Mitral Stenosis Flashcards
Aetiology of MS
Rheumatic fever most common
Others : Carcinoid (bronchogenic cause), Mucopolysaccharidosis, Whipples, SLE, Degenerative calcification, Cabergoline
Signs on examination (not auscultation)
AF
Left parasternal heave (pul HTN)
malar flush (spares nasal bridge)
tapping apex undisplaced
thoracotomy scar (?mitral valvoplasty)
giant a waves (pul htn)
bruising from anticoag.
CV waves if functional TR
Presentation of M.S
Heart failure
AF (reduced ETT, arrhythmia, embolic events)
Ortners syndrome
Haemoptysis
When does malar flush occur?
With severe pulmonary HTN
What is Ortner syndrome?
compression of the recurrent laryngeal nerve by enlarged left atrium
Why do you get haemoptysis?
Rupture of bronchial veins
Differentials of haemoptysis
PE
Bronchiectasis
Pneumonia
Chronic cough
Lung Ca
M.S
Signs on auscultation of MS
Mid-diastolic rumbling murmur with opening snap (diastolic doming of the anterior leaflet of the MV)
loud S1
Hear loudest in apex with bell
If pulmonary HTN
- functional TR
- RV heave
- loud P2
Signs of severe MS on auscultation
Loss of opening snap (thickened valve)
Longer duration of murmur
OS closer to S2
What is a graham steel murmur?
Early diastolic murmur due to pulmonary regurg secondary to pul HTN
What does P-Mitrale look like on ECG
II - bifid P
V1 - biphasic P
How is severity of MS measured clinically
AF/ Pul HTN/ Short distance between OS and S2, Longer murmur, signs of pulmonary congestions, low pulse pressure
Differentials of M.S
Atrial myoxoma
Austin flint murmur
Investigations of MS
ECG
XR chest
TTE/TOE
Cardiac catheterisation
CXR signs in MS
signs of pulmonary oedema
double heart boarder sign
pulmonary haemosiderosis
Widening of carina
straightening of left heart boarder
cardiomegaly
Does MS tend to occur in isolation?
No, 40% of patients who have MS due to rheumatic fever have multi-valvular heart disease with aortic being most common. Mixed MV disease also common
Why do a TTE?
Assessment valve area, severity of stenosis and whether there is pul htn
What is the valve area is severe MS and what is it normally
Severe = <1cm2
Normal = 4-6 cm2
What is the medical management in M.S?
ACEI/ ARBS
Diurectics
Beta blockers
Anticoagulation - warfarin
How should patients with MS be followed up
Patients who are asymptomatic and have mild MS (MVA > 1.5cm 2 or mean gradient <5mmHg) should be subject to annual follow-up.
What is the indication for anticoagulation in M.S?
AF
Thromboembolic disease
LA appendage thrombus
LA >55mm (even in sinus)
What makes a valve unsuitable for balloon mitral valvuloplasty
Calculate wilkins score (if >8 no amenable)
Mod/ Severe MR
Immobile leaflets
Heavily thickened
presence of LA thrombus
If the valve IS suitable - who are candidates for percutaneous balloon mitral valvuloplasty?
Mod/ severe MS with heart failure (NHHA >= 3)
High pulmonary artery pressures
New AF
Unfit for valve replacement
Symptomatic NYHA >= 2 with mod/severe MS
Mildly symptomatic MS with increased PA pressures with exercise
What are other surgical management options for M.S?
Closed mitral valvotomy
Open valvotomy
Valve replacement
Should young women with MS get pregnant
Advised not to get pregnant due to risk of decompensation when circulating volume increases and HR increases.
if develops symptoms may need PBMV with TOE guidance
Why is a TOE better than TOE in the context of M.S.
Better views of LA appendage - good if wishing to procedure with percutaneous balloon valvuloplasty
Causative organism of rheumatic fever
Streptococcus pyogenes
When does rheumatic fever occur
2-4 weeks post strept throat
Why does rheumatic fever occur
Type 2 hypersensitivity
Antibodies bind to valves due to molecular mimicry between M protein in pyogenes and valvular cells
What is found of histopathology in rheumatic fever
Aschoff Bodies
What is the Jones criteria?
Major:
Joint involvement
O (myocarditis)
Nodules (subcut)
Erythema marginartum
Sydenams chlorea
Minor
CRP increase
Arthraglia
Fever
ESR increase
PR prolongation
Anamnesis of rheumatism
Leukiocytosis
