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cardiology > 15) Mitral valve diseases (acquired) > Flashcards

15) Mitral valve diseases (acquired) Flashcards

1
Q

what is the cause of mitral valve stenosis ?

A

rheumatic fever -mitral valve is the most affected - leading to fibrosis then calcification
affects the leaflets

autoimmune diseases - SLE , RA
causing mitral ANNULAR Calcifications

congenital

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2
Q

what are the complication tot mitral valve stenosis ?

A

pulmonary thromboembolism

Peripheral arterial emboli – due to thrombi formation in mostly in the left atrium auriculus and by the common atrial fibrillation

atrial fib

heart failure

elevated end diastolic volume in LA -eccentric hypertrophy of the left atrium

pulmonary hypertension - DILATED PULMONARY ARTERY -pulmonary edema -

cor pulmonate - hepatomegaly , distended jugular veins and peripheral edema

secondary tricuspid regurgitation

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3
Q

what are the clinical symptoms of mitral valve stenosis ?

A

depending on the stages

mild = 3-2cm2

moderate =1- 2cm2
progressive dyspnea on exertion
paroxysmal night dyspnea

severe = less than 1cm2
progressive dyspnea on exertion
paroxysmal night dyspnea
Neck veins distension (filled upt to >7 сm vertically from the sternal edge

peripheral edema

============

hemoptysis
sudden hemoptysis- rupture of a dilated bronchial vein
or pinky foamy sputum - acute developing pulmonary edema with pulmonary capillary rupture

mitral face
periorall cyanosis
telengeictasia of the cheeks
conjunctival hyperemy

hoarseness

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4
Q

what are the physical examination signs of mitral valve stenosis?

A

depending on stages - PALPATIONS

mild = 3-2cm2

moderate =1- 2cm2
Palpating pulsations from а.Pulmonalis

Pulsations from the enlarged RV in the epigastria and in the left IV intercostal space parasternally

severe = less than 1cm2
apical diastolic thrill

================
lung palpations

mild = 3-2cm2

moderate =1- 2cm2
dull chest sound - pulmonary edema

==============
severe = less than 1cm2
hepatomegaly on palpation - significant tricuspid regurgitation we will also see a pulsating liver

================

diastolic murmur typically heard best in the 5th left intercostal space at the mid clavicular line of apex - WITH THE BELL OF THE STETHOSCOPE- loudest heard when the patient is lateral decubitus position

becomes louder after valsalva - increase preload
and exercise and squatting or handgrip - increase after load

mild = 3-2cm2
first accentuated S1

early diastolic opening snap AFTER S2 - caused when leaflet motion suddenly stops during diastole after the stenosed valve has reached its maximum opening

Diastolic murmur - Mesodiastolic

moderate =1- 2cm2
increase in S1

Diastolic murmur -
pandiastolic (entire diastolic period)

early diastolic opening snap AFTER S2 - caused when leaflet motion suddenly stops during diastole after the stenosed valve has reached its maximum opening

P2

severe = less than 1cm2
S1 can increase or decrease
Pandiastolic, sometimes missing

increase in p2- pulmonary hypertension

Shorter interval between S2 and opening snap

====================

Graham Steell murmur = in chronic cases
It is a high pitched early diastolic murmur heard best at the left sternal edge in the second intercostal space with the patient in full inspiration,
due to a high velocity flow back across the pulmonary valve; this is usually a consequence of pulmonary hypertension secondary to mitral valve stenosis.

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5
Q

from auscultation why is that

Shorter interval between S2 and opening snap higher the severity in mitral valve stenosis ?

A

because left atrial pressure is greater than left ventricular end-diastolic pressure (LVEDP

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6
Q

how do you diagnose mitral valve stenosis ?

A

golden standard as always echocardiography

==========

ECG
P MITRALE - sign of left atrial enlargement

p - mitrale
lead 2 - we see notched p wave - 40ms between each peak
and the whole p wave duration is more than 120ms

in v1 terminal portion of biphasic P wave = 1mm deep and 40ms wide

atrial fib

sokolow lyon index for right ventricular hypertrophy

Incomplete/complete RBBB

========

x ray
LA enlargement with prominent left auricle (left atrial appendage) → straightening of the left cardiac border

Lateral image
Dorsal displacement of the esophagus

Signs of pulmonary congestion

Kerley А and В lines

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7
Q

Main TTE criteria for MSt?

A

М-mode Echo:

  1. Thickening >2 mm and >2 echolines of the mitral leaflets
  2. Closure velocity of the anterior mitral leaflet < 50 mm/s
  3. Concordant movement of both leaflets anteriorly
 В-mode Echo: (parasternal position)
1. Thickening, increased echo intensity and deformation of the
leaflets
2. Doming of the anterior mitral leaflet
3. MVO planimetrically < 3.0 сm2

 Doppler Echo: (parasternal position)

  1. Vmax > 1.5 m/s
  2. Peak Gradient > 7 mmHg
  3. PHT>60ms

Decreased mitral valve area (MVA): ≤ 1.5 cm2 is considered to be severe MS.

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8
Q

what are the normal mitral valve parameters ?

A

mitral valve area more than or equal to 4.0-6 cm2

mean mitral valve gradient 1-4mmhg

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9
Q

what is the management of mitral stenosis

A

prophylaxis of β-hemolytic streptococcal infections- amoxicillin

Treatment of heart failure: only diuretics may be administered!

Beta blockers or calcium channel blockers: ↓ heart rate and ↓ cardiac output

Indication: severe
(MVA ≤ 1.5 cm2) and/or

symptomatic mitral stenosis

First-line: percutaneous balloon commissurotomy if the following criteria are fulfilled:
Favorable valve morphology e.g., no valvulvar calcifications
No left atrial thrombus
No or mild mitral regurgitation

open commissurotomy and surgical valve replacement

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10
Q

what is the definition of mitral valve stenosis ?

A

mitral valve area less than 3cm2

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11
Q

when do the lesions form in the mitral valve after having rheumatic fever ?

A

2 years after the rheumatic fever

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12
Q

what are the types of mitral valve stenosis ?

A

commissural

leaflet affecting

chordal

mixed

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13
Q

what is the etiological classification of mitral valve regurgitation

A

Ischemic MR - papillary muscle rupture following acute MI

Primary : caused by direct involvement of the valve leaflets or chordae tendinae

Degenerative mitral valve disease - mitral valve prolapse (Elongated chord), mitral annular calcification, ruptured chordae tendinae

Rheumatic fever

Infective endocarditis ( Chords rupture)

Secondary MR (functional): 
caused by changes of the left ventricle that lead to valvular incompetence

Coronary artery disease or prior myocardial infarction causing papillary muscle involvement

Dilated cardiomyopathy (e.g., peripartum cardiomyopathy) and left-sided heart failure

===========
chronic and acute

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14
Q

what is the classification of the clinical presentation of mitral regurgitation ?

A

acute - acute dysfunction leading to volume overload - symptoms of acute heart failure

↑ LV end-diastolic volume → rapid ↑ LA and pulmonary pressure → pulmonary venous congestion → pulmonary edema

> Dyspnea
pulmonary edema Cardiogenic shock: poor peripheral perfusion, tachycardia, tachypnea, and hypotension
Palpitations - new onset AFIB common

============

chronic

dyspnea

paroxysmal nocturnal dyspnea

dry cough

palpitation - Atrial fibrillation is common in chronic MR and thought to be due to the enlargement and remodelling of the left atrium

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15
Q

what are the physical findings of mitral valve regurgitation ?

A

palpation
apical beat shifted laterally
Expanded, lifting, and bouncing apical heart beat

==========

acute
auscultation
soft decrescendo murmur

chronic
lateral displacement of the apical impulse

quiet s1 heart sound - because the mitral valve do not close properly

S3 heart sound

Systolic murmur immediately after S1 HOLOSYSTOLIC DECRESCENDO OR BAND SHAPE (can be heard through systole just after S1 exception in mitral valve prolapse )
radiating to LEFT AXILLA - best heard over the 5th intercostal space and left midclavicular line
decrescendo or band shaped

intensity increased by increasing preload such as

S3 - as result f large blood volume in early diastole

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16
Q

describe the hemodynamics in mitral regurgitations ?

A

mitral regurgitation - retrograde blood flow to atrium - atrial dilation

  • retrograde pulse elevation in pulmonary veins
  • pulmonary vein hypertension

cor pulmonale

constant circulation of dead volume between lv and la = leading to eccentric lv and la dilation

17
Q

through appearance can we distinguish them into acute , subacute or chronic mitral insufficiency ?

A

acute - urgent surgery
chad rupture , rupture of papillary muscle ,rupture of leaflet in endocarditis

subacute -same causes - relatively better prognosis

chronic - good prognosis
all other causes

18
Q

how do we confirm diagnosis of mitral valve insufficiency ?

A

TTE

TEE - fr prior to surgery

chronic
hypertrophy of left atrium - p mitral
left ventricular hypertrophy criteria
atrial fib

===========
chest x ray

LV enlargement: laterally displaced left cardiac border

LA enlargement: straightening of the left cardiac border and double density sign
Annular calcification may be visible as a C-shaped density

19
Q

in echocardiography for mitral valve regurgitation what are the difference and similatries in acute and chronic

A

acute
abnormal valve movement

aortic valve opening decrease

pulmonary vein flow reversed

left atrium normal

left ventricle size normal

LVEJ normal

pulmonary artery pressure elevated

right ventriclee ejection fraction normal

========

chronic

valve movement abnormals- especially in early diastole
quick leaflet closure after the early filling phase

aortic valve opening decrease

pulmonary vein flow normal

left atrium dilated

Left ventricle size elevated or

LVEF - compensated: normal or increase
decompensated - decrease

pulmonary artery pressure -
compensated - normal
decompensated - elevated

right ventricle ejection fraction
compensated - normal
decompensated - reduced

20
Q

what is the AHA staging of MR

A

stage a
minimal risk

B
moderate regurgitation

C1
asymptomatic severe MR
LVEF >60 percent

C2
asymptomatic severe
LVEF equal to <60

d
severe symptomatic mr

21
Q

what are the functional classification of mitral regurgitation of carpentier using echo?

A

normal movement of leaflets but dilated valve annulus

supernormal movement’s of the leaflets
prolapse and rupture of the chordates tendon

restricted movement in systole and diastole
fusion leaflets?

THIS CLASSIFICATION IS USED FOR PLANNING OF SURGICAL REPAIR

22
Q

Intra-aortic balloon pump is contraindicated when ?

A

Contraindicated in acute aortic regurgitation

23
Q

mitral regurgitation therapy management ?

A

mitral valve REGURGITATION

acute primary MR
acute secondary MR which does not respond well to treatemnet
= undergo mitral valve repair preferred / mitral valve replacement

revascularisation therapy - in secondary causes by ischemia

tull then - acute decompensated - loop diuretics and spironolactone with caution
severely decompensated - decrease after load - nitroprusside

consider intraortic ballon pump symptoms continue to deteriorate despite medical therapy - reduced the preload , afteload , improves cardiac output , coronary blood flow - esp to those wh have ischemia causes
contraindicated in AORTIC VALVE INSUFFIENCY

=====

chronic

for heart failure
loop diuretics with spironolactone
ace
beta blockers

decrease the after load - nitroprusside
decrease the preload - nitroglycerine

surgery if lvef is low

transcather mitral valve clips - hemodynmaically unstable and severely symptomatic

however once LVEF is below 30 percent surgery is not recommended

LVAD and cardiac transplant for those with severe lv remodelling and heart failure through it

24
Q

what are the complication of mitral valve insufficiency

A

Heart failure, pulmonary edema
Atrial fibrillation and arterial emboli
Endocarditis

25
Q

what are the additional medication should give in mitral valve stenosis and regurgitation

A

blood thinners - aspirin

cardiology (32 decks)

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