Mitral Valve Disease

Mitral Valve Disease

1. Definition
   Mitral valve disease is any disorder that impairs the normal function of the mitral valve, the valve that controls blood flow from the left atrium to the left ventricle. It is one of the common valvular heart diseases encountered in clinical practice.

2. Synonyms (if any)
   Mitral valve disorder, mitral valve dysfunction – both terms are used interchangeably to describe the same condition.

3. Causes / Etiology

   a. Rheumatic heart disease – an immune reaction after streptococcal throat infection; the inflammatory process damages the leaflets and chordae, most often producing mitral stenosis.
   b. Degenerative (myxomatous) change – age‑related weakening of the valve tissue leading to prolapse and regurgitation.
   c. Infective endocarditis – bacterial infection of the valve surface destroys tissue and can cause acute severe regurgitation.
   d. Ischemic papillary muscle rupture – loss of blood supply to papillary muscles after myocardial infarction leads to sudden regurgitation.
   e. Trauma – blunt chest injury may tear chordae tendineae or papillary muscles, producing an acute leak.
   f. Congenital malformation – rare developmental defects such as cleft leaflet may predispose to regurgitation.

4. Types / Classification

   • Mitral Stenosis (MS) – narrowing of the orifice, usually chronic.
   – Cause: predominantly rheumatic.
   – Clinical picture: gradual onset dyspnoea on exertion, fatigue, palpitations due to atrial fibrillation, orthopnoea, paroxysmal nocturnal dyspnoea.
   – Duration: chronic, develops over years.
   – Acute form is rare; may occur with sudden severe rheumatic inflammation or thrombotic obstruction.

   • Mitral Regurgitation (MR) – backward flow of blood during systole.
   – Causes: degenerative prolapse (chronic), infective endocarditis, papillary muscle rupture (acute), trauma.
   – Clinical picture (chronic): exertional dyspnoea, easy fatigability, palpitations, later signs of left‑sided heart failure (pulmonary congestion).
   – Clinical picture (acute): sudden severe breathlessness, rapid onset pulmonary edema, hypotension, loud pansystolic murmur.
   – Duration: may be chronic (years) or acute (hours‑days).

5. Pathophysiology / Pathology

   • In MS the leaflets become thickened, fibrotic and fused; commissural calcification reduces the valve area. The left atrium has to generate higher pressure to push blood through, leading to atrial enlargement, pulmonary venous congestion and eventually pulmonary hypertension.
   • In MR the leaflets fail to coapt, so during systole blood regurgitates into the left atrium. The left atrium and ventricle undergo volume overload, dilate and develop eccentric hypertrophy. Over time the compensatory mechanisms fail, producing pulmonary congestion and reduced forward cardiac output.

6. Clinical Features

   General: shortness of breath, fatigue, palpitations, reduced exercise tolerance.

   Acute MS – rare; may present with sudden pulmonary edema, rapid atrial fibrillation, severe hypoxia.

   Chronic MS – gradual dyspnoea on exertion, orthopnoea, paroxysmal nocturnal dyspnoea, atrial fibrillation, a loud opening snap followed by a low‑pitched diastolic rumble.

   Acute MR – sudden severe dyspnoea, pink frothy sputum, hypotension, a high‑pitch holosystolic murmur radiating to the axilla, pulmonary crackles.

   Chronic MR – long‑standing exertional dyspnoea, fatigue, later signs of left‑sided failure (bibasilar crackles, peripheral edema), displaced apical impulse, holosystolic murmur.

7. Complications

   Acute complications – pulmonary edema, cardiogenic shock, infective endocarditis, arrhythmias (especially atrial fibrillation). Early recognition can prevent fatal outcomes.

   Chronic complications – chronic heart failure, atrial fibrillation (increases risk of thrombo‑embolism), pulmonary hypertension, right‑sided heart failure, thrombus formation in the enlarged left atrium. Preventive anticoagulation and timely surgery reduce morbidity.

8. Investigations / Diagnosis

   • Clinical examination – auscultation for opening snap (MS) or pansystolic murmur (MR).

   • Electrocardiogram – left atrial enlargement, atrial fibrillation, signs of ventricular hypertrophy.

   • Chest X‑ray – enlarged left atrium, pulmonary venous congestion, “double density” sign in MS, cardiomegaly in MR.

   • Transthoracic echocardiography – primary test; measures valve area, regurgitant volume, chamber sizes, pulmonary pressures.

   • Trans‑esophageal echocardiography – better visualization of leaflets and vegetations when endocarditis is suspected.

   • Cardiac catheterisation – used when non‑invasive studies are inconclusive; assesses hemodynamics and pulmonary artery pressure.

   • Stress testing – evaluates functional capacity and severity of MR in asymptomatic patients.

9. Differential Diagnosis

   a. Aortic stenosis – also causes exertional dyspnoea but murmur is systolic ejection click and crescendo‑decrescendo, not diastolic rumble.

   b. Congestive heart failure of non‑valvular origin – may have similar breathlessness but lacks characteristic mitral murmurs and echocardiographic valve lesions.

   c. Pulmonary disease (e.g., COPD) – dyspnoea present but auscultation shows wheeze rather than cardiac murmurs; chest imaging shows hyperinflation.

   d. Tricuspid regurgitation – produces holosystolic murmur louder at left lower sternal border and signs of right‑sided congestion.

10. Management / Treatment

General management – regular clinical review, avoidance of excessive physical strain, education about symptom monitoring, vaccination against influenza and pneumococcus to reduce respiratory infections.

Modern medicine treatment –

    • Pharmacotherapy: diuretics for pulmonary congestion, ACE‑inhibitors or ARBs to reduce afterload in MR, beta‑blockers for rate control in atrial fibrillation, anticoagulants (warfarin or DOAC) when atrial fibrillation is present.  

    • Interventional/surgical: percutaneous balloon mitral valvotomy for suitable rheumatic MS; mitral valve repair (preferable) or replacement (mechanical or bioprosthetic) for severe MR or symptomatic MS not amenable to balloon.  

Diet and lifestyle advice – low‑sodium diet (≤2 g salt per day) to limit fluid retention; moderate fluid restriction if severe heart failure; balanced diet rich in fruits, vegetables and lean protein to maintain body weight; regular, physician‑approved aerobic activity (e.g., walking 30 min most days) to improve functional capacity; avoidance of heavy lifting and extreme exertion which can precipitate acute decompensation.

11. Homeopathic Therapeutics (7–8 remedies, each with 7–8 bullet points)

12. Bryonia
    – Causation: trauma, over‑exertion, cold, damp exposure.
    – Characteristic symptoms: sharp, stitching chest pain worsened by motion; breathlessness that increases on slightest effort.
    – Modalities: better when at rest, worse on motion, cold, pressure.
    – Mental state: irritable, impatient, wants to be left alone.
    – Thirst/appetite: great thirst for large quantities of cold water; appetite poor.
    – Discharges/secretions: scanty, thick sputum if cough present.
    – Physical generals: dry skin, feeling of heaviness in limbs.
    – Suitable constitution: persons who are “stubborn”, who dislike being disturbed, often athletes or laborers.
    – How it helps: relieves the aggravation of mitral regurgitation caused by strain and reduces the feeling of breathlessness on exertion.

13. Digitalis
    – Causation: chronic heart failure, prolonged exertion, cold weather.
    – Characteristic symptoms: slow, weak pulse; feeling of heaviness in the chest; dyspnoea especially at night.
    – Modalities: better in warm rooms, worse in cold, after meals.
    – Mental state: melancholy, indifferent, often forgetful.
    – Thirst/appetite: thirst for cold water; appetite diminished.
    – Discharges/secretions: scanty urine, thick yellow sputum if pulmonary congestion.
    – Physical generals: pale, cold extremities, swollen ankles.
    – Suitable constitution: elderly, frail individuals with long‑standing cardiac weakness.
    – How it helps: strengthens the weakened myocardium, improves forward flow and reduces regurgitant volume.

14. Helleborus
    – Causation: sudden onset of cardiac decompensation after emotional shock or infection.
    – Characteristic symptoms: sudden severe dyspnoea, feeling of suffocation, tightness in the chest.
    – Modalities: better lying on left side, worse when sitting upright.
    – Mental state: anxious, fearful of death, restless.
    – Thirst/appetite: great thirst for cold water; appetite poor.
    – Discharges/secretions: frothy, pink sputum indicating pulmonary edema.
    – Physical generals: rapid, weak pulse; cyanosis of lips.
    – Suitable constitution: persons who are highly sensitive, often with a history of sudden illness.
    – How it helps: alleviates acute pulmonary congestion and eases the feeling of suffocation in acute MR.

15. Lycopus (Lycopodium)
    – Causation: chronic valvular insufficiency, prolonged stress, over‑work.
    – Characteristic symptoms: palpitations with a feeling of “fluttering” in the chest; breathlessness on mild exertion.
    – Modalities: better warm drinks, worse on cold drinks and after eating.
    – Mental state: lack of confidence, fear of public speaking, anticipatory anxiety.
    – Thirst/appetite: thirst for warm beverages; appetite irregular, often prefers sweet foods.
    – Discharges/secretions: sticky mucus in throat, occasional cough.
    – Physical generals: bloating, flatulence, cold feet.
    – Suitable constitution: individuals with a timid disposition, often students or clerks.
    – How it helps: stabilises irregular heart rhythm and reduces the sensation of palpitations in chronic MR.

16. Natrum muriaticum
    – Causation: emotional grief, suppressed tears, exposure to cold wind.
    – Characteristic symptoms: feeling of heaviness in the chest, intermittent breathlessness, occasional faintness.
    – Modalities: better in open air, worse in warm, stuffy rooms.
    – Mental state: reserved, prefers solitude, often holds back emotions.
    – Thirst/appetite: thirst for small sips of cold water; appetite moderate but prefers salty foods.
    – Discharges/secretions: dry mucous membranes, scanty sputum.
    – Physical generals: dry skin, brittle nails.
    – Suitable constitution: people who are introverted, often women with a history of emotional upset.
    – How it helps: addresses the underlying emotional component that may aggravate mitral valve dysfunction and improves overall vitality.

17. Phosphorus
    – Causation: prolonged fatigue, over‑exertion, exposure to cold drafts.
    – Characteristic symptoms: burning sensation in the chest, shortness of breath that worsens at night, feeling of weakness.
    – Modalities: better warm drinks, fresh air; worse in cold, damp environments.
    – Mental state: anxious, restless, easily frightened.
    – Thirst/appetite: great thirst for cold water; appetite variable, often prefers light foods.
    – Discharges/secretions: thin, watery sputum; occasional nasal discharge.
    – Physical generals: pallor, trembling hands, cold extremities.
    – Suitable constitution: young, active individuals who over‑work themselves.
    – How it helps: reduces fatigue and improves oxygenation, thereby easing the dyspnoea of chronic MR.

18. Spigelia
    – Causation: sudden emotional upset, over‑exertion, acute infection.
    – Characteristic symptoms: sharp, stabbing chest pain radiating to the back; sudden breathlessness.
    – Modalities: better lying on left side, worse on pressure over the chest.
    – Mental state: irritable, impatient, prone to anger.
    – Thirst/appetite: thirst for cold water; appetite poor.
    – Discharges/secretions: scanty, thick sputum if cough present.
    – Physical generals: weak pulse, cold sweat.
    – Suitable constitution: persons with a fiery temperament, often middle‑aged men.
    – How it helps: relieves acute pain and breathlessness associated with sudden worsening of mitral regurgitation.

19. Sulphur
    – Causation: chronic irritation, exposure to heat, sedentary lifestyle.
    – Characteristic symptoms: burning sensation in the chest, feeling of heat, intermittent dyspnoea.
    – Modalities: better in cool, open air; worse in warm, stuffy rooms.
    – Mental state: intellectual, restless, often dissatisfied with routine.
    – Thirst/appetite: great thirst for cold water; appetite for spicy, salty foods.
    – Discharges/secretions: yellowish sputum, occasional skin eruptions.
    – Physical generals: dry, itchy skin, foul body odour.
    – Suitable constitution: individuals with a tendency to over‑indulge in rich foods, often teachers or professionals.
    – How it helps: reduces chronic inflammatory irritation of the valve and improves overall cardiac stamina.

20. Prognosis
    The outlook depends on the severity of the valve lesion, presence of pulmonary hypertension, atrial fibrillation and the timing of intervention. Early detection and appropriate surgical repair or replacement give a good long‑term survival; untreated severe MS or MR leads to progressive heart failure and reduced life expectancy.

21. Prevention
    Primary prevention includes prompt treatment of streptococcal throat infection and secondary prophylaxis with long‑term penicillin to avoid rheumatic heart disease. Regular cardiac check‑ups in patients with known mild valve lesions, avoidance of excessive alcohol, smoking cessation and maintaining a healthy weight reduce the risk of progression.

22. Diet
    Recommended: low‑sodium diet (≤2 g salt per day) to prevent fluid overload; plenty of fresh fruits and vegetables for antioxidant support; lean protein (fish, poultry) to maintain muscle mass; moderate fluid intake (1.5–2 L/day) unless restricted by heart failure.

Avoided: salty processed foods, fast foods high in saturated fat, excessive caffeine and alcohol, heavy meals before bedtime (which increase cardiac workload).