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MITRAL VALVE DISEASES

WHAT IS MITRAL VALVE?

Valve is a structure between two tubes which allow flow of of fluid or air only in one direction. Mitral is one such valve between two left sided chambers of the heart namely left atria and left ventricle. It has two leaflets, held to the mitral annulus, which is a ring shaped fibroskeleton and to the anterior and posterior papillary muscles with numerous chordae attched to the free margin of the leaflets.

WHAT ARE THE DISEASES OF MITRAL VALVE?

As in any other valve pathology, mitral valve can either get narrowed when it is called Mitral stenosis or get leaky when it is called Mitral Regurgitation.

Mitral Valve

Mitral Valve

The mitral valve may be affected by birth( congenital mitral stenosis),got affected by Rheumatic fever,got infected  by bacterea or fungus ,got degenerated by calcification,got  leaky by annular dilatation as a part of general enlargement of heart, leaflets got degenerated by myxoma or leaflets got prolapsed into the atrium due to rupture of choedae or papillary muscle as part of myocardial ischemia.

CAUSES OF MITRAL STENOSIS

  • Congenital
  • Rheumatic
  • Calcific

CAUSES OF MITRAL REGURGITATION

  • Rheumatic
  • Myxomatus
  • Ischemic
  • Calcific
  • LVdilatation

WHAT ARE THE AFFECTS OF MITRAL STENOSIS ON HEART?

When mitral valve get choked, blood canot flow freely from left atrium to left ventricle which causes built up of pressure inside the left atrium. This building up of pressure lead to lung congestion and a condition called pulmonary edema in severe cases, which is flooding of lung alveoli with serum resulting in severe breathlessness and sometimes calamitous hypoxia and death.

Another complications are pulmonary hypertention, atrial fibrillation and thrombo-embolic episodes. Pulmonary hypertention is the increased pressure in the lungs.

Atrial fibrillation is the irregular beating of heart due to increased size of left atrium.

Thrombo-embolism occurs because of stagnation of blood in the left atrial appendage from atrial fibrillation. The thrombus can get dislodged to brain or limbs resulting in stroke or acute limb ischemia.

WHAT ARE THE COMPLICATIONS OF MITRAL STENOSIS?

  • Increasing breathlessness
  • Pulmonary edema
  • Frequent hospital admissions.
  • Coughing up blood
  • Frequent lung infections from lung congestion
  • Increased lung pressure(Pulmonary Hypertention)
  • Atrial fibrillation( irregularity of heart beat)
  • Thrombo-embolism leading to stroke or limb loss.

Mitral Valve

Mitral valve Stenosis

WHAT ARE THE EFFECTS OF MITRAL REGURGITATION ON HEART ?

When mitral valve is normal , no blood is suppose to leak to the left atrium when left ventricle ejects blood in its contracting phase.  But when it is leaky some blood leaks back into the left atrium rather than get ejected to the aorta. So the left atrium starts enlarging, ventricle also start enlarging as it has to recieve double the blood and the effective ejection from the left ventricle continue to get diminished.

WHAT ARE THE SYMPTOMS AND COMPLICATIONS OF MITRAL REGURGITATION?

  • Progressive enlargement of heart. Left ventricle and left atrium.
  • Progressive breathlessness.
  • Detereoration of heart function
  • Heart failure
  • Pulmonary Hypertention
  • Atrial fibrillation

HOW THE MITRAL DISEASES ARE DIAGNOSED?

Though history taking and auscultation with stethoscope point towards the evidence of mitrlal valve disease , an imaging by echo cardiogram give the definitive diagnosis.

Mitral Valve

Mitralvalve Repair

WHAT IS ECHO-CARDIOGRAM?

Echocardiogram is an imaging technique in which sound waves are used very much like ultra-sonogram. With this imaging technique,the size of the heart, functioning of heart, valves of the heart, inside of the heart,etc. With the echocardiogram it will be able to tell what happened to the mitral valve, whether it is stenosed or leaking, what is the likely pathology, how serious has it become, whether it can be repaired or need to be replaced. Echcardiogram is the most important test in the treatment of Mitral valve disease.

WHAT ARE THE TREATMENT OPTIONS FOR MITRAL VALVE DISEASES?

  • Medical follow up
  • Balloon mitral valvotomy
  • Closed Mitral Valvotomy
  • Open Mitral valvotomy
  • Key hole valve replacement or repair
  • open valve replacement or repair.
  • Catheter based Mitra-clip application .

WHAT ARE THE MEDICINES USED FOR MITRAL VALVE DISEASES?

Since both Mitral stenosis and Mitral regurgitation causes lung congestion and pulmonary edema, the mainstay of medical management is Diuretics which remove excess water from the body through urine. The commonly used such medicines are Lasix, Amifru,Dytor,etc.

WHAT IS MEDICAL FOLLOW UP?

If the symptoms are not very serious, lung pressures low, heart function is good,if heart is not getting enlarged, perhaps with medicines and regular echocardiogrphic follow up patient can go on for many years.

WHEN SHOULD A MITRAL VALVE DISEASE PATIENT SHOULD UNDERGO SURGICAL TREATMENT?

  • When the symptoms have become discomforting inspite of best medical management.
  • If lung pressures are seen increasing.
  • Frequent attacks of lung congestion needing hospital admissions.
  • Echocardiogram vise ,mitral valve area has reduced beyond a critical level of 1 sq.cm
  • Echocardiogram vise  leak is quite significant enough
  • Echocardiogram vice and chest xray vice, heart size has increased much.
  • Multiple episodes of acute heart failure.

WHAT IS BALLOON MITRAL VALVOTOMY?

This is a catheter based procedure where a wire is introduced through groin and brought across the stenosed mitral valve guided by cath-lab. After negotiating the valve ,a ballon is inflated across the valve which will split open the stenosed valves along the lines of fusion of leaflets. However this procedure canot be done if valve is severely calcified, if the papillary muscles below the leaflets badly involved, if there is blood clots iside the left atrium or if the patient is pergnant.

Mitral Valve

Balloon Mitral Valvotomy

As it is a blind procedure,though guided by cath-lab,sometime severe tearing can happen to the leaflets necessitating an emergency open heart surgery. If it is successfully done and valve area is improved, the symtoms will improve significantly.

WHAT IS CLOSED MITRAL VALVOTOMY?

This is an operative procedure done through a small cut on the left side of the chest whereby after exposing the heart and making a small cut on the left ventricle and an instrument called Tubbs dilator passed across the valve guided the index finger introduced through the appendage of the left auricle and the valve is split open. This procedure however is not done frequently nowadays with the advent of Ballon balvotomy whereby same result can be achieved without cutting open the boby. The results ,contra-indications and complications are same as that of Ballon Mitral valvotomy.

Mitral Valve

Valvuloplasty

 

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