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Valvular Heart Disease: The Mitral Valve

Valvular Heart Disease: The Mitral Valve. Case .

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Valvular Heart Disease: The Mitral Valve

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  1. Valvular Heart Disease:The Mitral Valve

  2. Case • A 45 year old man presents to establish care. He was told many years ago that he needed antibiotics prior to dental work because there was a problem with a heart valve. He has occasional palpitations. On exam he has brisk carotid upstrokes and a holosystolic murmur is heard best at the apex along with an S3 and a diastolic rumble.

  3. Case • What is the next best step? • Do nothing, this murmur is benign • Do an exercise stress test because the patient may have CAD and ischemic heart disease • Do nothing, exam findings suggest mild disease • Order an echocardiogram • Refer the patient to a cardiologist for further evaluation

  4. An echocardiogram shows moderately dilated left atrium, a normal appearing left ventricle with am EF of 55%, a prolapsing posterior mitral leaflet and severe MR. Now you should: Tell the patient to continue antibiotic prophylaxis prior to the dental work Have the patient follow up with a annual echo Refer the patient for valve surgery Refer the patient for a defibrilator to prevent sudden death from MVP Case

  5. What Makes A Heart Murmur? • High blood flow through a normal or abnormal orifice • Forward flow through a narrowed or irregular orifice • Backward flow through an incompetent valve

  6. These Murmurs Are Benign • Mid systolic murmur at the left sternal border with grade 2 or less with a normal S1 and S2 and no other abnormal findings in an otherwise asymptomatic patient • Associated with normal or increased blood flow across normal valves

  7. These Murmurs Need Further Evaluation • Diastolic Murmurs • Continuous Murmurs • Systolic • Loud • Early systolic • Late systolic • Holosystolic

  8. Strategy For The Evaluation Of Cardiac Murmurs Bonow. JACC. 2006.

  9. When To Order An Echo • Class I • Diastolic, continuous, holosystolic, late systolic, clicks, radiation to neck or back • Symptoms of underlying cardio-pulmonary disease • Grade 3 or louder mid systolic murmurs • Class III • Mid systolic mumur grade II or less thought to be innocent

  10. Mitral Valve Disease: From Many Structures • Mitral leaflets • Chordae • Papillary muscles • Mitral anulus Otto. NEJM, 2001.

  11. Etiology of Mitral Regurgitation • Organic (Primary pathology of the leaflets) • Degenerative • Rheumatic • Endocarditis • Congenital • Functional (Secondary to myocardial process) • Ischemic • Dilated cardiomyopathy • Hypertrophic cardiomyopathy

  12. Enriquez-Serano. Contemporary Cardiology, 2009.

  13. Mitral Regurgitation: Epidemiology • Prevalence: >5,000,000 • Incidence: >650,000 new cases/year in the US • Most common discharge diagnosis • Most common cause of readmission < 60 days • Cost: > 34.8 billion annualy Rosamond. Circulation, 2008. Braunwald. 2007.

  14. Pathophysiology • Volume overload -> • LV dilation • LA dilation • Acute: Rapidly increasing LA/PV pressures-> pulmonary edema • Chronic: Slow enlargement of the LA with low pressures • Left ventricular dilation and increased EF followed by LV deterioration Foster. NEJM, 2002.

  15. Hemodynamic Stages of Mitral Regurgitation Libby. Braunwald’s Heart Disease. 8th Ed.

  16. Natural History of Severe MR Libby. Braunwald’s Heart Disease. 8th Ed.

  17. Degenerative Mitral Valve Disease: Mitral Valve Prolapse • Most common organic mitral valve disease • Incidence about 2-3% • Usually results in mitral valve prolapse • Variable histology • Increased extracellular matrix • Thickened and redundant • Chordal elongation Sanders. Forensic Science International, 2007.

  18. Complications • Chordal rupture and flail leaflet • 12% of patients • Most common in older men • Heart failure • Sudden death • AF • Endocarditis • Most common compliation, but rare (100cases/100,000 patient years) • Higher risk with flail leaflet

  19. Mitral Regurgitation: Mitral Valve Prolapse Foster. NEJM. 2010.

  20. Echocardiogram: Flail Mitral Leaflet Foster. NEJM. 2010.

  21. Endocarditis • Destruction of tissue by infection • About 5% of severe MR

  22. Mitral Regurgitation From Connective Tissue Disease

  23. Functional Mitral Regurgitation • Affects 15-20% with HF, 12% 30 days post MI • Leaflets are normal • Coaptation is incomplete • Can also be associated with papillary muscle rupture Marasco. Heart, Lung and Circulation, 2008.

  24. Prosthetic Valve Failure Alexander. Circulation, 1995.

  25. Prosthetic Valve Failure Novarro. JASE, 2000.

  26. St Jude Mitral Valve Butany. J Clin Path, 2005

  27. Brisk carotid upstrokes, laterally displaced forceful apical impulse Murmur: characteristics don’t reliably predict severity Similar to AS, TR and VSD Constant intensitiy, holosystolic, loud blowing, apical with axillary radiation Dimimished S1, split S2, possible S3 and loud P2 Highly variable depending on structures involved Physical Exam Findings

  28. Dynamic Auscultation Libby. Braunwald’s Heart Disease. 8th Ed.

  29. XR Findings • Prominent left atrial enlargement • Left ventricular enlargement • Pulmonary edema in acute MR Enriquez-Serano. Contemporary Cardiology, 2009.

  30. Atrial Fibrillation Affects 50% of Patients Within 10 Years Enriquez-Serano. Contemporary Cardiology, 2009.

  31. Acute Mitral Regurgitation Elevated PAP and Large PCWP V Waves Libby. Braunwald’s Heart Disease. 8th Ed.

  32. Variable Presentations of Mitral Regurgitation Enriquez-Serano. Contemporary Cardiology, 2009.

  33. Mitral Regurgitation Severity By Echo • Structural • LA size • LV size • Mitral leaflets and apparatus • Doppler • Jet area and characterisitics • Mitral inflow • Pulmonary vein flow • Quantitative • Regurgitant orifice area • Vena contracta • Right ventricle Zoghbi. JASE, 2003.

  34. Medical Management • Diuretics to maintain euvolemia • Digoxin and beta blocker for rate control • Medical therapy directed at underlying ischemia • No benefits to vasodilators • Afterload reduction and inotropic support in acute mitral regurgitation

  35. Survival: Medical Management of Organic MV Regurgitation Mild Moderate Severe Enriquez-Serano. Contemporary Cardiology, 2009.

  36. Mitral Valve Prolapse Repair Foster. NEJM. 2010.

  37. Prosthetic Mitral Valve Bloomfield. Heart, 2002.

  38. Survival After Surgical Correction By EF Libby. Braunwald’s Heart Disease. 8th Ed.

  39. Repair vs Replacement • Repair can be accomplished in 80-90% • Advantages • Possible lower mortality rates • Possible reduced need for anticoagulation • Lower risk of endocarditis Foster. NEJM. 2010.

  40. Possible Survival Benefit With Mitral Valve Repair Shuhaiber. EJCTS, 2007.

  41. Chronic Severe MR Bonow. JACC, 2006.

  42. 1/3 of European patients with severe valve disease are denied surgery 1/2 of patients with severe symptomatic MR Percutaneous Therapies Piazza. JACC, 2009. Feldman. JACC, 2009

  43. Most commonly from rheumatic fever: 99% 2-20 years until symptoms of MS Likely worsened by recurrent RF Also Congenital CTD, RA Mucopolysaccharidoses Mimicks Tumors Infection membranes Mitral Stenosis http://www.yale.edu/imaging/echo_atlas/entities/mitral_stenosis.html

  44. Normal valve orifice 4-6 cm2 Small valve area requires higher pressure gradient Symptoms precipitated by fast heart rate Higher LA-LV pressure gradient Lower cardiac output Hemodynamics Libby. Braunwald’s Heart Disease. 8th Ed.

  45. Hemodynamics: Why Symptoms Develop • Increased left atrial pressure • Increase in left ventricular diastolic pressure • Pulmonary hypertension • Everything is worse with exercise • Chronic atrial changes lead to arrhythmia

  46. Clinical Findings • Presentation • Dyspnea, hemoptysis, chest pain, arrhythmia, embolic events, hoarseness • Exam findings • Accentuated S1 • Opening snap- at the apex with the diaphragm • A2-OS snap good indicator of severity • Findings of pulmonary hypertension • Low pitched rumbling murmur at the apex • Maneuvers that increase mitral flow increase murmur and decrease A2-OS time

  47. Echo Determinants Of Mitral Stenosis Severity Baumgartner. JASE, 2009.

  48. Echo Determinants Of Mitral Stenosis Severity

  49. Mitral Valvuloplasty Score Baumgartner. JASE, 2009.

  50. Natural History of 159 Patients With Un-Operated Mitral Valve Disease Expected survival Mitral stenosis Mitral regurgitation Libby. Braunwald’s Heart Disease. 8th Ed.

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