Valvular Heart Disease: Mitral Stenosis

by Carlo Raj, MD

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    00:01 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.

    02:30 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.

    02:42 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.

    05:12 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.

    05:23 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.

    05:38 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.

    07:36 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.

    08:30 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.

    09:19 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.

    09:34 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.

    09:57 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.

    10:18 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.

    10:29 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.

    11:05 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.

    12:22 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.

    12:54 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.

    13:06 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.

    13:15 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.

    14:10 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.

    15:04 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.

    16:45 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.

    16:51 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.

    17:52 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.

    18:29 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.

    18:44 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, right ventricular 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.

    20:32 What is the size of your left ventricle? Either normal or maybe decreased. It is never cardiomegaly.

    20:39 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.

    20:49 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.

    20:59 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.

    21:15 Where am I? Where are you upon cardiac auscultation? No issues between S1, S2.

    21:26 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.

    22:22 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.

    23:03 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.

    23:46 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.

    24:22 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.

    About the Lecture

    The lecture Valvular Heart Disease: Mitral Stenosis by Carlo Raj, MD is from the course Valvular Heart Disease. It contains the following chapters:

    • Mitral Stenosis
    • Pathogenesis
    • Visualisation
    • Signs & Symptoms
    • Diagnosis & Treatment

    Included Quiz Questions

    1. Mid-diastole, difficulty in opening
    2. Early-diastole, difficulty in closing
    3. Holosystolic, difficulty in opening
    4. Late systolic, difficulty in opening
    5. Pansystolic, difficulty in opening and closing
    1. Left ventricle
    2. Right ventricle
    3. Pulmonary veins
    4. Right atrium
    5. Left atrium
    1. Rheumatic heart disease.
    2. Congenital mitral stenosis.
    3. Bicuspid valve.
    4. Low output-cardiac failure.
    5. Pericarditis.
    1. Left atrium
    2. Left ventricle
    3. Right atrium
    4. Pulmonary vessels
    5. Right ventricle
    1. PCWP of 21 mmHg
    2. Central venous pressure of 7 mmHg
    3. Left atrial pressure of 9 mmHg
    4. Left ventricular systolic pressure of 120 mmHg
    5. Right ventricular systolic pressure of 25 mmHg
    1. P wave corresponding with the left atrial kick.
    2. Q wave corresponding with depolarization of the interventricular septum.
    3. T wave corresponding with repolarization of the ventricles.
    4. QRS complex corresponding with ventricular isovolumetric contraction.
    5. Delta wave associated with short PR interval.
    1. y-descent
    2. a-wave
    3. x-descent
    4. c wave
    5. v wave
    1. It is formed by atrial contraction.
    2. It represents bulging of the mitral leaflets back into the left atrium.
    3. It corresponds with isovolumetric contraction.
    4. It's only seen in 50% of patients.
    5. It represents early ventricular systole.
    1. It is usually followed by the y-descent.
    2. It occurs directly before diastole.
    3. It represents the portion of the cardiac cycle when the atria is most full.
    4. It is associated with opening of the mitral valve.
    5. It is the point in the cardiac cycle where the ventricle has the least volume.
    1. S2 directly following by opening snap, and then a mid-diastolic rumble.
    2. The opening snap occurs later in diastole in severe mitral stenosis compared to early mitral stenosis.
    3. The murmur extends across more of diastole in severe mitral stenosis compared to early mitral stenosis.
    4. A mid-systolic click is an added sound in severe mitral stenosis that is not present in early mitral stenosis.
    5. The murmur is best heard closer to the apex in severe mitral stenosis and closer to the 2nd intercostal space in mild mitral stenosis.
    1. Laterally displaced apex.
    2. Dysphagia.
    3. Hoarseness.
    4. Hemoptysis.
    5. Dyspnea on exertion.
    1. Compression of left recurrent laryngeal nerve.
    2. Increased hydrostatic pressure in the pulmonary veins.
    3. Compression of the vagus nerve.
    4. Decreased blood supply to the vocal cords.
    5. Pulmonary edema leading to upper respiratory tract infection.
    1. Cor pulmonale is the result of a primary lung condition, while RHF in mitral stenosis is secondary to left heart failure.
    2. RHF in mitral stenosis is due to cor pulmonale.
    3. RHF in mitral stenosis is the result of long standing pulmonary edema similar to cor pulmonale.
    4. Cor pulmonale is the result of a primary lung condition, while RHF in mitral stenosis is due to backflow of blood into the right ventricle.
    5. Cor pulmonale is the result of a primary lung condition, while RHF in mitral stenosis is the result of compression from the enlarged left atrium.
    1. Opening snap followed by mid-diastolic rumble.
    2. Mid-systolic click with mid-diastolic rumble.
    3. Systolic crescendo-decrescendo murmur.
    4. Early diastolic decrescendo murmur.
    5. High-pitched holosystolic murmur.
    1. Right ventricular failure
    2. Pulmonary capillary wedge pressure of > 20 mmHg
    3. Left atrial pressure > 15
    4. Dysphagia
    5. Voice hoarseness
    1. Increased risk of atrial fibrillation.
    2. Endothelial injury
    3. Coagulation disorder
    4. Bleeding diathesis
    5. Heart pump failure

    Author of lecture Valvular Heart Disease: Mitral Stenosis

     Carlo Raj, MD

    Carlo Raj, MD

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    Highlighted patho-physiology
    By Mariane B. on 27. February 2017 for Valvular Heart Disease: Mitral Stenosis

    This is after all a Pathology course. Normally, management is not discussed here, but you guys did. Thank you!

    What about valvuloplasty
    By Hamed S. on 18. February 2017 for Valvular Heart Disease: Mitral Stenosis

    Need to further explore surgical and percutaneous treatment options incl valvuloplasty and in which patients valve replacement vs valvuloplasty is preferred