Dr.

Abdul Ghani Waseem

The mitral valve (also known as the bicuspid valve or left atrioventricular valve) that lies between the left atrium (LA) and the left ventricle (LV).

The mitral valve is typically 46 cm in area.

It has two cusps, or leaflets, (the anteromedial leaflet and the posterolateral leaflet) that guard the opening. The opening is surrounded by a fibrous ring known as the mitral valve annulus.

The anterior cusp protects approximately two-thirds of the valve.

These valve leaflets are prevented from prolapsing into the left atrium by the action of tendons attached to the posterior surface of the valve, chordae tendineae.

The inelastic chordae tendineae are attached at one end to the papillary muscles and the other to the valve cusps.
Papillary muscles are fingerlike projections from the wall of the left ventricle. Chordae tendineae from each muscle are attached to both leaflets of the mitral valve. Thus, when the left ventricle contracts, the intraventricular pressure forces the valve to close, while the tendons keep the leaflets coating together and prevent the valve from opening in the wrong direction (thus preventing blood to flow back to the left atrium).

During left ventricular diastole, after the pressure drops in the left ventricle due to relaxation of the ventricular myocardium, the mitral valve opens, and blood travels from the left atrium to the left ventricle.
70-80% of the blood that travels across the mitral valve occurs during the early filling phase of the left ventricle. This early filling phase is due to active relaxation of the ventricular myocardium, causing a pressure gradient that allows a rapid flow of blood from the left atrium, across the mitral valve.

Left atrial contraction (left atrial systole) (during left ventricular diastole) causes added blood to flow across the mitral valve immediately before left ventricular systole..
The late filling of the LV contributes about 20% to the volume in the left ventricle.

The closing of the mitral valve and the tricuspid valve constitutes the first heart sound (S1).

Flow of blood into the heart during rapid filling is not normally heard except in certain pathological states where it constitutes the third heart sound (S3).

Mitral Stenosis

Mitral Stenosis
Mitral valve is present between LA & LV. Normal mitral valve orifice area (MVA): 4-6cm2..

MVA <2.5cm2 leads to symptoms

Mitral Stenosis
Decrease in Mitral valve orifice area leading to chronic & fixed mechanical obstruction to LV filling is termed as MS.

Causes
Rheumatic Heart disease SLE Carcinoid syndrome Active Infective Endocarditis Left atrial myxoma Congenital mitral stenosis Massive Annular Calcification

Rheumatic mitral stenosis

More common in females (2/3rd of all pts) Symptoms occur two decades after onset of Rheumatic fever Age of presentation Earlier in 20s-30s Now in 40s-50s (slower progression) Isolated MS in 40% cases of RHD Remaining 60% cases associated with other valvular diseasesMR/AR

Patho-physiology
Immunological disorder initiated by Group A beta hemolytic streptococcus. Antibodies produced against streptococcal cell wall proteins & sugars react with connective tissues & heart; result in rheumatic fever and symptoms like Carditis Arthritis Subcutaneous nodules Chorea Erythema marginatum

 Chronic cardiac & valvular inflammation leads to cardiac & valvular pathology

Valvular pathology
Rheumatic fever involving mitral valves Valve leaflet thickening and fusion of commissures Increased rigidity of valve leaflets

Thickening, fusion and contracture of chordae & papillary heads

Leaflet calcification (long standing MS) Progressive reduction in mitral valve orifice area Mitral Stenosis

Mechanical obstruction to left ventricular diastolic filling

Adaptative in LAP to maintain LV filling

------------------------------------------------------------------------LA enlargement in pulmonary venous pressure in pulmonary arterial pressure* Transudation of fluid into pulmonary interstitial space ed pulmonary compliance Work of breathing Progressive dyspnoea on exertion/rest pulmonary edema

Atrial fibrillation
Thrombus formation Systemic thrombo-embolism

in pulmonary arterial pressure*-------- Pulmonary arterial hypertrophy (Pulmonary HTN) RV hypertrophy and dilatation

RV failure

Effect of Atrial fibrillation in MS

Increased chances of thrombus formation and systemic thromboembolism.
Normally effective atrial contraction is important in LV diastolic filling. In presence of AF Loss of effective atrial contraction

Impaired LV filling (ed LV preload) decreased cardiac output

Clinical presentation
Dyspnea, Orthopnea, PND Fatigue, Cough. Hemoptysis.

Systemic thromboembolism (first symptom in 20% cases).

Physical examination
Low volume pulse. Sign & Symptoms of right sided heart failure - engorged neck veins, enlarged tender liver

Physical examination
Mitral facies Pink purple patches on the cheeks, Cyanotic skin changes from low cardiac output

Cardiac auscultation
Opening snap Rumbling diastolic murmur best heard at apex radiating to the axilla Loud S2: pulmonary hypertension

 ECG
Broad notched P wave (left atrial enlargement)

Atrial fibrillation

 Chest X-ray
Normal to ed cardiac shadow Straightening of the left heart of border and elevation of left main bronchus (left atrial enlargement) mitral calcification Evidence of pulmonary edema/ HTN

LAA: Left atrial appendages, MPA: Main pulmonary artery, LPA: left pulmonary artery, RPA: Right pulmonary artery, Ao- Aortic knuckle (Ao)

MS - chest x-ray

 Echocardiography
Anatomy/size of mitral valve & its appendages severity of MS (area of orifice) Size & function of ventricles Estimation of pulmonary artery pressure

Cardiac catheterization and invasive measurement

Are almost never necessary Reserved for situations ECHO sub-optimal/conflict with clinical presentation

Severity of MS Presence of pulmonary hypertension.

Length of MDM is proportional to severity

TREATMENT

Therapeutic goals in patients with mitral stenosis

Reduce symptoms of pulmonary congestion (dyspnea on exertion, PND, pulmonary edema): diuretics Prevent arterial embolism (cerebral or peripheral arterial embolism): anticoagulation Prevent infectious endocarditis: prophylactic antibiotics

Therapeutic goals in patients with mitral stenosis

Treat bacterial endocarditis: antibiotics

Prevent/treat atrial fibrillation: digoxin, blockers, antiarrhythmic agents, anticoagulants

Mitral stenosis Indications for anticoagulation

AF (chronic / paroxysmal) Prior embolism Severe MS

Large
>

LA:

50 mm

Mitral stenosis Indications for mechanical relief

Symptomatic

+ MVA < 1 cm2.

Mitral stenosis Options for mechanical relief

Percutaneous balloon mitral valvuloplasty (PBMV) Closed mitral commisurotomy Open mitral commisurotomy

Mitral valve replacement Mechanical Biological

Trasseptal ballon valvatomy balloon

TSBV

Open mitral commissurotomy

Mitral Regurgitation

 Retrograde flow of blood from LV to LA through incompetent mitral valve during systolic phase

Causes
MR is almost always (90%) associated with MS in RHD Infective endocarditis

Ischemic heart disease (Ischemic MR) Myocarditis Idiopathic dilated cardiomyopathy

Pathophysiology of MR
Mitral regurgitation

Systolic (Retrograde) ejection into LA

Acute Volume overload in LA & LV ed LA, LV Pressure Chronic ed LV afterload (into LA) ed LA/LV size/ compliance

Pulmonary edema ed Cardiac output

LA dilatation ed contractility AF CO Pulmonary congestion

MR

MS

Clinical presentation
Fatigue. Dyspnoea. orthopnoea. Systemic thrombo-embolis

Physical examination

Signs of RVF like JVP

Systolic thrill at apex (hyperdynamic circulation)

Physical examination

Cardiac auscultation Pansystolic murmur S1 is absent, soft or buried in the systolic murmur

 ECG Non-specific findings Atrial fibrillation LA enlargement/LV hypertrophy

Chest X-ray Left heart chamber enlargement Pulmonary congestion

 Echocardiography
Diagnosis/mechanism/severity of MR/MS Impact on cardiac chamber size, pressure & function Pulmonary artery pressure Presence of thrombus

Cardiac catheterization with left ventriculography

invasive Reserved for pts in whom ECHO is sub-optimal

Management

Therapeutic goals in patients with mitral regurgitation

Reduce symptoms of pulmonary congestion (dyspnea on exertion, PND, pulmonary edema): diuretics Prevent arterial embolism (cerebral or peripheral arterial embolism): anticoagulation Prevent infectious endocarditis: prophylactic antibiotics

Therapeutic goals in patients with mitral stenosis

Treat bacterial endocarditis: antibiotics

Prevent/treat atrial fibrillation: digoxin, blockers, antiarrhythmic agents, anticoagulants

Mitral regurgitation Indications for mechanical relief

Progressive

cardiac enlargement.

Thank you