M.S
Causes
Organic + almost always Rheumatic, so search for
other valve lesions.
( as Rh. F multi valvular )
+ M.S is the most common single valve lesion due
to Rh. fever
Functional

* Carey coomb M:

during Rh. activity (cusps are edematous) reversible so it is a functional M.S
* Austin flint M:

on top of severe A.I.
esp. $ A.I.

Regurged blood interferes with the
full opening of mitral valve.

* V.S.D. functional MS as it lead to


Over blood flow
Across mitral valve.

Haemodynamics

w M. S. left. A. pr ­ left A. dil. back pr.(pulm V.)

PVC
S.V.C.
¯ PVC
Rt. V. failure Rt. V.++ P++ reflex V.C. in
¯COP pulm. arterioles

N.B.

- patient with Rh. heart
Å P ++ suspect M.S.
- patient with S.V.C. (Rh. heart.) suspect M.S.
- rare types of M.S are congenital M.S and calcific M.S
in elderly.

C/P
Stages a symptomatic M.S
P.V.C. (congestive M.S)
P++
Å Rt. V. ++ (hypertensive)
S.V.C (Rt sided failure)

SymptomsÖ as above
P++
¯ C.O.P.
¯ P.V.C.
Ö¯ COP symptoms usually not occur early
as the dyspnea
¯ effort decrease
¯ COP sympt. So with development of
P++ this leading to
¯ P.V.C symptoms
of COP will appear
Signs

General

*
Malarflush (mitral facies), dusky pink
discoloration over cheeks due to A-V anastomoses
and vascular stasis !?
* P.V.C. fine basal crepitations
*
P++
¯ syst. bl. pr.
=
¯ COP weak pulse.
pallor
periph. cyanosis. cold extremities
* Rt . sided failure triad congest. neck. V.
++ tender liver
L.L. edema.

Local

Inspection & palpation Chamber ++
Thrill
Palpable sounds.



Stage of P.V.C

* Chamber ++ Lt. A
the dilated Lt. A. push. The heart forward
Rt.V become nearby chest wall.(Lf pasasternal
pulsation)
* diast. Thrill over apex in left lateral position.
* palpable S1 (apex) = tappering apex

Stage of P++
Pulm ++

Pulsating (pulm. area) palpable S2
d.t. dilated pulm. Ar. diastolic shock.

lung
Rt.V.
P++
Visoconstriction in pulm arterioles in the lung.

Stage of Rt sided failure

Rt. V.F. (dilated Rt V)
Auscultation

M.I.
S1
­ causes of ¯S1 Calcification.
Stage of PVC murmur with M.S Heart failure.
O.S. pre syst.



S1
syst. S2 diast. S1
murmur mid diastolic rumbling with presystolic accentuation.


Q
- Silent M.S. =
¯¯ bl. flow through mitral valve.
1. Associated A.S.D.

A.S.D. + M.S.


Lutembacher’ $

2. P++ i.e. Pulm. vasoconstriction.
¯¯ bl. flow to lt. Atrium.

O.S
It is due to opening of rigid mitral valve


S1 S2 S1
diagnosis of organic M.S isometric relaxtion phase
Value Pliable valve. absent in calcified M.S.
Severe M.S. Lt. atr. pr.
­ open the mitral valve early
O.S near by S2
It is heard by the cone over apex

Stage of P ++

left parasternal heave and pulsation on pulmonary area.
S2
­­ pulm. component. + closed splitting of S2
S4 asRt.V.pr.
­


vigorous Rt. atrial contraction
S4 (tricuspid)
·
Functional P.S. (syst. Murmur on pulm area.) due to dilated pulm Ar.
Rt. Rt.
V. V
p ++ Nr.
dil. Rt.
P.Ar. V.
Late dilatation of pulm. ring. P.I ( Graham steell, early diastolic
murmur)!?
Stage of Rt sided failure

Rt.V. failure Gallop tricuspid area = (3rd H.S.+ tachycardia)
Investigations
1. X-ray Lt. A+ - Rt.V. +
pulm. V. congestion
2. ECG Lt. A. + Rt. V. +
3. echo valve lesion.
valve area.
calcification.
chamber + +
p ++
4. Catheter :- Lt. A pr.
­
M.S. index = COP
´ 100
Lt. atr. pr.
= 5
´ 100 = 100%
5
in M.S.
¯ COP = ¯¯ index.
­ Lt. atr pr.
if < 25% = tight M.S.
we can measure M.S index by echo Doppler.

Treatment

PVCmedical
prophyl. prophyl. P.V.C.
Rh. F. endocarditis drugs
¯ venous Pr.

diuretic Nitrates Aminophylline
Lasix

P++ or PVC not responding to medical ttt


surgery
echo
s calcified pure M.S.
s M. I.
V.R valvotomy

balloon surgery
catheter
balloon valvoplasty

N.B.
It is better to operate early as long as the patient is symptomatizing e.g. dyspnea
Early operation before the development of P++ good results.
Late operation irreversible P++ even after surgery.
If there P++ , we can do test of reversibility of P++, measure pulm Bl. Pr by echo before and after in take of Ca Ch. B if the pulm Pr
¯ good prognosis after surgery

Complications of M.S
1.
P++ 2. Pulm edema 3. DVT & pulm embolism
4.
A.F 5. Infective endocarditis 6. Rt. Sided heart failure
7.
calcification of mitral valve 8. Systemic embolisation
Tight M.S
Diagnosis
murmur prolonged
O.S. nearly S2
echo valve area < 1 cm
M.S index < 25
Treatment
Surgery (valvotomy or valve replacement according
to echo findings)

Source: Internal Medicine Book of Dr.Osama Mahmoud (Ain Shams University)