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Mitral Stenosis
Yerizal Karani MD Cardiology Division Faculty of Medicine Andalas University
A 75 year old woman with loud first heart sound and mid-diastolic murmur
Chronic dyspnea Class 2/4 Fatigue Recent orthopnea/pnd Nocturnal palpitation Pedal edema
Mitral Stenosis
Etiology Symptoms Physical Exam Severity Natural history Timing of Surgery
...bridging the care gap
Scarring & fusion of valve apparatus Rarely congenital Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease Two-thirds of all patients with MS are female.
Continuing Medical Implementation ...bridging the care gap
Mitral Stenosis:
Pathophysiology
Normal valve area: 4-6 cm2 Mild mitral stenosis:
MVA 1.5-2.5 cm2 Minimal symptoms
Mitral Stenosis:
Pathophysiology
Right Heart Failure: Hepatic Congestion JVD Tricuspid Regurgitation RA Enlargement Pulmonary HTN Pulmonary Congestion LA Enlargement Atrial Fib LA Thrombi LA Pressure
LV Filling
...bridging the care gap
Palpitation
Continuing Medical Implementation
Auscultation:
Loud S1- as loud as S2 in aortic area A2 to OS interval inversely proportional to severity Diastolic rumble: length proportional to severity In severe MS with low flowS1, OS & rumble may be inaudible
...bridging the care gap
ECG:
LAE, AFIB, RVH, RAD
Continuing Medical Implementation
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)
...bridging the care gap
S1
S1
AuscultationTiming of A2 to OS Interval
Width of A2-OS inversely correlates with severity The more severe the MS the higher the LAP the earlirthe LV pressure falls below LAP and the MV opens
Continuing Medical Implementation
Timing Severity Other seconds of MS HSs 0.06 Severe .07-.08 .08-.09 0.10 .12 Modsevere Mod Mild PK
0.1-0.110
A2-S3
0.12-0.18
A 75 year old woman with loud first heart sound and mid-diastolic murmer
Mitral Stenosis:Therapy
Medical
Diuretics for LHF/RHF Digitalis/Beta blockers/CCB: Rate control in A Fib Anticoagulation: In A Fib Endocarditis prophylaxis
Balloon valvuloplasty
Effective long term improvement
Continuing Medical Implementation ...bridging the care gap
Mitral Stenosis:Therapy
Surgical
Mitral commissurotomy Mitral Valve Replacement
Mechanical Bioprosthetic
Mitral Regurgitation
Etiology Symptoms Physical Exam Severity Natural history Timing of Surgery
...bridging the care gap
Annulus
Calcification, IE (abcess)
Papillary Muscles
CAD (Ischemia, Infarction, Rupture) HCM Infiltrative disorders
Chordae
Fused/inflammatory Torn/trauma Degenerative IE
MR Etiology:Surgical series
MVP(20-70%) Ischemia (13-40%) RHD (3-40%) Infectious endocarditis(10-12%)
MR Pathophysiology
Chronic LV volume overload - compensatory LVE initially maintaining cardiac output Decompensation (increased LV wall tension) -CHF LVE annulus dilation increased MR Backflow LAE, Afib, Pulmonary HTN
Continuing Medical Implementation ...bridging the care gap
MR Symptoms
Similar to MS Dyspnea, Orthopnea, PND Fatigue Pulmonary HTN, right sided failure Hemoptysis Systemic embolization in A Fib
...bridging the care gap
Murmer-Fixed MR:
pansystolic loudest apex to axilla no post extra-systolic accentuation
Murmer-Dynamic MR(MVP)
mid systolic +/- click upright
RV lift TTE/TEE for diagnosis Chordal or papilllary muscle rupture/tear Infarction with papillary muscle ischaemia or tear Infectious endocarditis with leaflet perforation or disruption or chordal tear Flail MV segment
...bridging the care gap
Comparing AS and MR
Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis
Continuing Medical Implementation
S1
S1
MR Echocardiography
Baseline evaluation to identify etiology, quantify severity of MR Assess and quantify LV function and dimensions Annual or semi-annual surveillance of LV function, estimated EF and LVESD in asymptomatic severe MR To establish cardiac status after change in symptoms Baseline study post MVR or repair
Continuing Medical Implementation ...bridging the care gap
MR Echocardiography
Etiology:
flail leaflets (chord/pap rupture) thick (RHD) post mvt of leaflets (MVP) vegetations(IE)
Severity:
regurgitant volume/fraction/orifice area LV systolic function increased LV/LA size, EF
Continuing Medical Implementation ...bridging the care gap
MR Echo/Doppler
MR Pressure Tracing
MR Stages
LV size and function defined by echo Stage 1-compensated:
End-diastolic dimension less 63mm, ESD less 42mm EF more than 60
Stage 2-transitional
EDD 65-68mm, ESD 44-45mm, EF 53-57
Stage 3-decompensated
EDD more than 70mm, ESD more than 45mm, EF less than 50
Continuing Medical Implementation ...bridging the care gap
Echo Indicators for Valve Replacement in Asymptomatic Aortic & Mitral Regurgitation
Type of LVESD mm Regurgitation EF % FS
Aortic
> 55
< 55
<0.27
Mitral
> 45
< 60
< 0.32
...bridging the care gap
RECOMMENDED FREQUENCY OF ECHOCARDIOGRAPHY IN PATIENTS WITH CHRONIC MITRAL REGURGITATION AND PRIMARY MITRAL-VALVE DISEASE.
SEVERITY OF MITRAL REGURGITATION
Mild Moderate Moderate Severe Severe
*ESD denotes end-systolic dimension and EF ejection fraction. Continuing Medical Implementation
Symptoms
Class III or IV symptoms (even if transient) always indicate need for surgery Class II symptoms indicate need for surgery in patients with repairable valves ETT may reveal concealed symptoms
Surgery indicated if LVEF is below normal (60%) If EF normal, follow every 6 to 12 months If EF <30%, medical management (valve repair experimental in this setting)
End-systolic diameter
LVIDs >45 predicts poor outcome
Other Indications
Flail mitral leaflet Left atrial dimension >45mm Paroxysmal atrial fibrillation Pulmonary hypertension
Valve repair Mortality 2-3% No anticoagulation (unless Afib) Preservation of LVEF Valve repair always preferable Feasible in 70-90% of patients
...bridging the care gap
Acknowledgment
Some slides adapted from Cardiology Rounds presentation by Stephane Moffett R1 Anesthesia
AORTIC STENOSIS
Yerizal Karani MD Cardiology Division Faculty of Medicine Andalas University
CD
etc.
AORTIC SCLEROSIS
Irregular thickening of the valve leaflets seen on echo but without significant obstruction. May result in a systolic ejection murmur.
Approx. 25% over age 65 and over 40% over 85 Evidence suggests Ao sclerosis does progress to degenerative aortic stenosis.
AORTIC SCLEROSIS
Cosmi et al studied 2000 pts with aortic sclerosis and found 16% progressed to aortic stenosis and 10% had mild, 3% moderate, and 2% severe obstruction. The average time for progression from ao sclerosis to severe stenosis was 8 years.
Arch Int Med 2002; 62:2345
AORTIC STENOSIS
NATURAL HISTORY May be asymptomatic for many years Gradual onset and slow progression LVH allows large gradient to be tolerated for years with little or no reduction of cardiac output, left ventricular dilatation, or symptoms
AORTIC STENOSIS
Obstruction is progressive-but insidious
Rate of progression is variable so difficult to predict in an individual patient On average: AVA decreases 0.12 cm2/yr with average increase jet velocity of 0.32 m/sec per year and mean gradient increase of 7 mm Hg per year
AORTIC STENOSIS
Peak gradient >50 mm Hg in presence of normal output Effective oriface area <0.8 cm2
Normal ao valve area=2.6-3.5 cm2
AORTIC STENOSIS
In general: Mild Aortic Stenosis=1.5-2.0 cm2 Moderate Stenosis=1-1.5 cm2 Severe Aortic Stenosis=<1.0 cm2 Critical Aortic Stenosis=<0.8 cm2
AORTIC STENOSIS
Thickening and stiffening of the LV in the face of increasing obstruction results in Increased LVEDP Result=LAH and diastolic dysfunction Left atrium becomes critical in filling the ventricle and At Fib or AV dissociation are poorly tolerated
AORTIC STENOSIS
In significant ao stenosis, the cardiac output may be fairly well maintained at rest but fails to augment with exercise Late in the course of severe AS : cardiac output, stroke volume, and the gradient itself all declinewhile the Mean LA pressure, capillary wedge pressure and P.A. pressure increase
AORTIC STENOSIS
DIAGNOSIS: Symptoms Physical exam Chest X-Ray EKG Echo-major diagnostic tool and means of follow-up. Allows measurement of gradient, LV function, associated lesions
AORTIC STENOSIS
Symptoms: Can be asymptomatic Dyspnea on exertion Angina Syncope or light spells Palpitations not listed as major symptom, but common in significant heart disease
AORTIC STENOSIS
Implications of symptoms With unrelieved obstruction survival is approx 2 years after onset of failure, 3 years after onset of syncope, and 5 years after onset of angina Recent data: symptomatic pts with severe stenosis-average survival was 2 years with only 20% survival at 5 yrs
AORTIC STENOSIS
Physical Exam Narrow pulse pressure, slow arterial upstroke, carotid shudder Sustained PMI and with failure it is displaced laterally and inferiorly S4 common, S1 soft, S2 may be single, systolic ejection murmur best at the base
AORTIC STENOSIS
MANAGEMENT
Medical: medications and careful follow-up Surgical: Valve replacement is the best approach in most cases
AORTIC STENOSIS
Medical Management Patient education Medications-patients with associated hypertension or CHF can be treated with medications if AS is mild or moderate. Caution if Severe AS, especially with beta blockers and dilator type agents Favor use of statin drugs
AORTIC STENOSIS
Management-2 Periodic echo-if mild AS: echo every 2 years; for moderate AS every year, and for severe AS echo assessment every 6-8 months Question the role of SBE prophylaxis
AORTIC STENOSIS
Management-3 (surgical and related) Non-calcified congenital AS can be managed with open commissural incision at low risk Some cases of adult AS can be managed by Balloon Valvuloplasty often will need operative care in 2 yrs Most adult calcific AS if severe or progressive-symptomatic best care is AVR
AORTIC STENOSIS
Management-4 AVA <1.0 cm2 whose symptoms are believed to result from the stenosis Asymptomatic patients if progressive LV dysfunction, or if hypotensive response to exercise Threshold for AVR will likely lower in the future
AORTIC STENOSIS
Effects of successful AVR Substantial clinical and hemodynamic improvement Ten year survival approx 85% Exertional dyspnea improved as also frequency and severity of angina Impaired LV performance improves toward normal often and LV mass decreases toward normal-not normal
AORTIC STENOSIS
SUMMARY: Aortic stenosis of varying degree is common in adults Diagnosis and management are DEPENDENT on the internist, hospitalist, and family physician Follow up involves history, physical, and especially the echo-Doppler Valve replacement=best overall Rx
Aortic Regurgitation
Etiology Physical Examination Assessing Severity Natural History Prognosis Timing of Surgery
...bridging the care gap
Acquired
Rheumatic heart disease Dilated aorta (e.g. hypertension..) Degenerative Connective tissue disorders
E.g. ankylosing spondylitis, rheumatoid arthritis, Reiters syndrome, Giant-cell arteritis )
Aortopathy
Cystic medial necrosis Collagen disorders (e.g. Marfans) Ehler-Danlos Osteogenesis imperfecta Pseudoxanthoma elasticum
Continuing Medical Implementation
Acute AI: aortic dissection, infective ...bridging the care gap endocarditis, trauma
With extreme reductions in diastolic pressures (e.g. < 40) may see angina
Durosiers sign: femoral retrograde bruits Traubes sign: pistol shot femorals Hills sign:BP Lower extremity >BP Upper extremity by
> 20 mm Hg - mild AR > 40 mm Hg mod AR > 60 mm Hg severe AR
...bridging the care gap
High pitched, blowing, decrescendo diastolic murmur at LSB Best heard at endexpiration & leaning forward Hands & Knee position
Continuing Medical Implementation
S1
S2
S1
Assessing Severity of AR
Assess severity by impact on peripheral signs and LV
peripheral signs = severity LV = severity S3 Austin -Flint LVH radiological cardiomegaly
...bridging the care gap
%/Y
<6 < 3.5 < 0.2 25 > 10
Abnormal LV function
Progression to cardiac symptoms
Mortality
EF %
FS
Aortic
> 55
< 55
<0.27
Mitral
> 45
< 60
< 0.32
...bridging the care gap
ACC/AHA Class II a
Asymptomatic patients with preserved LVEF but severe LV dilatation (EDD>75 mm or ESD > 55mm)
Continuing Medical Implementation ...bridging the care gap