• Fibrous annulus of mitral valve (MV) is thin, incomplete ring of fibrous tissue
• Most MVs have anterior and posterior leaflets, attached by thin fibrous chordae tendineae to papillary muscle
• Closed during systole via action of papillary muscle contraction, open during diastole when LA pressure higher than LV pressure
• Mitral stenosis (MS) is fibrosis, narrowing of valvular area causing ventricular inflow obstruction during diastole
• Early valvular disease of rheumatic fever: Acute inflammatory infiltrate that heals by fibrous organization
• Leaflets become fibrotic and thickened causing reduced pliability and surface area
• Fusion of leaflets at commissures
• Calcification may occur in leaflets
• Chordae thickened, shortened, and fibrotic
• Mitral complex becomes "fish mouth"
• Results in pulmonary congestion, thickening of pulmonary capillaries, intimal fibrosis of arterioles
• Pulmonary hypertension progresses with time
• Causes of valve disease include:
• Less common causes include:
• Valvular heart disease: 89,000 hospital discharges in 1998
• Number 1 cause of MS is rheumatic fever associated with group A streptococcal pharyngitis
• Death due to heart failure in up to 70%
• Dyspnea (initially with exertion), orthopnea
• Atrial fibrillation with atrial dilation; often with clinical deterioration due to dependence on atrial kick (20% of cardiac output) and tachycardia
• Thin cachectic "mitral facies"
• Jugular pulsations from fluid overload
• v waves observed if in atrial fibrillation
• Peripheral edema and hepatic enlargement with "hepatojugular reflux"
• Pulmonary component of S2 pronounced and may be palpable
• Opening snap of MV common due to tensing of leaflets by chordae (heard best at apex)
• Diastolic low pitched rumbling murmur (heard best at apex), accentuated if in sinus rhythm with atrial contraction
-90% in sinus rhythm exhibit broad, notched P wave (P mitrale)
-Later stages: Atrial fibrillation and RV hypertrophy
• Percutaneous balloon valvotomy-moderate to severe symptomatic MS; ideal for minimally calcified, no MR
• Surgical commissurotomy (50%):
-Absence of leaflet calcification, better candidate
-Complete incision of commissures
-Thickened chordae resected
-Papillary muscles divided to lengthen
• MV replacement: If calcified or fibrous retraction, maintain subvalvular attachments to maintain geometry
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