Valvular Heart Disease

Mitral Regurgitation

Yerizal Karani MD
Cardiology Division
Faculty of Medicine Andalas University
 Mitral Regurgitation
• Etiology
• Symptoms
• Physical Exam
• Severity
• Natural history
• Timing of Surgery

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 Mitral Regurgitation:
Etiology
• Valvular-leaflets • Annulus
– Myxomatous MV – Calcification, IE (abcess)
Disease • Papillary Muscles
– Rheumatic
– CAD (Ischemia,
– Endocarditis Infarction, Rupture)
– Congenital-clefts – HCM
• Chordae – Infiltrative disorders
– Fused/inflammatory • LV dilatation &
– Torn/trauma functional regurgitation
– Degenerative
• Trauma
– IE

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 MR Etiology:Surgical series
• MVP(20-70%)
• Ischemia (13-40%)
• RHD (3-40%)
• Infectious endocarditis(10-12%)

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 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

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 MR Symptoms
• Similar to MS
• Dyspnea, Orthopnea, PND
• Fatigue
• Pulmonary HTN, right sided failure
• Hemoptysis
• Systemic embolization in A Fib

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 Recognizing Chronic
Mitral Regurgitation
• Pulse: • Murmer-Fixed MR:
– brisk, low volume – pansystolic
• Apex: – loudest apex to axilla
– no post extra-systolic
– hyperdynamic
accentuation
– laterally displaced
– palpable S3 +/- thrill
• Murmer-Dynamic MR(MVP)
– mid systolic
– late parasternal lift 2 to LA
filling – +/- click
• S 1 soft or normal –  upright

• S 2 wide split (early A2) • S 3 / flow rumble if severe

unless LBBB

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 Recognizing Acute Severe
Mitral Regurgitation
• Acute severe dyspnea, CHF • RV lift
& hypotension • TTE/TEE for diagnosis
• LV size normal – Chordal or papilllary
• LV may/may not be muscle rupture/tear
hyperdynamic – Infarction with papillary
• Loud S1 muscle ischaemia or tear
• Systolic murmur may/may – Infectious endocarditis
not be pan-systolic with leaflet perforation
• Inflow/rumble or disruption or chordal
• S3 present-may be only tear
abnormality – Flail MV segment

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 Comparing AS and MR

Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Mitral valve prolapse
• Tricuspid insufficiency
Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis
S1 Implementation
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 Assessing Severity of Chronic
Mitral Regurgitation
Measure the Impact on the LV:
• Apical displacement and size
• Palpable S3
• Longer/louder MR murmer (chronic MR)
• S3 intensity/ length of diastolic flow rumble
• Wider split S2 (earlier A2) unless HPT narrows
the split

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 Recognizing Mitral
Regurgitation
• ECG: • CXR:
– LA enlargement –  LV
– Afib –  LA
– LVH (50% pts. With –  pulmonary
severe MR) vascularity
– RVH (15%) – CHF
– Combined – Ca++ MV/MAC
hypertrophy (5%)

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 Mitral Valve Surgery
• Only effective treatment is valve
repair/replacement
• Optimal timing determined:
– Presence/absence of symptoms
– Functional state of ventricle
– Feasability of valve repair
– Presence of Afib/PHTN
– Preference/expectations of patient

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 Mitral Regurgitation
ACC/AHA recommendations
Surgery Recommended in patients who are
• Symptomatic
• Asymptomatic with
– Any LV dysfunction
– Atrial fibrillation
– Pulmonary hypertension
– Reparable valves
– Recurrent VT

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Valvular Heart Disease
Mitral Stenosis

Yerizal Karani MD
Cardiology Division
Faculty of Medicine Andalas University
 Mitral Stenosis
• Etiology
• Symptoms
• Physical Exam
• Severity
• Natural history
• Timing of Surgery

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 Mitral Stenosis: Etiology
• Primarily a result of rheumatic fever
(~ 99% of MV’s @ surgery show rheumatic damage )
• 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.

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 Mitral Stenosis:
Pathophysiology

• Normal valve area: 4-6 cm2

• Mild mitral stenosis:
– MVA 1.5-2.5 cm2
– Minimal symptoms
• Mod mitral stenosis
– MVA 1.0-1.5 cm2 usually does not produce symptoms
at rest
• Severe mitral stenosis
– MVA < 1.0 cm2

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 Mitral Stenosis:
Pathophysiology
Right Heart Failure:  Pulmonary HTN
Hepatic Congestion Pulmonary Congestion
JVD LA Enlargement
Tricuspid Regurgitation Atrial Fib
RA Enlargement LA Thrombi
 LA Pressure

RV Pressure Overload
RVH
RV Failure LV Filling

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 Mitral Stenosis: Symptoms
• Fatigue
• Afib
• Palpitations • Systemic embolism
• Cough • Pulmonary infection
• Hemoptysis
• SOB
• Right sided failure
• Left sided failure – Hepatic Congestion
– Edema
– Orthopnea
• Worsened by conditions that
– PND  cardiac output.
• Palpitation – Exertion,fever, anemia,
tachycardia, Afib, intercourse,
pregnancy, thyrotoxicosis

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 Recognizing Mitral
Stenosis
Palpation:
• Small volume pulse Auscultation:
• Tapping apex-palpable S1 • Loud S1- as loud as S2 in aortic
• +/- palpable opening snap area
(OS) • A2 to OS interval inversely
• RV lift proportional to severity
• Palpable S2 • Diastolic rumble: length
proportional to severity
ECG: • In severe MS with low flow- S1,
• LAE, AFIB, RVH, RAD OS & rumble may be inaudible

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 Mitral Stenosis: Physical Exam

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)

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 Common Murmurs and
Timing (click on murmur to play)

Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Mitral valve prolapse
• Tricuspid insufficiency
Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis
S1 Implementation
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 Auscultation-
Timing of A2 to OS Interval

• Width of A2-OS
Say Timing Severity Other
inversely correlates seconds of MS HS’s
with severity Prrr  0.06 Severe

• The more severe the Pada .07-.08 Mod-

severe
MS the higher the LAP Pata .08-.09 Mod
the earlirthe LV Papa  0.10 Mild PK
pressure falls below 0.1-0.110
Tu-  .12 A2-S3
LAP and the MV opens huh 0.12-0.18

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 Mitral Stenosis: Natural History
• Progressive, lifelong disease,
• Usually slow & stable in the early years.
• Progressive acceleration in the later years
• 20-40 year latency from rheumatic fever to
symptom onset.
• Additional 10 years before disabling symptoms

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 Mitral Stenosis: Complications
• Atrial dysrrhythmias
• Systemic embolization (10-25%)
– Risk of embolization is related to, age, presence of atrial
fibrillation, previous embolic events
• Congestive heart failure
• Pulmonary infarcts (result of severe CHF)
• Hemoptysis
– Massive: 20 to ruptured bronchial veins (pulm HTN)
– Streaking/pink froth: pulmonary edema, or infection
• Endocarditis
• Pulmonary infections

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 Mitral Stenosis: EKG
• LAE
• RVH
• Premature contractions
• Atrial flutter and/or fibrillation
–  freq. in pts with mod-severe MS for several years
– A fib develops in  30% to 40% of pts w/symptoms

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A 75 year old woman with loud first heart sound
and mid-diastolic murmer

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 Mitral Stenosis: Role of
Echocardiography
• Diagnosis of Mitral Stenosis
• Assessment of hemodynamic severity
– mean gradient, mitral valve area, pulmonary artery
pressure
• Assessment of right ventricular size and function.
• Assessment of valve morphology to determine
suitability for percutaneous mitral balloon valvuloplasty
• Diagnosis and assessment of concomitant valvular lesions
• Reevaluation of patients with known MS with changing
symptoms or signs.
• F/U of asymptomatic patients with mod-severe MS

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 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

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 Mitral Stenosis:Therapy
• Surgical
– Mitral commissurotomy
– Mitral Valve Replacement
• Mechanical
• Bioprosthetic

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Recommendations for Mitral Valve Repair for
Mitral Stenosis

• ACC/AHA Class I
– Patients with NYHA functional Class III-IV symptoms, moderate or
severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology
favorable for repair if percutaneous mitral balloon valvotomy is
not available
– Patients with NYHA functional Class III-IV symptoms, moderate or
severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology
favorable for repair if a left atrial thrombus is present despite
anticoagulation
– Patients with NYHA functional Class III-IV symptoms, moderate or
severe MS (mitral valve area <1.5 cm 2 ),* and a non-pliable or
calcified valve with the decision to proceed with either repair or
replacement made at the time of the operation.

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