Introduction
Etiology and pathology
?? ?, ??? rheumatic fever? ??.
MV orifice < 1cm2 ?? severe.
? ??? ??? 10-15?? ???
Rheumatic fever
Sx
NYHA I-II
Afib
NYHA III-IV
Pathophysiology
Symptoms
Exertional dyspnea, cough ?.
Pulmonary congestion with edema and alveolar hemorrhage
Pulmonary hypertension and eventual right-sided heart failure
Atrial fibrillation with associated risk for mural thrombi
Physical findings
C234 Physical Examination of the Cardiovascular System
- Apex?? ??? ?? (low-pitched, rumbling)
- Lt. decubitus? ??? ?????? ?? ??? ? ? ??
- When MS is mild, the murmur is mostly heard in late diastole.
- As the stenosis progresses, the diastolic murmur is heard earlier in the cardiac cycle.
- S1, P2 accentuation
- Opening Snap (OS; S2 ?? ??)
- Caused by the sudden opening of the mitral valve leaflets when the LV pressure falls below the LA pressure at the beginning of diastole.
- A2-OS interval? ???? severe
Laboratory examination
| ECG | LA enlargement ? P-mitrale in V1, Afib |
| Echo | EF slope ??, valve thickening & calcification |
| CXR | Straightening of the left cardiac border |
Differential diagnosis
Cardiac catheterization
Treatment
| ?? | |
| Afib | ??? RVR? BB or CCB? ?? (?? ???? ???? ? ??) |
| ??? | Indicated regardless of CHA2DS2-Vasc score. Wafarin??, ??? INR 2-3 (NOAC? ?? ??!!) |
Surgical indication
Management of rheumatic mitral stenosis. See legend for Fig. 256-4 for explanation of treatment recommendations (class I, IIa, IIb) and disease stages (C, D). Preoperative coronary angiography should be performed routinely as determined by age, symptoms, and coronary risk factors. Cardiac catheterization and angiography may also be helpful when there is a discrepancy between clinical and noninvasive findings. AF, atrial fibrillation; LA, lex atrial; MR, mitral regurgitation; MS, mitral stenosis; MVA, mitral valve area; MVR, mitral valve surgery (repair or replacement); NYHA, New York Heart Association; PCWP, pulmonary capillary wedge pressure; PMBC, percutaneous mitral balloon commissurotomy; and T ½, pressure half-time.
Mitral valvotomy
- Indication
- MVA <1.5cm2 (or 1.0cm2/m2 BSA) with symptom or pulmonary hypertension, new AF
- Contraindication
- MR ??, LA thrombus, extensive valvular calcification & thickening
Mitral valve replacement
- Indication
- MR ??? severe MS. s/p valvotomy, LA thrombus
Percutaneous balloon commissurotomy (PBMC)
- Mild ? ? ?? ? ??. Favorable valve morphology ? ? valvotomy ?? ??.
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