Difference between Mitral stenosis and Arotic regurgitation

1All about Mitral Stenosis
2Treatment of Mitral Stenosis
3All about Aortic regurgitation (AR)
4Treatment of aortic regurgitation:
5Difference between the signs of mitral stenosis and aortic regurgitation

In this article, we will learn how to differentiate between Mitral stenosis and Arotic regurgitation. There are 2 types of valvular heart disease. They are the most common type.  In this article, we first learn about the signs, symptoms, investigation, and treatment of these two variable-type disease conditions. After that, we make a comparison between these two conditions.

Difference between the signs of mitral stenosis and aortic regurgitation:

1. In mitral stenosis, the pulse may be irregularly irregular. 
In aortic regurgitation pulse may be found high volume and collapsing pulse.

2. In the case of mirtal stenosis, blood pressure is normal, usually 130/80mm Hg.
In aortic regurgitation, blood pressure is highly systolic, low diastolic, and wide. Usually, it will be 160/60 mm of Hg.

3. The face in mitral stenosis is malar flush.
In aortic regurgitation, the face is normal.

4.Cardiac murmur in mitral stenosis is a mid-diastolic murmur at the apex.
Cardiac murmur in aortic regurgitation  Blowing early diastolic murmur in the left sternal border at the 4th intercostal space.

5. A pistol shot murmur over the femoral artery in mitral stenosis is absent.
Pistol shot murmur over the femoral artery in aortic regurgitation is present.

First, let’s discuss mitral stenosis: 
 Symptoms of mitral stenosis:
• Breathlessness (pulmonary congestion).
• Fatigue (low cardiac output).
• oedema, ascites (right heart failure).
• Palpitation (atrial fibrillation)
 • hemoptysis (pulmonary congestion, pulmonary embolism).
• cough (pulmonary congestion). Chest pain (pulmonary hypertension).
• Symptoms of thromboembolic complications (e.g., stroke, ischaemic limb).

Signs:
 1. Face: Mitral facies or malar flush.
 2. Pulse: irregularly irregular (atrial fibrillation).
 3. JVP: If right heart failure develops, there will be a raised JVP.
 4. Precordium:
 5. Chest X-ray
 6. Treatment:
 

 Medical treatment:
• If atrial fibrillation: anticoagulant therapy, e.g., warfarin, and restoration of normal rhythm by digoxin, 3-blockers, rate-limiting calcium channel blockers, or other anti-arrhythmics.
• If features of pulmonary congestion Diuretics.
Intervention & surgical treatment: Treatment options are –
1. Mitral balloon valvuloplasty.
2. Closed valvotomy.
3. Open valvotomy. a) Palpation of precordium: tapping type apex beat. Palpable P2, if pulmonary hypertension. Left parasternal heave and epigastric pulsation may be found if there is right ventricus hypertrophy. Auscultation:
⁃   Loud first heart sound, opening snap. Mid-diastolic murmur: low-pitched mid-diastolic murmur, localized in the apex (i.e., no radiation), best heard with the bell of the stethoscope with the patient in the left lateral position and breath holding after expiration.
There may be pre-systolic accentuation. Loud P2 may be found if there is pulmonary hypertension.

Signs of raised pulmonary capillary pressure:
Crepitations, effusions.

Investigations:
1. ECG: Left atrial hypertrophy / P-mitrale (if not in AF). Right ventricular hypertrophy. Features of AF.
2. Chest X-ray: enlarged left atrium and appendage. Signs of pulmonary venous congestion.
3. Echocardiogram: thickened immobile cusps. Reduced valve area. Enlarged left atrium. Reduced rate of diastolic filling of the LV.
4. Doppler:
• Pressure gradient across the mitral valve.
> Pulmonary artery pressure. Left ventricular function.
5) Cardiac catheterization: coronary artery disease. Pulmonary artery pressure.

What are the complications of mitral stenosis?
Complications of mitral stenosis:
1. Atrial fibrillation.
2. Systemic embolism.
3. Pulmonary hypertension.
4. Right ventricular failure.
5. pulmonary oedema.
6. Pulmonary infarction.
7. Chest infections.
8. Haemoptysis.
9. Infective endocarditis (rare).

Treatment:
Medical treatment:
• If atrial fibrillation: anticoagulant therapy, e.g., warfarin, and restoration of normal rhythm
• If features of pulmonary congestion include diuretics digoxin, B-blockers, rate-limiting calcium channel blockers, or other anti-arrhythmics.

Intervention & surgical treatment: Treatment options are –
1. Mitral balloon valvuloplasty.
2. Closed valvotomy.
3. Open valvotomy.
4. Mitral valve replacement


Aortic regurgitation (AR)
Q. What are the causes of aortic regurgitation?
Answer
Causes of aortic regurgitation:
1. Congenital: bicuspid valve or disproportionate cusps.
2. Acquired:
• rheumatic disease.
• infectious endocarditis.
• Trauma.
Aortic dilatation (Marfan’s syndrome, aneurysm, dissection, syphilis, ankylosing spondylitis).

Q. What is the management of aortic regurgitation?
Management of aortic regurgitation:
Clinical features:
Symptoms:
1) Mild to moderate AR:
• Often asymptomatic.
> Palpitation.
2) Severe AR: breathlessness. Angina.

Signs (bed side signs) of aortic regurgitation:
1) Pulse and BP:
• large-volume, ‘collapsing’ or bounding pulse.
• Low diastolic and increased pulse pressure.
• Capillary pulsation in nail beds: Quincke’s sign.
• Femoral bruit (‘pistol shot’): Duroziez’s sign. Head nodding with a pulse: de Musset’s sign.
2) Murmurs:
• Early diastolic murmur.
> Systolic murmur (increased stroke volume). Austin Flint murmur (soft mid-diastolic murmur in the mitral area).
3) Other signs:
• Displaced, thrusting apex beat (volume overload).
> Presvstolic impulse. Third or fourth heart sound. Crepitations (pulmonary venous congestion).


Investigations, which are usually done to diagnose aortic regurgitation:
1. ECG: Initially normal, later LV hypertrophy.
2. Chest X-rav:
• Cardiac dilatation may be aortic dilatation.
• Features of left heart failure.
3. Echo:
• Dilated left ventricle.
• hyperdynamic left ventricle.
• Fluttering anterior mitral leaflet.
• Doppler detects reflux
4. Cardiac catheterization: dilated LV; aortic regurgitation.
• Dilated aortic root.

Treatment of aortic regurgitation: 
1. Treatment may be required for underlying conditions such as endocarditis or syphilis.
2. Aortic valve replacement is indicated if aortic regurgitation causes symptoms, and this may need to be combined with aortic root replacement and coronary bypass surgery.
3. Asymptomatic patients should be followed up annually.
4. Systolic blood pressure should be controlled with vasodilating drugs such as nifedipine or ACE inhibitors.
5. When aortic root dilatation is the cause of aortic regurgitation (e.g., Marfan’s syndrome), aortic root replacement may be necessary.


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