People always ask me "Dr. Raj, what is
the difference between mitral regurg and mitral
valve prolapse." Well, this topic of valvular heart
disease brings us to issues of the mitral
valve in general. Walk you through mitral stenosis
and then have you differentiate between mitral
regurgitation and mitral valve prolapse. And
for learning purposes, please make sure that
you distinguish and you keep separate mitral
regurg and mitral valve prolapse. Trust me
you will make here life so much more easier
and you will be the MVP of this particular
section. Let us begin. Mitral stenosis is where
we are. And before
we start you need to conceptualize this.
I already have, but it is about me imparting
that conceptualization onto you. Mitral valve
stenosis, what does that mean? Difficulty
with opening. In this case, the mitral valve
doesn't want to open. When is the mitral valve
supposed to open? During what? Diastole good.
During diastole was when the mitral valve
was supposed to open, but it does not. And
so, therefore, what kind of valvular heart
disease would you categorise this as? A diastolic
murmur. So now, we have two diastolic murmurs or
we will have two diastolic murmurs that we
have gone through. The first one being aortic
regurgitation. And with aortic regurgitation,
it was the fact that the aortic valve was
unable to close properly and the diastolic murmur
was early, immediately after S2. In this case,
well there is a little bit different actually
a lot different. And if you were doing an echocardiogram
and the mitral valve doesn't wish to open,
then your focus clinically is on a patient,
exactly like that actually, it wasn't me that have
a frog in my throat, it is the fact that my
left atrium was obstructing my esophagus.
So maybe I have dysphagia and maybe it was
disrupting my left recurrent laryngeal nerve
hence the soreness or should I say more or
less the hoarseness that I was exhibiting earlier.
Why? Because the left atrium has been enlarged.
Is that clear? Now as you as soon your left
atrium becomes enlarged, then obviously, things
are going to back up into where, please? Pulmonary
veins. So you have issues with the lungs.
Keep that in mind and as you move forward
the main distinguishing feature between mitral
valve stenosis and mitral valve regurgitation
as we shall see will be the size of the left
ventricle. And those of you that are already
ahead of me know exactly as to what I am referring
to and in mitral stenosis, the left ventricle
is going to be rather small because you cannot
get any blood into it. If that is the case
and we have mitral stenosis, and it doesn't
want to open during diastole. On your left
is the normal picture. On the right, guess
what? I cannot open my mitral valve, why?
Well, we would get to those etiologies here
in a second, but the left atrium becomes rather
large and when it does so you can only imagine
that those structures posterior to the left
atrium are then going to be compromised, including
what? The esophagus, your patient is going
to be complaining of dysphagia. In addition,
there is going to be hoarseness and maybe
there will be issues with breathing because
of pulmonary edema. Mitral stenosis, you are
having an issue in
which the orifice between the mitral valve
or between the left atrium and the left ventricle
has become narrowed. Major cause. Rheumatic
heart disease yet once again, so let us just
collectively think about this one more time.
If it is the patient, a child perhaps with
pharyngitis and wasn't properly treated for
the streptococcal infection, two
to four weeks later ended up developing issues
within the heart and you would call that
rheumatic disease, but one thing that I want
to get away from so that you understand the
big picture of rheumatic heart disease is
that only the endocardium that will be affected
by rheumatic heart disease. The operative
word here is heart. Granted, if you are talking
about damage to the valves, then what part
of the heart are you in? Meaning to say in
terms of positioning, you are in the endocardium
so therefore the endocarditis would then give
rise to the valvular heart problems, wouldn't
it? In rheumatic heart disease. But then could
you have issues with the myocardium, myocarditis?
Of course, you could. But that wouldn't lead
into valvular heart disease, but there will
be myocarditits, still part of the heart and
then please do not forget, you can have rheumatic
heart disease in which you could have pericarditis.
So these are things that when we talk about
rheumatic fever as a whole and you are thinking
about rheumatic heart disease as being a component
of what is known as your major Jones criteria.
You remember that? One of them is pancarditis.
What we're dealing with specific and what
we have been dealing with here? Specifically,
it has been the endocarditis component of
rheumatic heart disease. Is that clear?
I hope so.
Now, with endocarditits, taking place due
to rheumatic heart disease early on the damage
is taking place, the valves, what is the topic
here? Stenosis, not early on. Early on it
would be what kind of issues, please? Regurgitation.
What side of the heart are you paying attention
to? Left side. What are they? Aortic and maybe
the mitral regurg issues. Our topic here stenosis
and I have mentioned this a few times, let
us do it once more. When you have repair process
taking place due to damage, which is occuring
here due to rheumatic heart disease, then
the repair process will result in later on
chronically as mitral stenosis. "So Dr. Raj,
you tell me the rheumatic disease that there
could potentially be four different valvular
heart diseases?" That is exactly what I am
telling you. Two of those will be early with
regurgitation. Two of those will be later
on, chronically with stenosis. Right now we
are dealing with mitral stenosis. Let us continue.
Now, the pathophys as the valve area gets
smaller, orifice, where is that going to
be more work? Left atrium. As it increases
the pressure and such in the left atrium,
then please understand how would you measure
this clinically? PWCP. Pulmonary Wedge Capillary
Pressure. And there would a Swan-Ganz
catheter in which once it get wedged in your
pulmonary blood vessels, you are going
to be measuring the pressure where? Downstream
and so, therefore, can you expect your left
atrial pressure to be increased? My goodness.
Isn't that the main feature of mitral stenosis?
The pulmonary blood vessels would be affected
and early on you will have pulmonary edema.
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. Think
about rheumatic heart disease long term and
mitral stenosis. Is used to be called fishmouth,
barely my mouth is being opened. It used to
be called fishmouth because the fissure as
it pass through the mitral valve is like a
little slit. It is so tiny and so, therefore,
my point is when you become so thickened
in the mitral valve, and it closes right after
S2. And that closure of your S2 or mitral valve
so quickly only represent the severity of
the disease. So the opening snap getting close
to S2, the worse that the prognosis. 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?
Mitral stenosis, progressive dyspnea on exertion,
nonspecific for any valvular heart disease.
Hemotypsis, why? Why we are seeing this more
so than any other valvular heart disease?
It is the fact that the left atrium is not
emptying. It back up to your pulmonary veins
hence resulting in. Could you have increased
RBCs in your lungs and such? Sure. Coughing
up of blood, that is not good. Heart failure,
late finding, once again a bad prognosis. It
means what? Well the opening snap, we
talked about how it will be after S2 called
it as mid-diastolic murmur. The closer
that your opening snap is to S2, the worse
is the prognosis. Tell me the size of your
left ventricle. Very very tiny. Eventually,
what is going to happen? It become the pulmonary
edema? Sure. We will talk about that increased
hydrostatic pressure. Right? Then you have what?
It may transmit this disease into the right
ventricle. Might have right ventricular failure.
Is this, very important question pay attention,
is this cor pulmonale? Nope. "But Dr. Raj, right ventricular
failure secondary to left-sided heart failure?"
Yes. That is not cor pulmonale? No. So what
is cor pulmonale? It is right ventricular
failure secondary to a primary pulmonary disease
such as maybe pneumonia, maybe pulmonary fibrosis
so on and so forth. But when you have right
ventricular failure here due to left-sided
heart failure, that's not cor pulmonale. But
if you do find it, mitral stenosis, not a
good prognosis. Physical examination. Palpation,
heave. What does that mean? It means pulmonary
hypertension. What about the PMI? Pay attention
here. What is PMI? Point of maximal impulse.
So I don't know that means. Ya you do. PMI is the apex
of the heart and where is the apex? What chamber
is that when you refer to the apex? Left ventricle.
What is the size of your left ventricle? Either
normal or maybe decreased. It is never cardiomegaly.
It makes no sense. The left ventricle
is not going to go laterally displaced. Is
that clear? Every single statement that we
have here has huge clinical relevance.
I have information that goes outside of the apparent
slide and such, but it is only so that we
have a complete story, so that we have more
differentials, so that we integrate more material.
All this information at some point in time,
is touched, will be touched, and forever will
be part of your understanding. Mid-diastolic
murmur is what we talked about occurs during
diastole. Heard loudest well, we talked about
this where, when it comes to mitral issues.
Where am I? Where are you upon cardiac auscultation?
No issues between S1, S2.
So that will be wholly systolic.
It is after S2, you have an opening snap and
then you have it. It is after S2. It
is after that "dadup". You are going to hear
an opening snap, where you can hear this? Auscultation,
fifth intercostal space, midclavicucular,
apex is where you are. What kind of murmur?
A mid-diastolic murmur. Afib is something
that you want to worry about. What does afib mean to you?
It means that you are going
to mess up your conduction system. And with
atrial fibrillation what might you be
looking for? What wave? Are you paying attention?
You tell me. Atria. If you say QRS complex,
I will find a way to come there and slap you.
No. But the P wave is what you are paying
attention to, atria. What is the wrong with
those P waves? They are not present, are they
wavy? Not saw-tooth. That's atrial flutter.
That is another discussion for another day.
Atrial fibrillation is wavy P waves. You don't
have them. Now, what are you worried about
afib, please? Well you have heard of Virchow's
triad, haven't you? Not Virchow's node, Virchow's
triad. A direct triangle there because it
is three different points. One point would
be endothelial injury, is that what this is? No.
Number 2 hypercoagulability, is that what this is? No.
Number 3, turbulent, blood
flow stasis. This is turbulence. So what does
Virchow triad mean to you? The development
of what? A thrombus. And so therefore if a patient
has afib, aren't you prone to thrombi? Absolutely.
And as soon as you hear afib, what are you
putting this patient on immediately as prophylaxis?
Prophylaxis for what? Atrial fibrillation, a form of trauma.
Then what? And then you break it off. You break
off am emboli, where does it go? It goes maybe
up in the carotid. That is the most devastating
manifestation. Going up into the carotid resulting
in a cerebrovascular accident. Why would you
want a stroke? Prevent it from happening. The
drug by research shown to be the best for
prophylaxis of thrombi formation afib is
going to be warfarin. Wage war against the
thrombi for prophylaxis in atrial fibrillation.
Let us continue.
Mitral stenosis. Echo, what might you found here?
Valves are very very stenosed. Left atrium
very very enlarged. Let us manage our patient
with mitral stenosis. Remember when we talked
about that opening snap, when did we say that
the severity is worse with that opening snap?
Closer to S2. You with me? Good. So if you hear that opening
snap closer to S2, surgical intervention,
mandatory. What about that atrial fibrillation?
What are you worried about? Thrombi formation
so, therefore, what kind of drug might you
be thinking about for prophylaxis? Warfarin.
A beautiful mnemonic I worked for this is WEPT.
W warfarin, E extrinsic, PT. Now I am not a mnemonic man, you
will not find a big fat M on my chest. It's not
going to happen. But every once in a while,
strategically why not have a little fun. Treatment.
Fluid overload. And why? What happened?
Pulmonary edema. So what might you want to
use so that you can get rid of that fluid?
How about diuretic? So these are things that
you want to keep in mind when dealing with
management. What's my next step of management
when dealing with mitral stenosis specifically.