Mitral Stenosis

• The heart contains two atrioventricular valves: the mitral and tricuspid
• Also consists of two semilunar valves: the aortic and pulmonary

Mitral Stenosis

• Most commonly caused by rheumatic heart disease following previous rheumatic fever
• Rarer causes include congenital mitral stenosis, carcinoid tumors metastasizing to the lung, or primary bronchial carcinoid

Pathophysiology

• Normal valve orifice area range is 4–6 cm2
• Usually, there are no symptoms until the valve orifice is moderately stenosed, with an area less than 2 cm2
• Severe mitral stenosis occurs when the normal valve orifice area is reduced to less than 1 cm2
• This causes the left atrial pressure to increase, and left atrial hypertrophy and dilation to occur
• Pulmonary venous, pulmonary arterial, and right heat pressures also increase, leading to pulmonary oedema
• This is partially prevented by alveolar and capillary thickening and pulmonary arterial vasoconstriction (reactive pulmonary hypertension)
• Pulmonary hypertension can lead to right ventricular hypertrophy, dilation and failure, with subsequent tricuspid regurgitation

Clinical Features

• Symptoms include progressively severe dyspnea
• There may be a cough productive of blood-tinged, frothy sputum or frank hemoptysis
• Right heart failure may occur, resulting in fatigue and abdominal or lower limb swelling
• Palpitations and systemic emboli are possible
• An enlarged left atrium may lead to the pressure posteriorly on the esophagus, also known as dysphagia
• Additional affects include left recurrent laryngeal nerve compression in result of a hoarse voice, and left main bronchus compression, resulting in left lung collapse
• Signs include a Pulse, a small-volume pulse, regular sinus rhythm and atrial fibrillation
• Face can include a mitral facies or malar flush
• JVP distension is common
• Palpation consists of a tapping apex beat and localized
• Sustained parasternal impulse can is due to right ventricular hypertrophy
• Diastolic thrill at the apex
• Palpable P2 can be due to pulmonary hypertension
• Auscultation includes loud first heart sound if in sinus rhythm and valve is pliable and an opening snap if the mitral valve is heavily calcified
• Loud second heart sound is heard if there is pulmonary HTN
• Early diastolic murmur can be due to pulmonary regurgitation from pulmonary hypertension, a rarer sound often referred to as the Graham steel murmur

Severe MS Features

• The length of murmur increases
• Opening snap becomes closer to S2
• Opening snap is characteristically lost with heavy valvular calcification

Investigations

• Chest X-Ray shows left atrial enlargement with straightening of the left heart border and a double shadow is created at the border of the right and left atria
• ECG in sinus rhythm shows a bifid P wave which is also known as P mitrale
• Commonly it presents as atrial fibrillation
• Right ventricular hypertrophy is often present, including right axis deviation and, tall R waves in lead V1
• Both TTE is able to determine left atrial size and the degree of thickening, calcification and mobility of the mitral leaflets
• Cardiac catheterization is often used

Management

• Early symptoms can be treated with diuretics
• Atrial fibrillation requires treatment with beta-blockers or DC cardioversion, along with anticoagulation to prevent atrial thrombus and systemic embolization
• Severe mitral stenosis requires surgery, including trans-septal balloon valvotomy, closed valvotomy which is no longer recommended , open valvotomy and mitral valve replacement

Mitral Regurgitation (MR)

• Degenerative disease myxomatous is a common cause
• Additional elements can include Ischemic heart disease, rheumatic heart disease and infectious endocarditis
• Dilated and hypertrophic cardiomyopathy can also be a cause, as can rheumatic autoimmune diseases , or collagen diseases
• Causes of acute mitral regurgitation, can be categorized as either IHD or myxomatous degeneration
• Additional elements can include infectious endocarditis and or trauma

MR Clinical Features

• Symptoms include dyspnea and orthopnea, fatigue and lethargy
• A common affect is right heart failure or Cardiac cachexia
• Signs include Laterally displaced diffuse apex beat and a systolic thrill if severe
• Soft first heart sound
• Auscultation should consist a pansystolic murmur loudest at the apex but radiating widely over the precordium and into the axilla

MR Investigations

• CXR : shows both left atrial and left ventricular enlargement
• ECG shows the features of left atrial delay and left ventricular hypertrophy
• Echocardiogram is often used and eventually cardiac catheterization
• Mild to moderate mitral regurgitation can be managed conservatively by following the patient with serial echocardiograms.
• Symptomatic severe mitral regurgitation requires surgical intervention

Aortic Stenosis

• Calcific aortic valvular disease also known as CAVD is a common cause of aortic stenosis of the elderly
• Bicuspid aortic valve or a BAV, as well as rheumatic fever and or chronic kidney disease
• Paget's disease of bone additional systemic lupus erythematosus can all play a role
• Obstructed left ventricular emptying leads to increased left ventricular pressure and compensatory left ventricular hypertrophy, which results in relative ischemia of the left ventricular myocardium
• These conditions if untreated can lead to angina, arrhythmias and left ventricular failure

• Usually no symptoms until aortic stenosis is moderately severe
• SAD which stands for Syncope, angina or chest pain and dyspnea

Clinical Features (Cont.)

• Pulse is small-volume and slow-rising
• BP: narrow pulse pressure, in advanced AS systolic BP decrease
• Precordial palpation : apex is not displaced unless congestive heart failure has occurred that said a systolic thrill may be felt in the aortic area.
• Auscultation :-ejection systolic murmur can best heard in the aortic area and radiates into the carotid arteries
• A soft or inaudible aortic second heart sound will occur when the aortic valve becomes immobile
• Reversed splitting of the second heart sound
• Prominent fourth heart sound
• Systolic ejection click, unless the valve has become immobile and calcified

Investigations

• Chest X-ray reveals a relatively small heart with a prominent, dilated, ascending aorta
• ECG shows left ventricular hypertrophy
• Transthoracic echocardiogram (TTE) should initially be used over transesophageal echocardiogram when possible
• Left heart catheterization is often used for the most accurate diagnostic test to assess pressure gradient across the valve

Management

• Symptomatic patients with aortic stenosis that are fit for surgery will likely be suggested with aortic valve replacement
• Those who are not fit for aortic valve replacement may choose to undergo transcatheter aortic valve implantation usually known as TAVI or balloon valvuloplasty
• Asymptomatic patients who develop severe stenosis with a transvalvular gradient over 50 mmHg, valve area less than 1 cm2 should be referred for aortic valve replacement or TAVI
• For patients with severe stenosis and a 50% or greater ejection fraction, exercise testing can be used for recommendations followed by a full review process within six months

Aortic Regurgitation (AR)

• It is categorised as due to disease of the value or of the root of the aorta
• Causes of disease from the valve come from a bicuspid aortic root
• This being the most common cause of AR in young people
• Infective endocarditis and rheumatic fever can be common
• Connective tissue disease can also have an affect
• Additional causes can come from of aortic root disease such as aortic dissection
• Other roots can be sourced from Spondyloarthropathies and hypertension
• An uncommon root for aortic dissection is syphilis, or Marfan's Syndromes with very rare causes arising from Ehler-Danlos syndrome, acute rheumatic fever, dissection of the aorta and failure of prosthetic values

Aortic Regurgitation Clinical Features

• Left ventricular failure symptoms
• Angina pectoris pain is present
• Arrhythmias presents

aortic Regurgitation Signs and Symptoms

• Pulse: sinus rhythm & large volume with collapsing, wide pulse pressure
• Apex displaced, diffused & forceful
• High-pitched early diastolic murmur at left sternal edged
• Mid-diastolic Austin-Flint murmur
• Ejection systolic flow murmur volume overload
• Corrigan's pulse which is visible and vigorous arterial pulsations in neck
• Musset's Sign head bobbing
• Quincke's sign or nail bed pulsation
• Muller's sign where the uvula pulsations are visible
• Loud systolic sound that is arterial, also known as the pistol show
• Pulses show
• Diastolic murmur and proximal artery compression

Treatment

• Symptomatic patients that are ACEIs will improve prognosis for left ventricle as it is asymptomatic
• Beta blockers should be avoided as they prolong the dilations and increase re-gurgitations
• Surgery is needed for symptomatic patients with more severe diagnosis patients need it when LV is under 50%, diastolic is over 7 and systolic is over five