Mitral Stenosis

Question 1

MC Etiology of MS

Answer 1

Rheumatic fever

Question 2

Clinical presentation of MS

Answer 2

• Dyspnea
• Fatigue
• Palpitations
• Hemoptysis
• Afib

Question 3

Physical Exam findings characterstic of MS

Answer 3

• Loud 1st heart sound
• Diastolic rumble
• Opening snap

Question 4

Modality used for definitive diagnosis of MS

Answer 4

Echocardiogram

• Valve area
• Valve morphology

Question 5

Normal and abnormal MVA

Answer 5

• Normal: 4.0-5.0 cm2
• Symptomatic MS: <2.5 cm2 (<1.5 cm2 at rest)
• Critical MS: < 1.0 cm2

Question 6

Natural History of MS

Answer 6

• Continuous progressive lifelong disease
• Slow, stable early course
  
  • latent period of 20-40 years after Rheumatic fever to onset of sx.
• Onset of symptoms to disability : ~ 10 years
• Atrial fibrillatin (30-40%)
  
  • MC in older pts (50-60%)
  • Often paroxysmal at first
  • Indicated relatively advanced MS

Question 7

Characteristics of Atrial Fibrillation with MS

Answer 7

MC in older pts (50-60%)

Often paroxysmal at first

Indicated relatively advanced MS

Question 8

% of MS patients asymptomatic on presentation

Answer 8

>80%

(60% with no progression of symptoms)

Question 9

% of MS patients in NSR

Answer 9

45-50% (46%)

Question 10

% of MS patients that are symptomatic on presentation

Answer 10

0-15%

Question 11

% of MS patients with severe pulmonary hypertension

Answer 11

<3%

Question 12

MCC of death in MS patients

Answer 12

• CHF (60-65%)
• Systemic embolism (20-30%)
• Pulmonary embolism (10%)
• Infection (1-5%)

Question 13

Characteristics of Pulmonary Hypertension in MS

Answer 13

• Elevated at rest and can become near systemic pressures with exercise
• PA systolic > 60 mmHg significantly affects RV performance
• LA pressure > 30 mmHG results in reduced lung compliance and pul edema

Question 14

MS characteristics ammenable to MV repair

Answer 14

• Prominant opening snap
• No calcification
• Pliable leaflets
• Commissural fusion
• Normal Chordae and papillary muscles

Question 15

Balloon vs. Open Commissurotomy

Answer 15

• Based upon surgeon experience
• LA thrombus or MR = NO BALLOON
• MR occurs in 2-5% of patients after open commissurootomy
  
  • Mild postocommissurotomy MR has little effect on long-term surival or need for MVR
• 50% of commissurotomy patients witll require addittional operation (i.e. MVR) within 20 years

Question 16

Indictions for Surgical Intervention for MS

Answer 16

• Symptomatic patients (i.e. NHYA III or IV)
  
  • MVA < 1.5 cm2
  • PA pressures > 50 (rest) or > 60 (with exercise)
• Asymptomatic patients:
  
  • New onset Atrial Fibrillation
  • LA thrombus or embolism after anticoagulation
  • PA pressure > 60 at rest

Question 17

Surgical Procedures of MS

Answer 17

• Closed mitral commissurotomy
• Open mitral commissurotomy +/- anterior leaflet augmentation
• MVR
  
  • Thick anterior leaflet
  • Calficication
  • Mitral regurgitation
  • Thick, short chordae

Question 18

MVR Surgical Options

Answer 18

• Bioprosthesis
• Mechanical prosthesis
• MV homograft

Question 19

Risks associated with MVR

Answer 19

• Type of prosthesis not a factor
• Previous valvotomy or commissurotomy not a factor
• NHYA class
• MR
• LV size
• LA size
• Age
• Concomitant TV disease
• CAD (3x risk)
• Subvalvular apparatus (preservation of chordae reduces risk)

Question 20

Outcomes after MVR

Answer 20

• Hospital mortality (non-ischemic valve disease): 2-7%
• Hospital mortality higher for MVR+CAB
• 10 year survival: 55%
• 70% of MVR patients alive without compications at 5 years