15) Mitral valve diseases (acquired) Flashcards
what is the cause of mitral valve stenosis ?
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
what are the complication tot mitral valve stenosis ?
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
what are the clinical symptoms of mitral valve stenosis ?
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
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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
what are the physical examination signs of mitral valve stenosis?
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
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lung palpations
mild = 3-2cm2
moderate =1- 2cm2
dull chest sound - pulmonary edema
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severe = less than 1cm2
hepatomegaly on palpation - significant tricuspid regurgitation we will also see a pulsating liver
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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
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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.
from auscultation why is that
Shorter interval between S2 and opening snap higher the severity in mitral valve stenosis ?
because left atrial pressure is greater than left ventricular end-diastolic pressure (LVEDP
how do you diagnose mitral valve stenosis ?
golden standard as always echocardiography
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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
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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
Main TTE criteria for MSt?
М-mode Echo:
- Thickening >2 mm and >2 echolines of the mitral leaflets
- Closure velocity of the anterior mitral leaflet < 50 mm/s
- 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)
- Vmax > 1.5 m/s
- Peak Gradient > 7 mmHg
- PHT>60ms
Decreased mitral valve area (MVA): ≤ 1.5 cm2 is considered to be severe MS.
what are the normal mitral valve parameters ?
mitral valve area more than or equal to 4.0-6 cm2
mean mitral valve gradient 1-4mmhg
what is the management of mitral stenosis
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
what is the definition of mitral valve stenosis ?
mitral valve area less than 3cm2
when do the lesions form in the mitral valve after having rheumatic fever ?
2 years after the rheumatic fever
what are the types of mitral valve stenosis ?
commissural
leaflet affecting
chordal
mixed
what is the etiological classification of mitral valve regurgitation
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
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chronic and acute
what is the classification of the clinical presentation of mitral regurgitation ?
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
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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
what are the physical findings of mitral valve regurgitation ?
palpation
apical beat shifted laterally
Expanded, lifting, and bouncing apical heart beat
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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
describe the hemodynamics in mitral regurgitations ?
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
through appearance can we distinguish them into acute , subacute or chronic mitral insufficiency ?
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
how do we confirm diagnosis of mitral valve insufficiency ?
TTE
TEE - fr prior to surgery
chronic
hypertrophy of left atrium - p mitral
left ventricular hypertrophy criteria
atrial fib
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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
in echocardiography for mitral valve regurgitation what are the difference and similatries in acute and chronic
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
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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
what is the AHA staging of MR
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
what are the functional classification of mitral regurgitation of carpentier using echo?
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
Intra-aortic balloon pump is contraindicated when ?
Contraindicated in acute aortic regurgitation
mitral regurgitation therapy management ?
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
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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
what are the complication of mitral valve insufficiency
Heart failure, pulmonary edema
Atrial fibrillation and arterial emboli
Endocarditis
what are the additional medication should give in mitral valve stenosis and regurgitation
blood thinners - aspirin
