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

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

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