Mitral Valve Disease

• Causes;
  • Rheumatic
  • Congenital
  • Mucopolysaccharidoses
• Presentation
  • Dyspnoea
  • Fatigue
  • Palpitations
  • Chest pain
  • Systemic emboli
  • Haemoptysis
• Signs
  • Malar flash
  • Low volume pulse
  • AF common
  • Tapping non displaced apex beat (palpable S1)
  • On auscultation – loud S1, opening snap, rumbling mid-diastolic murmur (best heard in expiration on the patients left side)
  • The more severe the stenosis the longer the diastolic murmur
• Tests
  • ECG – AF, P-mitrale if in sinus, RVH, progressive RAD
  • CXR – left atrial enlargement, pulmonary oedema, mitral valve calcification
  • ECHO – diagnostic
• Management
  • If in AF rate control
  • Anticoagulate with warfarin
  • Diuretics decrease preload and pulmonary venous congestion
  • Balloon valvuloplasty, open mitral valvotomy or valve replacement
• Complications;
  • Pulmonary hypertension
  • Emboli
  • Pressure of large LA on other structures e.g. recurrent laryngeal nerve (hoarseness), oesophagus (dysphagia), bronchial obstruction
  • Infective endocarditis

Mitral regurgitation

• Causes;
  • Function (LV dilatation)
  • Annular calcification
  • Rheumatic fever
  • Infective endocarditis
  • Mitral valve prolapse
  • Papillary muscle dysfunction/rupture
  • CT disorders – Ehlers-Danlos, Marfan’s syndrome
  • Cardiomyopathy
  • Congenital
• Symptoms
  • Dyspnoea
  • Fatigue
  • Palpitations
  • Infective endocarditis
• Signs
  • AF
  • Displaced hyperdynamic apex
  • RV heave
  • Soft S1, split S2, loud P2 (pulmonary hypertension)
  • Pansystolic murmur at apex radiating to the axilla
• Tests
  • ECG – AF, P-mitrale if in sinus, LVH
  • CXR – big LA and LV, mitral valve calcification and pulmonary oedema
  • ECHO – diagnostic
• Management
  • Control rate if in AF
  • Anticoagulate if -  history of AF, history of embolism, prosthetic valve, additional mitral stenosis
  • Diuretics improves function
  • Surgery for deteriorating symptoms – aim to repair or replace valve before LV is irreversibly impaired

Mitral valve Prolapse

• Prevalence 5%
• Occurs alone or with ASD, PDA, cardiomyopathy, Turner’s syndrome, Marfan’s syndrome and osteogenesis imperfecta
• Symptoms
  • Asymptomatic or atypical chest pain and palpitations
• Signs
  • Mid-systolic click and or late systolic murmur
• Complications
  • Mitral regurgitation
  • Cerebral emboli
  • Arrhythmias
  • Sudden death
• Tests
  • ECHO is diagnostic
  • ECG may show inferior T wave inversion
• Treatment
  • ?-blockers may help palpitations and chest pain