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Valvular Heart Disease - Mitral Disorders
Michael S. Feldman, MD, is a Clinical Professor of Medicine at the University of Pennsylvania School of Medicine. He served as director of cardiology services at the Philadelphia Heart Institute from 1980 to 1998, and is chairman of the Graduate Education Foundation. Bernard Segal, MD, is a professor of medicine and director of the Jefferson Heart Institute as well as director of cardiology at Thomas Jefferson University. Here, they discuss the etiology and pathophysiology, clinical manifestations, medical management, and indications for surgical intervention in mitral valve disease. Most mitral stenosis (MS) is the result of rheumatic fever, has a 20-year latent period, and is more common among women than men. As it becomes more severe, symptoms occur with minimal exertion. The authors describe the clinical presentation of MS, and the factors affecting the physical examination, including auscultatory findings, such as the presence of atrial fibrillation and structural changes in the mitral valve. In addition to the physical examination diagnosis may include ECG, chest X-ray, and Doppler echocardiography which determines the severity of MS and the suitability for mitral valve repair. Medical management of MS consists mainly in treating atrial fibrillation with a variety of antiarrhythmics, anticoagulants, and diuretics. Prophylactic antibiotic usage is recommended. Surgical intervention and catheter dilatation relieve mitral valve obstruction, and, the authors state, percutaneous mitral balloon valvuloplasty "is an acceptable alternative to surgery in selected patients," although there are potential complications such as embolism, left ventricle perforation and atrial septal defects. Surgical intervention consists of either repair or replacement of the mitral valve. Valve repair is usually via open commissurotomy. Closed commissurotomies are rarely performed today. The lecture concludes with a discussion of mitral valve prolapse, and acute and chronic mitral regurgitation (MR), their clinical manifestations and physical findings which may include a holosystolic murmur which is the hallmark of MR. As well as auscultation, ECG, chest X-ray, and echocardiography are the diagnostic tools for evaluating the morphology of the mitral valve, the annulus, the commissures, and the papillary muscles. For both Mitral Stenosis and Mitral Insufficiency the surgical risk of valve repair or replacement is related to multiple factors, the most significant of which are co-morbidities. Patients with certain co-morbidities may have a 25% mortality rate following surgery. |
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