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 Mitral Stenosis
 Mitral Regurgitation

 Mitral Valve Prolapse Syndrome

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 Etiology
 Rheumatic Fever
Rheumatoic involvement is present in 99%
patients who have been done MVR.
Approximately 25% patients with RF have pure
MS, especially in women and additional 40%
have combined MS and MR.
 Congenital
 Malignant Carcinoid
 SLE
 Rheumatoid Arthritis

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 Pathophysiology
 Normal adults valve orrifice is 4 to 6 cm²
 When the orrifice is reduced to approximately 2
cm² (mild MS), blood can flow from the left
atrium to left ventricle only if propelled by small
pressure gradient.
 When the orrifice is reduced to 1 cm² (critical MS),
a left atrioventricular pressure gradient of
approximately 20 mmHg is required to maintain
normal cardiac output at rest. The elevated left
atrial pressure raises pulmonary venous and
capillary pressure resulting exertional dyspnea.

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 Pathophysiology
 To assess the severity of MS, both
transvalvular pressure gradient and
transvalvular flow rate must be
measured.
 Condition that increase transvalvular
pressure gradient (tachycardia, AF) and
transvalvular flow rate (pregnancy,
hypervolemia, exercise) can augments
the symptomps of MS.
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 Pathophysiology
Right Heart Failure: LA Thrombi
Hepatic Congestion Atrial Fib
JVD LA Enlargement
Tricuspid Pulmonary HTN
Regurgitation Pulmonary
RA Enlargement Congestion
 LA Pressure

RV Pressure
Overload
RVH LV Filling
RV Failure
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 Clinical Manifestations
 MS is a slowly progressive disease and
many patients remain asymptomatic
 Exertional dyspnea (the principal symptom)
 Orthopnea
 Heart Failure
 Hemoptysis
 Chest pain (about 15 %)
 Systemic embolism
 Infective endocarditis (more common in
mild MS)
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 Physical Examination
 Patients with severe MS may exhibit mitral
facies (pinkish-purple patches on the
cheeks).
 In auscultation we can hear diastolic
murmur (low-pitched, rumbling murmur).
Sometimes S1 become accentuated and we
can hear Opening Snap.
 If there is a marked right ventricular
enlargement, the left ventricle can be
rotated posteriorly, so the murmur is not
audible or can be heard in the mid or
posterior axillary line. This condition called
silent MS.
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 Examinations
 ECG
Relatively insensitive for MS. The
principal ECG finding in MS is left
atrial enlargement (P wave duration
in lead II≥0.12 s).
 Echocardiography
Is the cornerstone of the diagnostic
assessment of patients with MS.

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 Exercise Testing with Doppler
Echocardiography
 To ascertain the level of physical
conditioning and to elicit covert
cardiac symptomps.
 To confirm that asymptomatic
patients has satisfactory effort
tolerance.

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 Management
 Patients with MS who are asymptomatic
frequently remain so for years and usually
do not need any specific treatment.
 However, once moderate symptomps
develop (NYHA Class II), if the stenosis is
not relieved mechanically, the disease may
progress relatively rapidly.

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 Management

 Medical Treatment
 Valvotomy
 Mitral Valve Replacement

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 Medical Treatment
 Patients with MS due to rheumatic heart
disease should receive penicillin
prophylaxis.
 Beta blocker and CCB may be used if the
patients have AF.
 Anticoagulant therapy should be used in
patient with high risk of systemic
embolization (persistent or transient AF;
especially age > 70 years, and those with
previous systemic emboli)
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 Indication of Valvotomy
 Symptomatic patients with moderate to
severe MS (mitral valve orifice area ≤ 1.0
cm²/m² Body surface area [BSA] ).
 Mild stenosis patients(mitral valve orifice
area 1.0 to 1.5 cm²/m² BSA) who are
symptomatic during ordinary activity.
 Pulmonary arterial systolic pressure > 60
mm Hg.
 Pulmonary capillary pressures > 25 mm
Hg during exercise.

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 Valvotomy
 Balloon Mitral Valvotomy (BMV).
Results are especially impressive in younger
patients without severe valvular thickening or
calcification. BMV is contraindicated in
patients with severe MR or AR.
 Closed Mitral Valvotomy.
 Open Mitral Valvotomy.
Most frequently performed in patients with
MS whose mitral valves are to calcified for
BMV.
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 Mitral Valve Area After Valvotomy
Mitral Valve Area (cm2)
2.5

1.5

0.5

0
Baseline 6 months 7 years

BMV Open Valvulotomy Closed Valvulotomy

From Farhat MB, Ayari M, et al : Percutaneous ballon versus surgical closed
and open mitral commissurotomy. Circulation 97:245, 1998)
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 Mitral Restenosis
 Mitral valvotomy is rather palliative than
curative, and even when succesful, this
produce merely “turns the clock back”.
 Most patients maintain clinical
improvement for 10 to 15 years of follow
up.
 When second procedure is required
because of symptomatic deterioration, the
valve is usually calcified and more
seriously deformed. MVR is often
necessary at that time.

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 Indications Of Mitral Valve
Replacement
 Mitral valve area less than 1.5 cm² in
NYHA Class III or IV.
 Severe MS with NYHA Class II and severe
pulmonary hypertension.
 Combine MS and moderate MR.
 Extensive commisural calcification.
 Severe fibrosis and subvalvular fusion.
 Those who have undergone previous
valvotomy.
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 Mitral Valve Replacement

 It should be remembered that MVR

have a quite high mortality rate
ranging about 3 to 8 % and even 10
to 20% in patients in NYHA Class IV.
 Also the hazards of lifelong
anticoagulant treatment must be
considered.

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 Etiology and Pathology
 Abnormalities of Valve Leaflets (RHD,
especially in men)
 Abnormalities of the Mitral Annulus
 Dilation (Dilated Cardiomyopathy)
 Calcification (Idiopathic/degenerative
calcification, especially in women with
hypertension, DM, hypercholesterolemia)
 Abnormalities of Chordae Tendinae (MVP)
 Involvement of Papillary Muscle (CHD)
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 Clinical Manifestations
 Fatigue and exhaustion (related to the
depressed cardiac output)or symptoms of
pulmonary congestion
 Right Heart Failure can be prominent in
patients with acute MR.
 Hemoptysis and systemic embolization are
less common than in those with MS.
 AF usually does not affects the course as
dramatically as MS.
 Most patients with MR of rheumatic origin
have only mild disability.
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 Diagnosis
 The most prominent physical finding is
systolic murmur, usually holosystolic
murmur, blowing, high pitched, and
radiating to the left axilla and left
infrascapular area.
 The principal ECG findings are left atrial
enlargement and atrial fibrillation.
 Echocardiography is the main key to
diagnose MR.
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 Management

 Medical Treatment.
 Surgical Treatment.

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 Medical Treatment
 Acute MR/severely symptomatic patients
have to be given drugs to decrease afterload
(nitroprusside IV, ACEI), but it is not
recommended to give this drugs to
asymptomatic/chronic MR patients.
 Patients with MR should receive penicillin
prophylaxis.
 All patients with AF should receive
anticoagulant.

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 Surgical Treatment
 Without surgical treatment, the prognosis of
patients with MR and HF is poor.
 Indication for surgical treatment :
 Asymptomatic patients (NYHA Class I) with EF ≤
0.6 and/or left ventricular end-systolic diameter ≥
40 mm.
 Asymptomatic patients with severe MR who shows
progressive deterioration or progressive
enlargement of the left atrium (>45 to 50 mm).
 Patients with severe MR and moderate or severe
symptoms (NYHA Classes II, III, and IV) in the
absence of severe left ventricular dysfunction

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 Surgical Treatment
 There are 2 ways of surgical treatment :
mitral valve repair and mitral valve
replacement (MVR).
 MVR usually indicated in older patients
with rigid, calcified, deformed valves.

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 Definition
 It is a variable syndrome that results from diverse
pathogenic mechanisms of the mitral valve
apparatus, valve leaflets, chorda tendinae,
papillary muscle, and valve annulus.
 Occurred in about 2.4% population and this
syndrome twice as frequent in women as in men.
However serious MR occurs more frequently in
older men.

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 Etiology and Pathology

 Most frequently, MVP is a primary

conditions that usually hereditary.
 There is a myxomatous proliferation
of the mitral valve and chorda
tendinae, in which the spongiosa
component of the valve is prominent.
This make lose of the strenght of the
valve and the valve become prolapse.
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 Clinical Manifestations

 MVP is usually a benign condition

and that the vast majority of patients
with this syndrome remain
asymptomatic for their entire life.
 In symptomatic patients it can cause
palpitations, syncope, chest
discomfort, and it can also cause MR.

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 Diagnosis

 The auscultatory findings that unique

for MVP syndrome is a nonejection
systolic click at least 0.14 s after S1.
It occurs after the beginning of the
carotid pulse upstroke.
 Echocardiography is the key role in
diagnosing MVP.

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 Common Murmurs and
Timing
Systolic Murmurs
 Aortic stenosis

 Mitral insufficiency

 Mitral valve prolapse

 Tricuspid insufficiency

Diastolic Murmurs
 Aortic insufficiency

 Mitral stenosis

S1 S2 S1
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 Management
 Asymptomatic patients should be encourage to do
normal life but should have follow up examination
every 3 to 5 years.
 Penicillin prophylaxis is recommended for
patients with typical click and systolic murmur.
 Beta blocker is useful if there is palpitation.
 Patients with MVP and severe MR should be
treated similarly to other patients with severe MR
and usually require mitral valve surgery.

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