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Native Mitral Valvular Disease A Focused Review

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Presentation on theme: "Native Mitral Valvular Disease A Focused Review"— Presentation transcript:

1 Native Mitral Valvular Disease A Focused Review
David M. Harris MD, FASE, FACC

2 Disclosures- None

3 Goals Review the physical examine finding of mitral valvular disease.
Learn the evaluation and treatment of mitral valvular heart disease. Incorporate the information into your daily practice and patient care.

4 Mitral Valve Anatomy Annulus Leaflets Carpentier Classification
A1, A2, A3, P1 Lateral , P2 Middle; P3 medial Chordae Tendinae Papillary Muscles Posteror Lateral (RCA/OM3) Anterior Medial (OM/D1) Left Ventricular Wall Posterior Left Atrial Wall Annulus Fulcrum for the Leaflets Moves towards the apex in systole Chordae Tendinae Primary- attachment free edge Secondary-attachment rough zone (anchoring role) Posterior Left Atrial Wall Contiguous with the base of the posterior leaflet Otto, CM. Clinical practice. Evaluation and management of chronic mitral regurgitation. N Engl J Med 2001; 345:740

5 VHD Stages

6 Assessment for Mitral Valvular Disease
History and physical examination Transthoracic Echocardiography Transesophageal Echocardiography Bicycle Stress Echocardiography RHC +/- LHC Stress RHC

7 Murmur Systolic Diastolic Increases Also Mitral Stenosis
Diastolic Rumble Sqaut/Expiration Opening Snap-think rheumatic fever Mitral Regurgitation Holosystolic Squat/Expiration/ handgrip If acute murmur could soft and short MVP Mid Systolic Handgrip/ Expiration Mid systolic click-occurs earlier with standing or valsalva HCM Systolic-LVOT Mid Systolic-MR Standing/valsalva Decreases with squatting Bifid carotid upstroke, possible S4

8 Causes of Mitral Regurgitation
Primary Secondary Leaflet Myxomatous Valve Disease (MVP) Hypertrophic Cardiomyopathy (SAM) Rheumatic Fever Chordae Tendineae Infective Endocarditis Myocardial infarction Systemic Inflammatory Disorders (SLE) Papillary Muscle Connective Tissue Disease (Marfan's, Ehlers-Danlos) Ischemia/Infarction Congenital (Mitral Valve Clefts, Endocardial Cushion Defects) Dilated Cardiomyopathy Drug Related (Fen-Phen) Left Ventricular Aneurysm Mitral Annulus Dilitation (Dilated Cardiomyopathy) Dysynchrony Left Bundle Branch Block Spontaneous rupture (Flail Leaflet) Ischemia Rupture Calcification (Rheumatic, Renal failure) Dilitation ( Myxomatous Disease)

9 Mitral Regurgitation Hemodynamics
Regurgitant Volume Left Atrial Compliance Intravascular Volume

10 Acute and Chronic Physiology
FIG 1. The 3 phases of mitral regurgitation (MR) are shown and are compared with (A) normal physiology. (B) In acute MR, an increase in preload and a decrease in afterload cause an increase in end-diastolic volume (EDV) and a decrease in end-systolic volume (ESV), producing an increase in total stroke volume (TSV). However, forward stroke volume (FSV) has diminished because 50% of the TSV is regurgitated into the left atrium in which it increases left atrial pressure (LAP). (C) In the compensated phase, eccentric hypertrophy has developed, and EDV now is increased substantially. Afterload has returned toward normal as the radius term in the LaPlace equation increases with an increase in left ventricular heart size. Normal muscle function and a large increase in EDV permit a substantial increase in TSV from the acute phase. This, in turn, permits a normal FSV. Left atrial enlargement now accommodates the regurgitant volume at lower filling pressure. Ejection fraction (EF) remains greater than normal. (D) In the chronic decompensated phase, muscle dysfunction has developed, impairing ventricular ejection. Thus, ESV has increased substantially from the chronic compensated phase, diminishing both TSV and FSV. EF, although still normal, has decreased to 55%, and LAP is re-elevated because less volume is ejected during systole, causing a higher EDV (RSV, regurgitant stroke volume). Carbello BA: Progress in mitral and aortic regurgitation. Curr Probl Cardiol 28: 553, 2003

11 Stages for Mitral Regurgitation

12 Management of MR Determine etiology
Decrease afterload (control blood pressure) Maintain euvolemia (diuretics) Surgery (Repair over replace) Mitraclip Percutaneous Mitral Valvular Replacement

13 How often to image

14 Recommendation for surgery
Always repair if possible. If replace leave the subvalvular structures intact (spare). Symptomatic severe and EF >30% Asymptomatic severe and EF 30-60% and LVESD >40mm. Severe and undergoing other cardiac surgery New onset atrial fibrillation, resting PAP > 50 or exercise PAP > 60 mmHg St. Jude Mechanical Mitral Valve Edwards Bioprosthetic Mitral Valve

15 MitraClip Indications
For Significant Symptomatic Pts Severe MR (>/= 3+) Primary abnormality (degenerative) Prohibitive risk for surgery (determined by heart team) Expected to benefit from reduction of MR J Am Coll Cardiol 2011;58:2190-5

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17 Case 1 The patient is a 65 year old with significant past medical history of 40 pack year smoking history, diabetes, hypertension, hypercholesterolemia, BMI of 40 and HIV who presented four days ago with chest pain and was found to have an occluded dominant left circumflex developed acute onset shortness of breath. He is post PCI and stenting of the LCX. He states that he had an episode of chest pain several days ago, which was located in the center of his chest, was exacerbated by walking and was a 10/10. He had waited for several hours at home prior to presenting initially, hoping the pain would subside. Today he developed acute SOB. His vital signs include a respiratory rate is 30, pulse 110 BPM, blood pressure 90/54 mmHg.

18 Case 1 Examination Cardiac: tachycardic with a regular rhythm, there is a new I/VI blowing holosystolic murmur located at the apex which radiates to the axilla, decreases with valsalva and increases with expiration. The PMI is not deviated. JVP measures 16 cm H2O. PULM: Diffuse crackles in the lung fields bilaterally

19 Echocardiogram Results
Wide open mitral regurgitation-flail posterior leaflet and ruptured posterior lateral papillary muscle

20 Case 1 What is the initial best medical management?
Lasix Nitroprusside Dobutamine BiPAP All of the Above

21 Mitral Stenosis Most common etiology- Rheumatic Fever (10 % of native valve disease) Cross reactivity between A hemolytic strep and heart through an M protein Other causes Severe MAC Congenital MS Inflammatory Disease Amyloidosis Prosthetic Malfunction Drug Induced Inflammatory Diseases (Lupus, RA); Infiltrative Disease (Amyoid) Drugs Methysergide File:Rheumatic heart disease, gross pathology 20G0013 lores.jpg

22 Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

23 Pathophysiology Limited flow into the LV has 3 major sequalae:
Elevation of Lt. Atrial pressure Secondary RV pressure overload Reduced LV ejection performance Due to diminished preload Tachycardic response to compensate to decreased SV worsens the transmitral gradient

24 Stages of Mitral Stenosis

25 How often to image Stage Mitral Stenosis Progressive (stage B)
Every 3-5 years: MVA >1.5 cm2 Severe (stage C) Every 1-2 years: MVA cm2 Every year: MVA <1cm

26 Anticoagulation and MS
Atrial fibrillation Prior Embolic Event LA Thrombus

27 Percutaneous Balloon Mitral valvotomy
A score of <8 is considered amenable to balloon Valvuloplasty. MVA < 1.5 cm2 and new afib MVA > 1.5 cm2 if sig MS on exercise. RV systolic Pressure > mmHg MVA < 1.5 cm2 and not a candidate for valve surgery Contraindicated if Clot Severe MR Severe Commissural Calcification AV Disease Severe Tricuspid Disease (TS) Severe CAD

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29 Recommendations for Surgery
MVA < 1.5 cm2 with symptoms (NYHA class III/IV) MVA < 1.5 cm2 and other cardiac Surgery MVA < 1.0 cm2 and asymptomatic (if favorable anatomy and no contraindications

30 Case 2 The patient is a 25 year-old 26 week pregnant G1P0 woman from India without significant past medical history who presents with increasing dyspnea on exertion, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea and lower extremity swelling.

31 Case 2 Physical examination
Cardiovascular: There is a crisp early diastolic snap followed by a 2/6 diastolic rumble best heard in the axilla. The murmur is loader with squatting and with exercise. JVP is 14cm H2O. The point of maximal impulse is normal in size and there is no gallop. There is a right ventricular heave Pulmonary diffuse crackles bilaterally +3 bilaterally LE pitting edema

32 Case 2 What is the best initial step for evaluation
Treadmill Exercise EKG only Stress Transthoracic Echocardiogram Transesophageal Echocardiogram Right Heart Catheterization Chest CT (PE protocol)

33 Case 2 Echocardiogram Results
LVEF 55-60%- normal wall motion Mitral valve decrease leaflet motion with a “hockey stick” appearance to the anterior leaflet; mean gradient of 12 mmHg at a heart rate of 108 BPM. Wilkins score= 4. Left and right atria moderately dilated Right Ventricle with moderate hypertrophy and normal function.

34 Case 2 What is the most appropriate management?
Balloon Mitral Valvuloplasty Surgical Valve Repair Surgical Valve Replacement Lasix and Labetolol Watchful waiting-normal in pregnancy

35 Thank you Questions


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