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Mitral Valve Disease ©2010 David Stultz, MD MitralMitral valvevalve diseasedisease DavidDavid Stultz,Stultz, MD,MD, FACCFACC SouthwestSouthwest Cardiology,Cardiology, Inc.Inc. SeptemberSeptember 28,28, 20102010 ©2010 David Stultz, MD ObjectivesObjectives IdentifyIdentify thethe principleprinciple causecause ofof mitralmitral stenosisstenosis NameName severalseveral mechanismsmechanisms ofof mitralmitral regurgitationregurgitation IdentifyIdentify howhow oftenoften mitralmitral regurgitationregurgitation shouldshould bebe followedfollowed byby echocardiogramechocardiogram ©2010 David Stultz, MD ThisThis ConferenceConference isis anan OverviewOverview ManyMany aspectsaspects cannotcannot bebe coveredcovered inin aa 11 hourhour conferenceconference ThisThis isis meantmeant toto serveserve asas aa frameworkframework forfor furtherfurther knowledgeknowledge ©2010 David Stultz, MD OutlineOutline ofof conferenceconference MitralMitral StenosisStenosis MitralMitral regurgitationregurgitation MitralMitral valvevalve prolapseprolapse SurgicalSurgical andand endovascularendovascular repairrepair ©2010 David Stultz, MD Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007. ©2010 David Stultz, MD SurgicalSurgical AnatomyAnatomy Fedak PW, McCarthy PM, Bonow RO. Evolving concepts and technologies in mitral valve repair. Circulation. 2008 Feb 19;117(7):963- 74. ©2010 David Stultz, MD MitralMitral StenosisStenosis NarrowingNarrowing ofof thethe mitralmitral valvevalve orificeorifice RestrictsRestricts flowflow fromfrom leftleft atriumatrium toto leftleft ventricleventricle duringduring diastolediastole RheumaticRheumatic feverfever almostalmost alwaysalways thethe causecause SenileSenile calcificcalcific (annular(annular calcification)calcification) AnorecticAnorectic drugs,drugs, carcinoidcarcinoid MitralMitral valvevalve areaarea normallynormally 44--6cm6cm2 2cm2cm2 isis mildmild stenosisstenosis <1cm<1cm2 isis criticalcritical stenosisstenosis Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease). J Am Coll Cardiol 2008;52:e1–142. Carabello BA. Modern management of mitral stenosis. Circulation. 2005 Jul 19;112(3):432-7. ©2010 David Stultz, MD Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007. ©2010 David Stultz, MD SymptomsSymptoms ofof MitralMitral StenosisStenosis ExertionalExertional dyspneadyspnea HemoptysisHemoptysis ChestChest painpain SystemicSystemic embolizationembolization MostlyMostly duedue toto atrialatrial fibrillationfibrillation Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007. ©2010 David Stultz, MD PhysicalPhysical ExaminationExamination forfor MSMS DiastolicDiastolic murmurmurmur LowLow pitchedpitched rumblerumble atat apexapex withwith bellbell BestBest heardheard inin leftleft laterallateral decubitusdecubitus positionposition ProminentProminent S1S1 (If(If leafletsleaflets areare pliable)pliable) OpeningOpening snapsnap CausedCaused byby aa tensiontension onon thethe valvevalve leafletsleaflets whenwhen thethe valvevalve opensopens AudibleAudible atat apex,apex, withwith bellbell ofof stethoscopestethoscope FollowsFollows AA2 byby 4040--120ms120ms ShorterShorter AA2--OSOS intervalinterval == moremore severesevere MSMS Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007. ©2010 David Stultz, MD PhonocardiogramsPhonocardiograms http://en.wikipedia.org/wiki/File:Phonocardiograms_from_normal_and_abnormal_heart_sounds.png ©2010 David Stultz, MD SeveritySeverity ofof MitralMitral StenosisStenosis Severity MVA Gradient PAP Symptoms Signs Therapy cm2 mmHg Mild >1.8 2-4 Normal Usually absent S2-OS > 120ms; normal P2 Moderate 1.2-1.6 4-9 Normal Class II S2-OS Diuretics 100- 120ms; normal P2 Moderate 1.0-1.2 10-15 Mild Class II-III S2-OS 80- BMV if to Severe pulmonary 100ms; P2 applicable or HTN increase surgery if more than mild Sx Severe <1.0 15 Mild to Class II-IV S2-OS BMV or surgery severe <80ms; P2 pulmonary increase; HTN RV lift Carabello BA. Modern management of mitral stenosis. Circulation. 2005 Jul 19;112(3):432-7. (Adapted) ©2010 David Stultz, MD MSMS AuscultationAuscultation http://depts.washington.edu/physdx/heart/tech.html ©2010 David Stultz, MD AsymptomaticAsymptomatic MitralMitral StenosisStenosis Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease). J Am Coll Cardiol 2008;52:e1–142. ©2010 David Stultz, MD MedicalMedical ManagementManagement DiureticsDiuretics SaltSalt restrictionrestriction AnticoagulationAnticoagulation ifif indicatedindicated AtrialAtrial fibrillationfibrillation TreatmentTreatment ofof atrialatrial fibrillationfibrillation Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007. ©2010 David Stultz, MD MitralMitral StenosisStenosis ““HockeyHockey StickStick”” ©2010 David Stultz, MD MeanMean PressurePressure GradientGradient MitralMitral StenosisStenosis ©2010 David Stultz, MD SymptomaticSymptomatic MitralMitral StenosisStenosis Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease). J Am Coll Cardiol 2008;52:e1–142. ©2010 David Stultz, MD NaturalNatural HistoryHistory ofof MitralMitral ValveValve diseasedisease (1991)(1991) Blue = Mitral Stenosis; Purple = Mitral Regurgitation Solid = Medical Management; Dashed = Surgical Management ©2010 David Stultz, MD SurgicalSurgical ManagementManagement IndicatedIndicated forfor ModerateModerate (NYHA(NYHA ClassClass 2)2) symptomssymptoms PAPA pressurepressure >60mmHg>60mmHg PCWPPCWP pressurepressure >25mmHg>25mmHg PercutaneousPercutaneous balloonballoon valvotomyvalvotomy FavoredFavored ifif echoecho showsshows High leaflet mobility Low calcification, thickening, and subvalvular thickening Open/ClosedOpen/Closed SurgicalSurgical valvotomyvalvotomy MitralMitral ValveValve replacementreplacement Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease). J Am Coll Cardiol 2008;52:e1–142. ©2010 David Stultz, MD InoueInoue methodmethod ofof balloonballoon mitralmitral valvotomyvalvotomy ((transseptaltransseptal approach)approach) Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007. ©2010 David Stultz, MD MeanMean pressurepressure gradientgradient acrossacross MitralMitral ValveValve PrePre-- andand PostPost-- BalloonBalloon ValvotomyValvotomy Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007. ©2010 David Stultz, MD WhyWhy isis mitralmitral regurgitationregurgitation soso complicated?complicated? VariableVariable etiologiesetiologies VariableVariable symptomssymptoms GenerallyGenerally slowslow onsetonset SymptomsSymptoms oftenoften overlapoverlap withwith deconditioningdeconditioning andand agingaging VariableVariable comorbitiescomorbities CardiacCardiac Role of coronary & myocardial disease SystemicSystemic GuidelinesGuidelines oftenoften basedbased onon specificspecific numericalnumerical cutoffscutoffs forfor variousvarious measurementsmeasurements ©2010 David Stultz, MD SymptomsSymptoms ofof MRMR TypicallyTypically developdevelop overover aa longerlonger timetime frameframe thanthan mitralmitral stenosisstenosis ShortnessShortness ofof breathbreath Weakness/fatigueWeakness/fatigue DevelopmentDevelopment ofof atrialatrial fibrillationfibrillation ©2010 David Stultz, MD PhysicalPhysical ExaminationExamination forfor MRMR SystolicSystolic murmurmurmur HolosystolicHolosystolic ConstantConstant intensityintensity Blowing,Blowing, highhigh pitchpitch LoudestLoudest atat apex,apex, radiatesradiates toto axillaaxilla
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