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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020年10月2日,*,Pathophysiology of Mitral Valve disease,Alan Sihoe,Cardiothoracic Surgery Teaching Round,2,nd,August 2002,2020年10月2日,1,Pathophysiology of Mitral Val,Epidemiology,1998 in the UK:,6471 first time valve replacements,of which,28%MVR,Numbers increasing,2020年10月2日,2,Epidemiology1998 in the UK:202,Mitral Annulus:fibro-muscular skeleton,Anchors base of valve leaflets,Leaflets:,conn tissue+muscle+vessels/nerves,Anterior(aortic):larger;1/3 of annulus,Posterior(mural):2/3 of annulus,Anatomy,2020年10月2日,3,Mitral Annulus:fibro-muscular,Anatomy,Papillary muscles:,Anterolateral,Posteromedial,Chordae tendinae,1,st,2,nd,3,rd,order,Approx 25 major chordal trunks,100 attachments to leaflets,No consensus on timing of muscle activity with cardiac cycle,2020年10月2日,4,AnatomyPapillary muscles:2020年,Annular dynamics,Annular size,Increases in late systole(maximum in diastole),Contracts in pre-systole(minimum in midsystole),Annular shape,More eccentric in systole,Annular position,Moves up towards LA in diastole,Moves down towards LV apex in systole,2020年10月2日,5,Annular dynamicsAnnular size 2,Leaflet dynamics,Opening,Starts in center,moving to edges,Flapping of edges at max.opening,Closing,(begins in late diastole),Bulging at base/annular attachment,Leaflet ascends towards LA,Bulging rolls from annulus to edge,2020年10月2日,6,Leaflet dynamicsOpening2020年10,Mitral Stenosis(MS),Aetiology:,Rheumatic,Male:female ratio is 1:2-3,Acquired early(30mmHg:pulm transudation,reduced lung compliance,Pulm art systolic pressure 60mmHg,impedes RV emptying,right heart failure,Ultimately irreversible pulm vascular changes,2020年10月2日,11,MS:Pulmonary changesIn severe,MS:Natural history,Progressive life-long disease,Long latency,Symptoms:,Low cardiac output:dyspnoea,fatigue,Pulmonary congestion/HT(orthopnea,PND),right heart failure,h,emoptysis,Atrial fibrillation/Thromboembolism,Cardiac cachexia,2020年10月2日,12,MS:Natural historyProgressive,MS:Natural history,Onset of symptoms to disability:10 years,10 year survival:,Asymptomatic(NYHA class I)80%,(progression),Symptomatic(NYHA class III)20%,Causes of death:,CHF 60-70%,Systemic embolism 20-30%,Pulmonary embolism 10%,Infection 1-5%,2020年10月2日,13,MS:Natural historyOnset of sy,MS:Investigations,CXR:LA enlargement,pulm congestion,ECG:LA enlargement,(notched P in II,V,1,),atrial arrhythmias,?RVH,Echo:valve area,LA/LV dimensions,Doppler:measures pressure gradients,TOE:better mitral/LA visualization,Cardiac catheter:,not essential,Assoc,d,disease;LV ventriculography&pressures,2020年10月2日,14,MS:InvestigationsCXR:LA enla,MS:Medical therapy,Pharmacological Tx of mild heart failure,bronchitis,arrhythmias,hemoptysis,Endocarditis prophylaxis,Anticoagulation:Hx of AF/thromboembolism,Balloon(or open)Valvuloplasty,2020年10月2日,15,MS:Medical therapyPharmacolog,MS:Indications for surgery,Symptomatic(NYHA class III-IV):,MVR,h,long-term survival,10 year survival:0-20%,90%(89%at 15 yrs),h,functional capacity,Valve area 1-1.5cm,2,(normal 4-6,cm,2,),Systemic emboli,2020年10月2日,16,MS:Indications for surgerySym,MS:Indications for surgery,Class I-II:controversial,Risk of SCD if asymptomatic:negligible,Survival not improved by MVR,?role of valvotomy(pulmonary HT,AF),MVR indicated when:,Valve area NYHA class II+,2020年10月2日,17,MS:Indications for surgeryCla,Mitral Regurgitation(MR),Aetiology more diverse than MS,Myxomatous degeneration,Leading cause in West(30-70%),Defective fibroelastic tissue,floppy valve,Most asymptomatic,Complicated by annular dilatation,chordal rupture,endocarditis,Rheumatic disease next most common,2020年10月2日,18,Mitral Regurgitation(MR)Aetio,MR:Carpentier classification,Normal leaflet motion,Annular/ventricular dilatation,Leaflet disease/perforation,2020年10月2日,19,MR:Carpentier classificationN,MR:Carpentier classification,Excessive leaflet motion(prolapse),Chordal/papillary muscle elongation or rupture,2020年10月2日,20,MR:Carpentier classificationE,MR:Carpentier classification,Restricted leaflet/chordal motion,e.g.fibrosis,calcification,retraction,2020年10月2日,21,MR:Carpentier classificationR,MR:Aetiology,Mitral Annulus,Myxomatous degeneration,Senile calcification,Functional dilatation(e.g.myocarditis),Ring abscess,Marfans,2020年10月2日,22,MR:AetiologyMitral Annulus202,MR:Aetiology,Mitral leaflets,Rheumatic disease,endocarditis,(1-30%),Unknown why some develop MS,others MR,Fibrocalcific leaflet thickening,(without fusion),Chordae shortened,annulus dilated,also:congenital,connective tissue disease,2020年10月2日,23,MR:AetiologyMitral leaflets20,MR:Aetiology,Chordae,Ischaemia,Myxomatous,Infective,Connective tissue,Trauma,Idiopathic,2020年10月2日,24,MR:AetiologyChordae2020年10月2日,MR:Aetiology,Papillary muscle,(10-25%),Dysfunction/rupture,IHD/MI:muscle&annular injury,frank rupture rare,usually fatal,esp.Posteromedial muscle,Also:abscess,sarcoid/amyloid,myocarditis,Malalignment,e.g.LV aneurysm,dilatation,myopathy,2020年
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