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. Bloodflow LA to LV restricted
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 Chest Radiograph Echo Doppler
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 Chest Radiograph Echo Doppler
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 Surgical 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