ,  pulmonary vascularity , Ca++ MV/MAC Echo Assessment of severity and mechanism of the MR. Assessment of LV size and function. Cardiac cath Assessment of severity of MR.

Management Only effective treatment is valve repair/replacement Optimal timing determined: Presence /absence of symptoms Functional state of ventricle Feasability of valve repair Presence of Afib/PHTN Preference/expectations of patient