That is not a good thing. What does pulmonary
edema mean to you? Shortness of breath, dyspnea
because of improper respiratory functioning.
Now as we have done with many of the other
valvular heart diseases, we have brought in
the pathophysiology. Let us do the same thing
here as well, please. It is in your best interest
once more to make sure that your physiology
is absolutely emboldened so that you can understand
the pathology here. Let us take a look at
the two graphs, yet once again. Now I am going
to make sure that you are able to identify
exactly as to what each curve represents.
For example, on the left that graph there
represents the left ventricular pressure curve.
Now, before the type of curves that you have
seen has been the comparison of your left
ventricular pressure curve to your aortic
pressure, and so with that we had seen it with
aortic stenosis, aortic regurg. Let it go.
You can do this. Let it go. It is okay. Don't
be so attached to something especially when
it is not relevant. The relevance here is
the fact that I cannot properly open up my
mitral valve. So why would you want to use
the aortic pressure curve? Really why? So
what might you want to use? The atrial tracing
curve. The first time that really we are seeing
this is to make sure that we dissect the normal
and then see exactly as to what the pathology
is. The pathology is the discrepancy. Do you
see that orange grey shaded area? That shaded
area underneath that curve, underneath the
y-descent, the discrepancy between the atrial
tracing curve and the left ventricular pressure
curve represents mitral stenosis. Normally
there should be no discrepancy, there should
be no difference between those two curves.
There should be almost instinct curve,
work with me here. But the fact that you find
such a large seperation between those two
curves. What two curves again? Left ventricular
pressure curve and the atrial tracing curve,
represents right off the bat, mitral stenosis.
No doubt. Now, before we get there though,
there is an important point that we need to
identify along the way. Just take a look at
the atrial tracing curve, which is that red
solid line. We have an a wave. Before
we begin, you tell me really quick where
am I in terms of your cardiac cycle? Diastole
or systole? Diastole. We are part of diastole.
Early or late, is this important? Oh! yeah.
This is late diastole. How can you confirm
that? Ask me that. "Dr. Raj how can you confirm
that?" The a wave represents what? It represents the
SA node, it conducts an impulse. So an impulse
has now originated where? In the right atrium.
Are you with me? The SA node starts up an
impulse. Now that impulse travels through
first, which are represented on an EKG as
what wave? Work with me, all about integration.
You cannot compartmentalize this information
any longer. Welcome to medicine. Welcome to
pathology. Welcome to our course. So our SA
node on your EKG represents the P wave. This
is the a wave. One has nothing to do with
the other. Well, it does, but let us talk
about how. The electrical activity is the
P wave. It will run through the heart first,
followed by mechanical activity always in that
order. So that a wave represents mechanical
activity of what chamber? The atria. Which
atria? Obviously referring to mitral stenosis.
So, therefore, it is the left atria. Right?
So that a wave is going to kick in. It kicks
the last bit of blood about 10 to 15 percent
of the blood from the left atrium into left
ventricle. It creates an a wave. Part of what?
Late diastole. Right?
Next, what are you going to do? Well next
I am going to try to close my mitral valve,
isn't that right? You see where there S1 is
on the heart sound, on the top of the curve
here. That S1 represents closure of what?
The mitral valve. Any problems with closing?
No. This is not regurgitation. These are problems
with opening, mitral stenosis. So you are
not going to have a problem there. Do not choose
that as being an answer choice. That makes
no sense. So you will close your valve as
you should. Now you have a c wave? What does
that mean? Fifty percent of your patients
won't even show you a C wave. Now technically,
what does that actually mean? Well here is
my left ventricle. It is about to do what?
Isovolumetric contraction, increase in the
pressure in the left ventricle so that it
can guarantee blood moving from left ventricle
into the aorta. Are you with me? Are you feeling
me? I hope so. That left ventricle is shooting
the blood into the aorta. So that build enough
pressure to open up that aortic valve. The
aortic pressure curve is not represented here.
No need. Why put unnecessary information when
it's not even relevant? But you are building
up that pressure. When you build up that pressure
is it possible, it is just possible that the
mitral valve might then bulge its cusps into
the atria? Of course. Welcome to c wave. Bulging
of the cusps. So now what happens? Blood is
being ejected from the ventricle into the
aorta. Close your eyes. In the meantime, what
about that atria? That atria was empty but
you got to fill it up. So how do you fill
it up? You fill it up with pulmonary veins.
So the pulmonary veins are filling up the
left atrium. Are you with me? All of this
is occuring as one unit, as one organised
syncytium, absolute miraculous.
Unbelievable. So now you create the v wave.
What does that v wave represent? It is the
fullest that the atria is going to get and
in this case, it would be the left atrium.
Filled by whom? The pulmonary veins. Are we
clear? Answer restoundingly yes. So now,
left atrium is completely filled with blood.
You created the v wave. I wanted you to take
a look at S2. What does S2 mean to you? Why
isn't S2 corresponding to the V wave?
Because S2 is closure of whom? Of the aortic
valve, isn't it? So what does the v wave represent?
Opening of the mitral valve. That is her pathology.
So the v wave is when the left atrium
being the fullest and you are about to begin
diastole. You are about to open up the mitral
valve when the blood should be rushing into
the left ventricle passively 85 to 90 percent
of your filling takes place, then and there.
But your mitral valve doesn't want to open.
So, therefore, what happens to my left atrial
pressure? It increases. Where is this in correlation
to my heart sounds? S2, aortic valve closes.
No problem with aortic valve. Let it go. Opening
snap, diastolic rumble. Welcome to mid diastolic
rumble. Right before that it had an opening
snap. Is that clear? So what is it that you
have after the v wave? Normally you should
have what? Tell me what you should have normally?
A descent. What descent? The x or y-descent?
The y-descent. But this is a pathology. You
don't have the y-descent. How could you?
What does the y-descent represent? It represents
the passive filling of majority of your blood
from left atrium into left ventricle. It ain’t
happening. Is that clear? So when you have absence of your
y-descent, you will have seperation of the
curves, which to you should mean mitral stenosis.
Do you see the four picture? Do you really see it
in your head? And that is why you won't misses a
question? What I wish to point out
to you, that you may or may not like, but you
have to accept, is the fact that opening snap
do not confuse with the mid-systolic click,
alright? Because what kind of murmur is this?
It is a diastolic murmur. So why in the world
would you even call it a mid-systolic click. A mid-systolic
click we will see with MVP, mitral valve prolapse,
but not here. So an opening snap is part of
your diastolic murmur, part of your mitral
stenosis, but what does that mean to you clinically?
What you must know is that opening snap, the
closer that it gets, listen to what I am saying
and forever etch it in your head. The closer
that the opening snap gets to S2, the worse
the valvular heart disease is. Clear?
What does the opening snap mean to you?
It means that the thicker
that the mitral valve becomes, very thick.
The opening snap occurs in diastole after
the second heart sound.
It relates to the opening of the mitral valve leaflets.
The interval between the second heart sound
and the opening snap represents the isovolumetric
relaxation of the left ventricle.
When the mitral valve is severely stenosed,
the left atrial pressure is very increased.
The closer the opening snap is heard to the second heart sound,
the greater the left atrial pressure
and the greater the severity of mitral valve stenosis.
Remember as to how we did aortic regurgitation and
Austin flint murmur, worst case scenario and
I gave you what? The rule of 5, 3, 2. Same concept.
This is opening snap with mitral stenosis
and that is a more complicated issue. Let
us take a look at the one in which you can
really sum things up.
So look at the pressure-volume loop on your
right. Then we have the red loop, which is
perfectly normal whereas the blue curve then
represents mitral stenosis. Now the first
thing that you want to do first and foremost,
what does that loop represent? What chamber
does that loop represent? It represents the
left ventricle. That is it. So if that loop
only represents the left ventricle and your
mitral valve doesn't want to open, then what
is the size of your left ventricle? It is
tiny. It is small. Now, what graph or what
component or what axis represents the volume
on this graph? The X-axis. So, therefore,
if there is less volume in your left ventricle,
what would you expect this loop to do? It's shifted
to the right. Would you please listen what
I am saying? Why would it ever shift to the right?
That would mean an increase in volume of your
left ventricle. That is the opposite of what
is happening here. See you would never choose
the loop in red as being mitral stenosis.
When you have obviously a loop that shifted
to the left, which represents what? A smaller
left ventricle. Welcome to mitral stenosis.
Now where is my problem? What if you see the
circle around where the mtiral valve should
open on your pressure-volume loop? That black
circle. That black circle represents the actual
pathology. The mitral valve doesn't want to
open. You chose that as being your answer
choice. And if they put A, B, C, D, E, F,
I don't care how many are there, A to Z, if
they are able to put around that loop,
you choose the one. That represents, where
the circle is representing the pathology.
The mitral valve doesn't want to open. You
have understood that you are gold when it
comes to mitral stenosis. How can you miss
the question, seriously?