Mitral valve

승모판막 질환

강동경희대병원 심장혈관내과

손 일 석

학습목표 (한국의과대학장협의회,2006)

• 승모판막증의 병태생리를 설명한다.

• 승모판막증의 증상을 열거한다.

• 판막 질환의 치료원칙을 설명한다.

References

• Harrison's Principles of Internal Medicine, 19^th ed

• Braunwald’s Heart Disease, 10^th ed

Mitral valve

승모판 僧帽瓣

이첨판 二尖瓣

Mitral valve 승모판 僧帽瓣

N Engl J Med 345:740, 2001

승모판의 구조

Otto. Practice of clinical echocardiography. 4^th

경식도 심초음파, 승모판막

Mitral valve disease

• Structure

– Annulus, leaflets, chordae

• Function

– Opening, blood flow from LA to LV, diastole – Closing, prevents regurgitation, systole

• Diseases

– Stenosis

– Regurgitation

“saddle”-shaped

Structure

Stenosis Regurgitation

Opening Closing

승모판 협착증

M ^itral S ^tenosis

Mitral stenosis

• Mostly rheumatic carditis, women>

• Leaflet thickening, commissural fusion

• Limited opening

 mechanical obstruction  impairs LV filling  Increase LA & pul. V. pr.  pul. congestion

• Increase in LA pressure by

– higher C.O. (anemia, preg., hyperthyroidism) – faster HR (↓diastolic filling time)

– atrial fibrillation

Pathophysiology

• Sx develop when valve area <50%

• Severe MS (MVA < 1 cm

),

• DOE (dyspnea on exertion, 운동성 호흡곤란)

 increase in LA & pul. V. pr. during exertion  decrease in diastolic filling time

• DOE, orthopnea, PND, pul. edema

• Hemoptysis

 rupture of pul.-bronchial submucosal venous connections

• Thrombi in LA

 embolization: with AF, > 65 yo, reduced CO

Symptoms and Signs

• History of rheumatic fever (age 5-15 yrs)

• Auscultation

– loud S1 (↓ when heavily calcified, limited mobility)

– opening snap (승모판 개방음)

• sharp sound, shortly after S2

– mid-diastolic rumbling murmur

• heard best at apex in Lt. lat. recumbent position

• ECG :

• CXR :

Diagnosis

Becoming severe,

• Larger ΔP during diastole  rumble persists throughout diastole.

• Greater LA pressure  shorter A2-OS interval

• Secondary pulmonary hypertension  loud P2, narrow splitting

청진 – 심잡음 (murmur)

- loud S1

- opening snap - mid-diastolic

rumbling murmur

청진 – 심잡음 (murmur)

Listening at Base:

• abnormally loud S1 at base

• shorter A2-OS interval indicates severe MS

Listening at Apex:

• crescendo, presystolic murmur

• loud S1

• S2, OS

• mid-diastolic murmur

Inspection:

• JVP is a-wave dominant

• a-wave occurs with loud S1

Patient, MS

• Echocardiogram

– valve thickening, subvalvular thickening calcification, leaflet mobility

– severity: MVA by planimetry, pressure-half time – concurrent aortic/ mitral valve dis.

– LA size

– pulmonary A. pr. From TR jet

– indication & timing of valvuloplasty or surgery – thrombus with atrial fibrillation

Diagnosis

Mitral stenosis

2D

Mitral stenosis

2D, M-mode

Mitral stenosis

3D

Mitral stenosis

2D, Color Doppler, MR

Mitral stenosis

Color Doppler, AR, Thrombus

Mitral stenosis

TEE, SEC, LAA Thrombus

SEC, Spontaneous Echo Contrast

+ Atrial fibrillation

• Medical

– diuretics  alleviating pulmonary congestion – treating AF

• digitalis, beta-blocker, non-DHP CCB, anticoagulation

– low salt intake, avoid excess physical activity

• Surgical, symptomatic severe MS

– percutaneous mitral balloon valvotomy (PMV) – open mitral commissurotomy

– MV replacement

Treatment

• Medical

– diuretics  alleviating pulmonary congestion – treating AF

• digitalis, beta-blocker, non-DHP CCB, anticoagulation

– low salt intake, avoid excess physical activity

• Surgical, symptomatic severe MS

– percutaneous mitral balloon valvotomy (PMV) – open mitral commissurotomy

– MV replacement

Treatment

• Increase in LA pressure by

– higher C.O. (anemia, preg., hyperthyroidism) – faster HR (↓diastolic filling time)

– atrial fibrillation

Inoue balloon technique for mitral balloon valvotomy

LV

Mitral valve

LA

Interatrial septum

RA IVC

Femoral v.

LV RA LA

Percutaneous Mitral balloon Valvotomy

(PMV, PMBV, PTCommissurotomy)

Percutaneous Mitral balloon Valvotomy

(PMV, PMBV, PTCommissurotomy)

• Percutaneous Mitral balloon Valvotomy (PMV, PMBV, PTMV, PBMC, PTC

)

– young MS

– pregnant woman with pulmonary edema – without heavy Ca⁺⁺, significant MR

– complication: severe MR, residual ASD

Percutaneous Mitral balloon Valvotomy

(PMV, PMBV, PTCommissurotomy)

J Am Coll Cardiol 63:e57: 2014

35세 여자가 호흡곤란으로 왔다. 임신 5개월째로 산부인과에 다니던 중 최근 누우면 숨이 차서 힘들다고 하였다. 신체검사에서 맥박은 규칙적이었으며,

심장 끝(apex)에서 이완기 심잡음과 승모판 개방음(opening snap)이 들리고 제 1심음이 항진되어 있었다. 양쪽 폐 하부에서는 수포음이 청진되었다.

현재 옳은 치료는?

1) 현재 임신 중으로 분만 때까지 증상 완화하는 약물 치료를 한다.

2) 심장초음파보다는 흉부 자기공명영상으로 진단 후 치료방법을 결정한다.

3) 폐부종이 동반된 승모판 질환이므로 수술적 치료를 해야 한다.

4) 심도자 (cardiac catheterization) 검사 후 시술이 필요하다.

5) 와파린을 포함한 항응고요법이 필요하다.

승모판 역류증

M itral R egurgitation

Mitral valve apparatus

• Etiology

– myxomatous degeneration, rheumatic (1/3, M),

chordal rupture, endocarditis, coronary dis. etc

• Inadequate closure during systole

 blood regurgitates into LA  LA enlargement

 LV volume overload (eccentric hypertrophy, dilatation)  MV cusp malcoaptation  increase MR

• Non-ischemic, ischemic, functional MR

• Acute vs. chronic

Pathophysiology

Causes of MR

Pathophysiology of MR

Mitral regurgitation

Flail MV

(chordal rupture)

Vegetation

(infective endocarditis)

Functional, ischemic MR

Mitral regurgitation - Functional

“Tethering”

Mitral Regurgitation

Curr Probl Cardiol 28:553, 2003

LA size LA pressure

• Chronic severe MR

– asymptomatic for years due to compensation – DOE, orthopnea, PND, fatigue

• Acute severe MR

– mostly symptomatic e.g., chordal rupture

(sudden volume load in non-dilated LV  pul. congestion)

Symptoms & Signs

• Auscultation

– blowing holo-systolic murmur

• heard best at apex

• radiation to axilla or cardiac base

• intensified by isometric exercise (handgrip) reduced by Valsalva maneuver

• ECG :

• CXR :

Diagnosis

• Echocardiogram

– etiology: valve morphology, myocardial dis.

– severity by color Doppler – LA and LV size

– LV function

– pulmonary A. pr. From TR jet

– timing of surgery (repair or replacement)

• Cardiac MRI

Diagnosis

• Acute vs

chronic

• Ischemic ^vs

non-ischemic

• Medical

– almost same as MS

• diuretics, treating AF, low salt intake, avoid excess physical activity, antibiotic prophylaxis

– vasodilators (ACE inhibitor)  reduce afterload – percutaneous device

• Surgical, symptomatic severe MR

– MV repair vs. replacement

Treatment

J Am Coll Cardiol 63:e57, 2014

MV repair

Percutaneous devices for correction of MR

MitraClip, Abbott Vascular

NEJM 2011;364:1395-406

승모판 탈출증

M itral V alve P rolapse

Systolic click-murmur syndrome Barlow’ syndrome

Floppy-valve syndrome

Billowing mitral leaflet syndrome

Mitral valve prolapse

Mitral valve prolapse

• More common in young female (15~30yrs)

• Mostly asymptomatic, benign course

• Complications

– highest in men, > 45yo, holosystolic murmur – infective endocarditis

– cerebrovascular events – progressive severe MR

Symptoms and Signs

• Auscultation

– mid-systolic click

• heard best at apex

• Tensing of mitral apparatus during leaflet prolapse

– late-systolic murmur

• Echocardiogram

– displacement of mitral leaflet into LA – parasternal long-axis view

– associated MR, LA size, LV function

Diagnosis

Hemodynamics of Acute and Chronic

Normal:

• S1, S2, no murmurs

Mitral valve prolapse:

• midsystolic click, possible late systolic murmur of MR

Acute MR:

• here, from chordal rupture

• loud S1, initiates explosive systolic murmur

• S3 with mid-diastolic murmur

Compensation:

• increased compliance of LA, LV

• blowing holosystolic murmur

• mid-diastolic rumble

Mitral valve prolapse

Supine

Standing

Squatting

Click, murmur, position

Click and murmur occur earlier

• Standing

• Valsalva strain

 decreasing LV volume

Click and murmur occur delayed

• Squatting

• Isometric exercise

 increasing LV volume

Mitral valve prolapse

TTE, 2D, color Doppler

Mitral valve prolapse

TEE, 2D, color Doppler

• Asymptomatic – no treatment, reassurance

• Medical

– endocarditis prophylaxis

• Only for Pts with a prior history of endocarditis

– ß-blockers

• Alleviating palpitations, anxiety, chest pain

• Surgical

– symptomatic severe MR – MV repair

Treatment

Mitral valve disease

• Structure

– Annulus, leaflets, chordae

• Function

– Opening, blood flow from LA to LV, diastole – Closing, prevents regurgitation, systole

• Diseases

– Stenosis

– Regurgitation