Mitral stenosis and homoeopathic management

Dr Naziya Gous Moiddeen Naik

Abstract
Mitral stenosis (MS) is a condition characterized by structural abnormality of the mitral valve apparatus that results in obstruction to left ventricular inflow.

Keywords–  Mitral stenosis, Homoeopathy

Introduction

• The mitral valve apparatus is composed of the annulus, anterior and posterior mitral leaflets which are attached to the anterolateral and posteromedial papillary muscles via the chordae tendinae (about 120 in number).
• The normal mitral valve orifice area is 4-6 cm

Aetiology

• Rheumatic heart disease.
• Congenital valvular heart disease- parachute mitral valve.
• Hunter’s syndrome.
• Hurler’s syndrome.
• Mitral annular calcification.
• Rheumatoid arthritis.
• Systemic lupus erythematosus.
• Infective endocarditis with large vegetation.
• Lutembacher’s syndrome.
• Drugs- Methysergide.

Pathophysiology of mitral stenosis.

• LA pressure increases.
• Increased PV pressure and flow.
• Increased PA pressure.
• Increased RV pressure.
• RV hypertrophy.
• RV failure.
• Increased RA pressure.
• Increased systemic veins pressure.

Mechanism

• The mechanism by which the initial episode of rheumatic fever progresses onto MS, has been explained by two theories, namely the smoldering process of rheumatic carditis and ‘Selzer and Cohn’ hypothesis. According to this hypothesis, the initial mitral valvulitis leads to abnormal flow patterns across the mitral leaflets that promote thickening, fibrosis and calcification of leaflets. The thickened leaflets fuse along their edges, i.e. commissures, resulting in a stenosed mitral valve which has a ‘Fish mouth’ or ‘Buttonhole’ appearance. This commissural fusion may be associated with cuspal or chordal fusion or both.

Signs and Symptoms of mitral stenosis.

Symptoms.

• PND- paroxysmal nocturnal dyspnoea.
• Hoarseness of voice.-Ortner’s

Signs.

• Pulse- tachycardia, irregular rhythm due to AF., pulse deficit.
• JVP- large a wave with Y descent slow.
• Apex- normal.
• Malar flushes.
• Peripheral cyanosis.

Auscultation-

• S1- loud.
• S2 – split s S2
• A. hypertension- narrowing split.
• RVF- wide split .
• S3- heard because of RVF.
• S4 heard due to RVH .

Murmur

• Mid diastolic murmur.-
• Site- apex.
• Pitch- low.
• Radiation- no.
• Clinical criteria for severity
• A2-OS gap – A2 & OS is inversely proportional to severity.
• Murmur length – murmur length is directly proportional to severity.

 Investigations

Chest x-ray- PA view.

• Straightening of left upper border .
• Carinal angle will become blind.
• Double atrial shadow.
• RV type of apex.

ECG-

1. LA enlargement in lead II, P wave widening, .> 2.5mm- P MITRALE.
2. RVH sign- right axis deviation, >+ 110.
3. 2 D ECHO CARDIOGRAPHY.
4. TRANS THORACIC ECHOCARDIOGRAPHY.
5. CARDIAC CATHETERISATION.¹

Management of Mitral stenosis

• Medical management.
• Surgical management.

Medical management –  treatment for AF, Pulm. Oedema , infective endocarditis.

Surgical management–

• Balloon mitral valvotomy.

Balloon mitral valvotomy (BMV) in the procedure of choice when indicated.  BMV is indicated in patients with suitable valve morphology, when they are:

• Symptomatic (NYHA class II, III or IV) with moderate to severe MS;
• Asymptomatic with severe MS with PA pressure > 50mmHg at rest or > 60 mm Hg on exercise or new onset AF;
• MR less than moderate; and
• Absence of LA thrombus.

BMV is contraindicated in patients with

• Bicommisural calcification;
• Densely calcified valve;
• More than moderate MR;

(iv)      Specific types of LA clot; Lack of expertise.

Mitral valve replacement.

Mitral valve replacement is indicated in:

• Symptomatic (NYHA class III or IV) patients with moderate to severe MS when BMV is contraindicated.
• Symptomatic (NYHA class I or II) with severe MS when PA pressure is > 60 mmHg if BMV is contraindicated.
• Other value requiring surgery.¹

Homoeopathic management of mitral stenosis.

Naja tripudians – chronic hypertrophy, valvular lesions, oppression in the chest, pulse irregular in force but  regular in rhythm, threatened paralysis of heart,s ympathetic cough in the acute stage of rheumatic carditis.

Cactus g.- constriction as of an iron band, endocarditis, mitral insufficiency, cardiac incompetence, enlarged ventricles, increased precordial dullness.

Apis m.- oedema, effusion, retention of water within the tissues, gen.anasarca, feels as if each breath will be the last,oliguria, insufficiency of mitral valve, organic heart disease.

Kalmia lat.-  cardiac troubles developed from rheumatism, or heart is involved as a sequel of rheumatism or gout. Sharp pain in the heart with extreme dyspnoea and anguish. Palpitation worst leaning forward, bradycardia- 35-40b/m.

Adonis ver.- mitral and aortic regurgitation, chronic aortitis.fatty heart pericarditis,rheumatic endocarditis.palpitation, dypnoea ,cardiac asthma, pulse rapid, irregular, irregular cardiac action.

Digitalis —The least movement causes violent palpitation, and sensation as if it would cease beating, if he moves (Opposite; Gels). Frequent stitches in heart. Irregular heart especially of mitral disease. Very slow pulse. Intermits; weak. Cyanosis. Inequality of pulse; it varies. Sudden sensation as if heart stood still. Pulse weak, and quickened by least movement. Pericarditis, copious serous exudation. Dilated heart, tired, irregular, with slow and feeble pulse. Hypertrophy with dilatation. Cardiac failure following fevers. Cardiac dropsy.

Strophanthus.-Pulse quickened. Heart’s action weak, rapid irregular, due to muscular debility; and insufficiency. Cardiac pain.

Ars. Iod– Irregular pulse; cardiac weakness; pain either with or without valvular disease, esp. when accompanied with induration of lung tissue.

Lithium carb – Rheumatic soreness in cardiac region. Sudden shock in heart. Throbbing, dull stitch in cardiac region. Pains in heart before menses, and associated with pains in bladder, and before urinating; better, after. Trembling and fluttering in heart, extending to back.

Aur. Met.- Sensation as if the heart stopped beating for two or three seconds, immediately followed by a tumultuous rebound, with sinking at the epigastrium. Palpitation. Pulse rapid, feeble, irregular. Hypertrophy. High Blood Pressure Valvular lesions of arterio-sclerotic nature .

Crata Oxycantha- Cardiac dropsy. Fatty degeneration. Aortic disease. Extreme dyspnśa on least exertion, without much increase of pulse. Pain in region of heart and under left clavicle. Heart muscles seem flabby, worn out. Cough. Heart dilated; first sound weak. Pulse accelerated, irregular, feeble, intermittent. Valvular murmurs, angina pectoris. Cutaneous chilliness, blueness of fingers and toes; all aggravated by exertion or excitement. Sustains heart in infectious diseases.

Rubrics related to mitral stenosis.
Chest – heart; complaints of the valve- mitral valve- Adon.³

Circulatory system- valvular disease-  Acon., Adon. v., Apoc., Ars., Ars. iod., Aur. br., Aur. iod., Aur. m., Cact., Calc. fl., Camph., Conv., Crat., Dig., Ferr., Galanth., Glon., Iod., Kal., Lach., Laur., Lith. c., Lycop., Naja, Ox. ac., Phos., Plumb., Rhus. t., Sang., Serum ang., Spig., Spong., Stigm., Stroph., Thyr., Viscum.⁴

MNEMONICS OF MITRAL STENOSIS

STENOSIS.

• S – S1 –
• T– tapping apex
• E – enlargement of left atrium.
• N– normally split S2.
• O– OPENING SNAP./ ORTNER’S SYNDROME.
• S – Systemic vascular resistance increases.
• I –indentation of oesophagus is seen in CXR.
• S– STAG ANTLER’S SIGN seen on X ray.

References

1. Munjal Y. API textbook of medicine. 9th ed. Mumbai: Association of Physicians of India; 2012.
2. Boericke William. Pocket Manual of Homoeopathic Materia & Repertory ,9 e, New Delhi,  BJain Publishers,2012
3. Clarke JH. The Prescriber. Available from: http://www.homeoint. org/books1/clarkeprescriber/n.htm
4. Schroyens F Synthesis(Repertorium Homoeopathicum Syntheticum) 9.1 ed. New Delhi. B Jain Publishers;2008

Dr Naziya Gous Moiddeen Naik.
P.G.Scholar, Dept.of Practice of Medicine.
U/G/O- Dr. Veeradhadrappa C.
Associate professor and PGguide.
Dept. of Practice of Medicine, Govt. Homoeopathic medica college and hospital .
Bangalore, Karnataka- 560079