MITRAL STENOSIS

1
MITRAL STENOSIS

• Dr R Schulenburg
• Division of Adult Cardiac Surgery,
• Universitas Hospital, BFN

2
Etiology and Essential Pathology

• Predominately post-inflammatory scarring(other
  malignant carcinoid, SLE)
• Fibroreactive transformation of the valve
• Affecting all segments of the valvular apparatus
• Calcifications at commisural edges lead to
  classic fish-mouth appearance
• Only 25 have pure MS

3
Pathophysiology

• Reduction in MVA with a rise in atrioventricular
  gradient
• LA hypertrophy and imposes a pressure load on the
  RV through the development of pulmonary
  hypertension
• Increases in RV end-diastolic pressure and volume
  cause RV dilatation which may result in
  funtional TVR(annular dilatation)

4
Pathophysiology

• LV diastolic function is usually preserved
  although there may be(25) dysfunction in
  patients with severe, chronic MS(chronic preload
  reduction and/or extension of scarring from the
  valve to adjacent myocardium)
• Systemic effects of severe TVR

5
Classification and Natural History

• Mild(MVAgt1.5, MGlt5mmHg, PASPlt30mmHg)
• Moderate(MVA 1-1.5, MG 5-10mmHg, PASP 30-50mmHg)
• Severe(MVAlt1, MGgt10mmHg, PASPgt50mmHg)

6
Natural History

• MVgt1.5 usually does not produce symptoms at rest
• Symptoms develop when the LAP increases(Dyspnoea)
  gt5mmHg
• Occurs when there is an increase in transmitral
  flow or a decrease in diastolic filling
  time(exercise, emotional stress, infection,
  pregnancy, AF with a rapid ventricular response)

7
Nutural History

• MS is a continuous, progressive, life-long
  disease, usually consisting of a slow, stable
  course in the early years followed by a
  progressive acceleration in later life
• Once symptoms develop, there is another period of
  almost a decade before symptoms become disableing
• Asymptomatic/minimally symptomatic survival is
  80 at 10yrs but once significant limiting
  symptoms develop, there is a dismal 0-15 1-year
  survival rate

8
Natural History

• When severe pulmonary HPT develops , mean
  survival drops to lt3yrs
• 60-70-progressive pulmonary and systemic
  congestion
• 20-30-systemic embolism
• 10-pulmonary embolism
• 1-5-infection

9
Diagnosis

• History slow, indolent increase in dyspnoea and
  general fatigue(any sudden change in symptom
  complex should raise suspicion!)
• ClinicalRV heave, Apex beat, Diastolic rumble,
  Opening snap
• ECG
• CXRCardiac chamber enlargement, Pulmonary venous
  hypertension, Pulmonary arterial hypertension
• ECCHO/TEE
• Cardiac cath

10
Management

• Medical AB prophylaxis, diuretics, negetive
  chronotropic drugs, atrial fibrillation
• Interventional Percutaneous balloon valvotomy
• Surgical Cosed/open commissurotomy, MVR