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, 19th ed
• Braunwald’s Heart Disease, 10th 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. 4th
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%
(NL, 4-6 cm2)• Severe MS (MVA < 1 cm
2),
LA pr. ~25mmHg• 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 :
LA enlargement (“p mitrale”)• CXR :
LA enlargement, pul. congestionDiagnosis
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
(MVA<1cm2)– 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
(MVA<1cm2)– 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
ommissurotomy)
– 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 :
LA enlargement, LVH• CXR :
LA & LV enlargement, pul. congestionDiagnosis
• 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
