| Mitral Regurgitation: Etiology | Etiology: Primary (1&2 because its valvular) vs. Secondary (3. because its functional)
1- Acute - trauma, IE, AMI (chordal/papillary rupture), Acute Rheumatic Fever, Spontaneous chordal rupture, degeneration of valves
2- Chronic Organic changes of leaflets, rings, chords, papillary muscles
3- Chronic Functional (LV & Mitral annulus dilatation) - Dilated/ Ischemic/ Hypertensive Cardiomyopathy |
| Mitral Regurgitation: Pathophysiology | Systolic reversal of blood flow to LA causes
1) LA volume overload and hypertrophy -> Pulmonary hypertension/edema (venous congestion) -> RV hypertrophy& dysfunction
2) LV dilation &hypertrophy -> LV systolic & diastolic dysfunction |
| Mitral Regurgitation: Symptoms | (*Chronic can be asymptomatic, acute has:)
- Fatigue
- Weakness
- Palpitations
- Dyspnea (↓ stroke volume)
- Atrial fibrillation (↑LA pressure)
(maybe : diaphoresis & peripheral edema) |
| Mitral Regurgitation Diagnosis: Physical & ECG | Physical exam:
- ↓ S1, audible S3
- Holosystolic murmur (at apex) spreading to the armpit
- Systolic thrill on palpation (LVD)
ECG:
-LVH &volume overload
-Atrial fibrillation, Old MI (ischemic MR),
- LAH(P mitrale) |
| Mitral Regurgitation Diagnosis: Xray & Echo | Chest Xray:
- Heart chamber dilation: left heart enlargement (LA,LV)
-Pulmonary HTN, edema
Echo:
- Evaluation of the Mitral valve leaflets, annulus, chords, papillary muscles: Primary vs Secondary etiology
- LA, LV systolic and diastolic diameter and volume (LV-ESD <40 mm)
- LV systolic and diastolic function, PH (LV EF >60%)
- Mitral regurgitation quantification (Volume, fraction, regurgitant orifice, vena contracta) |
| Mitral regurgitation: Treatment | - Prophylaxis of IE and rheumatic fever
-Asymptomatic: no meds or physical restriction
1- Medication- if LVD or dysfunction present
a) ACEI/B-blockers
b)HR Control: RAAS inhibitors, Beta blockers, CCB, amiodarone - A.fib
c) Anticoagulants eg Vit.K antagonists, warfarin -thromboembolic complication. 2- Surgical/Interventional:
a) Repair: Open or Mitraclip
b) Replacement: Open with CPB |
| Mitral Stenosis : Etiology | - Rheumatic fever (95%)
- Congenital
- Degenerative: Annulus calcification
- SLE
- Myxoma
- RA
- Fabry disease |
| Mitral Stenosis: Pathophysiology | 1- Diastolic pressure gradient between LA and LV
2- ↑ LA pressure, dilatation and hypertrophy
3- Blood regurgitates back into venous system = Raise pulmonary venous and capillary pressures
4- Pulmonary artery hypertension
5- RV hypertrophy, dilatation and dysfunction + TR |
| Mitral Stenosis: Symptoms | Symptoms depend on degree of stenosis:
- Weakness
- fatigue
- palpitation
- dyspnea (exertional, orthopnea, paroxysmal, nocturnal)
- peripheral edema
- chest pain/syncope (thromboembolic complications)
-dysphagia/hoarseness |
| Mitral Stenosis: Physical findings | Facies mitralis
Mitral melody (accentuated S1, opening snap following S2)
Protodiastolic murmur at apex
Graham-Steel diastolic murmur of pulmonary regurgitation |
| Mitral Stenosis: ECG & Xray findings | ECG:
P mitrale (LA enlargement)
RV hypertrophy (in V1; R axis, QRS deviation, tall R waves)
Atrial fibrillation
Right heart overload signs (big prominent R on V1-V3, deep S on V4-V6)
Chest Xray: enlarged LA displaces oesophagus + straightening of left cardiac border
Exercise test: to evaluate hemodynamic significance of MS |
| Mitral Stenosis: Echo | -Calcification/ fibrosis of mitral valve leaflets
-Decreased motion of mitral valve leaflets
-Doming/hockey-stick deformity of anterior leaflet
- Posterior leaflet restricted
- Reduced mitral valve orifice area (fish mouth)
- Damage of sub-valvular structures; calcification, fibrosis
- Dilation of LA + right heart chambers
- LA thrombosis , TV insufficiency |
| Mitral Stenosis: Treatment - medications | a) Prophylaxis for B-hemolytic streptococcal infection, IE, Rheumatic fever
b) HR control: B blockers (metoprolol, bisoprolol), CCB ( verapamil, diltiazem)
c) For Permanent AF, HF: Digoxin/ Nitrates/ Diuretics
d) Prophylaxis of thromboembolic events: VitK antagonists, warfarin |
| Mitral Stenosis: Surgical Treatment | Indications:
-MVOA< 1.5cm2 (C+D stages)- hemodynamically significant MS
-Severe symptomatic MS (D stage), NYHA III-IV when MVOA <1.5cm2 + percutaneous commissurotomy can't be performed + recurrent sys embolisation
- Moderate MS: MVOA 1.6- 2.0 cm2
Intervention:
-Percutaneous balloon commissurectomy (for younger + not heavily calcified valves)
- Surgical commissurotomy ( for severe subvalvular disease, valvular calcification or LA thrombi)
- Valve replacement (for severe morphological changes not suitable for balloon or surgical commissurotomy) |
| Aortic Regurgitation: ACUTE Etiology | - Aortic dissection
- IE
- Trauma |
| Aortic Regurgitation: CHRONIC Etiology | (a) Cusp pathology:
- Congenital diseases - unicuspid/ bicuspid/ quadricuspid aortic valve, AV prolapse,
- Inflammatory - IE, rheumatic fever/disease
- Degenerative - atherosclerosis, calcinosis
(b) Abnormalities of aortic root & ascending aorta geometry:
- Idiopathic anuloaortoectasy, Inflammatory CT diseases (Spondyloarthritis, ulcerative colitis), Arterial HTN, Aneurysm of sinus vasalva, Marfan's syndrome & Ehler's Danlos
- syphilis aortitis, degenerative aneurysm of ascending aorta, bicuspid AV w/ aorthopathy |
