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

2. Mitral Valve Diseases

3. Mitral stenosis

4. 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)

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

9. 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

10. 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)

11. 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

12. Auscultation First heart sound (S1) is accentuated and snapping
S 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)

13. 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)

14. 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 .

15. 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.

16. 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

17. Mitral Regurgitation

21. 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

23. 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)

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

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

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

27. MVP
S Click S S1
Mitral valve prolapse

28. 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.

29. 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