Mitral stenosis

Association with Rheumatic heart disease
1. 25% of patients with rheumatic heart disease have isolated MS
2. 40% of patients with rheumatic heart disease have combined MS/MR
Other associated diseases
1. Malignant carcinoid diseae
2. SLE
3. Rheumatoid Arthritis
4. Fabry syndrome
5. Whipple disease
Mitral annular calcification
1. Common in elderly
2. Causes functional stenosis
3. Rarely causes severe disease
Mitral valve orifice measurements (mid diastole)
1. Normal : 4-6cm
2. <2cm: moderate MS
3. <1cm: severe MS
4. <4cm: Mild MS
Clinical presentations
1. Common
  1. Dyspnoea/Fatigue/ Reduced ETT
    1. Causes include: reduced CO, PHT, reduced vital capacity
    2. Insidious onset, often masked by patient changes in lifestyle
  2. Palpitations and embolic events
    1. Secondary to AF either permanent or paroxysmal
2. Rare
  1. Chest pain
    1. Clinically indistinguishable from Angina
  2. Haemoptysis
    1. Sudden-onset and severe
    2. Caused by big increases in LA pressure and associated bronchial vein rupture
  3. "Ortner Syndrome"
    1. Hoarsness of voice in MS patient
    2. Caused by LA enlargement pressing on recurrent laryngeal nn.
Physical exam findings
1. AF: most common
2. "Mitral Facies"
  1. Pink-purple pacths on cheeks
3. Auscultatory findings
  1. Diastolic, low-pitched rubbing murmur (longer duration = severity)
  2. Opening Snap, just after A2 (sooner after A2 = severity)
  3. Loud P2 (sign of PHT)
  4. If any auscultatory findings become palpable = severity
Clinical Outcomes/Sequale
1. Natural History
  1. NYHA3 Dyspnoea: 65% 5yr survival
  2. NYHA4 Dyspnoea: 12% 5yr survival
2. AF
  1. Incidence related to age, not severity of MS
  2. Likley treatment resistant
3. Systemic embolism
  1. 20% of patients have sinus rhythm!
  2. Depends on LA dilation and appendage thromboses
4. PHT
5. Endocarditis
  1. Increased risk as compared to population
  2. much lower risk than MR or aortic valve disease
Treatment
1. Medical
  1. Managing complications
    1. AF
      1. Rhythm control often ineffective
      2. Anticoagulation at higher INR
    2. Dyspnoea
      1. Diuretics and salt restriction
  2. Monitoring disease
    1. Mild disease
      1. 3rd annually Echo
    2. Moderate disease
      1. 2nd annually Echo
    3. Severe Disease
      1. Annual echo
2. Valvulotomy
  1. Contraindications (all assessed on pre-op TOE)
    1. Co-existing MR
    2. Thrombus in LAA
    3. Unsuitable anatomic findings eg, heavily calcified valves, cordae thickening and shortening
  2. Indications
    1. Asymptomatic disease
      1. Moderate-Severe disease
      2. co-existant PHT
    2. Symptomatic disase
      1. Mod-severe disease
      2. Mild disease controlled medically
  3. Outcomes
    1. Equal to open repair in appropriately selected patients
    2. Early BMV may prevent development of AF
    3. Permanent MR a complication
3. Open Repair
  1. All other patients with disease severity as per BMV but otherwise contraindicated
  2. Patients with recurrent embolic events despite anticoagulation
  3. Comissurotomy, valve decalcified, cordae separated and split
  4. Atrial maze/atrial ablation procedure often dose at same time
4. Mitral valve replacement
  1. Most often for patients with combined MS/MR
  2. Patients with previous valvulotomy or repair
  3. Metallic valves for patients under 65 to avoid the possibility of repeat operation
  4. Bioprosthetic valves for all patients over 65 or those who anticoagulation is contraindicated
5. Ongoing symptoms after valvulotomy or replacement?
  1. Six possibilities
    1. Valve restenosis
    2. Technically inadequate procedure
    3. Worsened MR
    4. Aortic valve disease
    5. Coronary artery disease
    6. Infective endocarditis

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Mitral stenosis

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	Erstellt von ben.ramsay vor mehr als 11 Jahre