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1、Valvular Heart DiseaseValvular Heart Disease Mitral Stenosis Mitral Stenosis Continuing Medical Implementation.bridging the care gap.bridging the care gap A 75 year old woman with loud first heart sound and mid-diastolic murmur Chronic dyspnea Class 2/4 Fatigue Recent orthopnea/pnd Nocturnal palpita
2、tion Pedal edema Continuing Medical Implementation.bridging the care gap.bridging the care gap Mitral Stenosis Etiology Symptoms Physical Exam Severity Natural history Timing of Surgery Continuing Medical Implementation.bridging the care gap.bridging the care gap Mitral Stenosis:Etiology Primarily a
3、 result of rheumatic fever(99%of MVs 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.Continuing Medical Implementation.bridg
4、ing the care gap.bridging the care gap Right Heart Failure:Hepatic CongestionJVDTricuspid RegurgitationRA Enlargement Pulmonary HTNPulmonary CongestionLA EnlargementAtrial FibLA Thrombi LA Pressure RV Pressure OverloadRVHRV Failure LV FillingMitral Stenosis:Mitral Stenosis:PathophysiologyPathophysio
5、logy Continuing Medical Implementation.bridging the care gap.bridging the care gap Mitral Stenosis:Symptoms Fatigue Palpitations Cough SOB Left sided failure Orthopnea PND Palpitation Afib Systemic embolism Pulmonary infection Hemoptysis Right sided failure Hepatic Congestion Edema Worsened by condi
6、tions that cardiac output.Exertion,fever,anemia,tachycardia,Afib,intercourse,pregnancy,thyrotoxicosis Continuing Medical Implementation.bridging the care gap.bridging the care gap Recognizing Mitral StenosisPalpation:Small volume pulse Tapping apex-palpable S1+/-palpable opening snap(OS)RV lift Palp
7、able S2ECG:LAE,AFIB,RVH,RADAuscultation: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 flow-S1,OS&rumble may be inaudible Continuing Medical Implementation.bridging the care gap.bridging
8、 the care gap 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 S2 S1 Continuing Medical Implementation.bridging the care gap.bridging the car
9、e gap Auscultation-Timing 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.bridging the care gap.bridging the care gap Mitral Stenosis:Complica
10、tions 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:pulm
11、onary edema,or infection Endocarditis Pulmonary infections Continuing Medical Implementation.bridging the care gap.bridging the care gap A 75 year old woman with loud first heart sound and mid-diastolic murmer Continuing Medical Implementation.bridging the care gap.bridging the care gap Mitral Steno
12、sis: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 determinesuitability for percutaneous mitral balloon valvuloplast
13、y 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 Continuing Medical Implementation.bridging the care gap.bridging the care gap Continuing Medical Implementation.bridging t
14、he care gap.bridging the care gap Continuing Medical Implementation.bridging the care gap.bridging the care gap 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 lo
15、ng term improvement Continuing Medical Implementation.bridging the care gap.bridging the care gap Mitral Stenosis:Therapy Surgical Mitral commissurotomy Mitral Valve Replacement Mechanical Bioprosthetic Continuing Medical Implementation.bridging the care gap.bridging the care gap Recommendations for
16、 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-
17、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.Continuing Medical Implementation.bridging the care gap.bridging the care gap