Mitral Stenosis: Nick Tehrani, MD
Mitral Stenosis: Nick Tehrani, MD
Mitral Stenosis: Nick Tehrani, MD
Nick Tehrani, MD
Epidemiology of MS
Major
Minor
Carditis
Fever
Erythema marginatum
PR prolongation
Chorea
ESR elevation
Subcutaneous nodules
Hx of Rheumatic fever
Histopathology
The acute valvular pathology caused by Rheumatic fever is:
Mitral Regurgitation
Over the next several decades stenosis accrues by:
Thickening of the leaflets
Fusion of the commisures
Fusion or shortening of the chordae
Pathophysiology
Incr. Gradient.
Elevated LA
pressure
HR=72
HR=100
Problems
are
Variability
Introduced by:
The three inter-related parameters are:
HR
CO
Trans-mitral gradient
Mitral valve area
Torricellis Law:
Cc =Coefficient of
Orifice contraction
Area
Flow
V x Cc
V Cv
2 gh
C
Simplification of the above:
44.3
Flow
Area
C x 44.3
Flow
C x 44.3
CO
Flow
(SEP or DFP) (HR)
For Mitral (and Tricuspid) valve:
CO
Flow
DFP x HR
Flow
Area
44.3 x C
CO
Flow
DFP x HR
h P
Valve Area
CO
DFP x HR
44.3 x C P
CO
DFP
HR
44.3
C
Cardiac output
Diastolic Filling Period
Heart Rate
Derived Constant
Correction factor for valve type
C=1.0 for all valves except Mitral
C=0.85 for Mitral valve
CO
Flow
DFP x HR
Dimensional analysis:
cc/min
cc/sec
(sec/beat) x (beats/min)
Valve Area
CO
DFP x HR
44.3 x C P
DFP in mm / beat
CO
DFP x HR
Valve Area
44.3 x C P
HR in Beats/min
Valve Area
CO
DFP x HR
44.3 x C P
Valve Area
CO
DFP x HR
44.3 x C P
No Mitral Stenosis
C
V
Planimeter
DFP
Shifted Over
Instrumentation
0.0000
5 tracings
If patient is in A-Fib.=>
10 tracings
Valve Area
CC/sec.cm2.(mm Hg)P0.5
CO
DFP x HR
44.3 x C P
mm Hg
Potential Pitfalls
Wedge vs. LA Pressure
Stiff End-hole catheter:
Cournand
Verify true wedge by checking O2 Sat
Mean Wedge should be less than Mean PA
Cardiac Output
True Fick vs. Thermodilution vs. Green dye
Concurrent MR with MS:
Gradient across the valve reflects forward and
regurgitant flow
CO reflects the net forward flow only
Likely underestimation of the true valve area
Pulmonary Hypertension
10-15 mm Hg
Expected mean PA in Mitral Stenosis:
Mean LA (elevated of course) + (10-15 mm Hg)
In MS, Mean PA pressure often exceed the
expected.
Pulmonary Hypertension
This pulmonary hypertension has two components:
Reactive pulmonary arterial vasoconstriction,
Potentially Fixed resistance, secondary to
morphologic changes in the pulmonary
vasculature
CO
Flow
DFP x HR
Dimensional analysis:
cc/min
cc/sec
(sec/beat) x (beats/min)
Valve Area
CO
DFP x HR
44.3 x C P
DFP in mm / beat
CO
DFP x HR
Valve Area
44.3 x C P
HR in Beats/min
Valve Area
CO
DFP x HR
44.3 x C P
C
A
Planimeter
DFP