B P8 C76 Mitral Regurgitation

Question 1

The prevalence of valvular heart disease increases with age, and population studies have shown _____ of either primary or secondary cause is the most prevalent valvular disorder, occurring in 9% to 10% of elderly patients in United States

Answer 1

MR

Question 2

The MV is a complex three-dimensional structure involving multiple, anatomically distinct components. Coordinated interaction of the _____ is crucial for MV functional integrity

Answer 2

Annulus
Commissures
Leaflets
Chordae tendineae
Papillary muscles
Left ventricle

Abnormalities of any of these structures may cause MR.

Question 3

The mitral annulus is not a single, well-defined ring of connective tissue but is instead a multifaceted structure made up of the convergence of several components:

Answer 3

• Atrial and ventricular muscular walls
• Hinge line of the mitral leaflets
• Epicardial adipose tissue
• Discontinuous semi-circle of fibrous tissue on its posterior aspect
• Band of connective tissue at its anterior aspect

Question 4

The annulus is often described as _____-shaped on three-dimensional studies with anterior and posterior peaks and nadirs near the medial and lateral fibrous trigones

Answer 4

Saddle-shaped

Question 5

The _____ leaflet is longer radially and thicker than the posterior leaflet, because it must withstand significantly higher tensile load.

The _____ leaflet is longer circumferentially and more flexible

Answer 5

Anterior

Posterior

Question 6

The ______ are responsible for determining the position and tension on the leaflets at LV end-systole

Answer 6

Chordae tendinae

The chordae are composed of collagen and elastin, are surrounded by a layer of endothelium, and originate from the heads of the papillary muscles or infrequently from the inferolateral ventricular wall.There are multiple chordal classification systems based on the origin (i.e., apical or basal portion of the papillary muscles), attachment site within the mitral complex (i.e., leaflet, interpapillary, myocardial wall), and insertion site on the mitral leaflets, to name a few

Question 7

The classification by leaflet insertion is the most often used with _____ chordae inserting on the free margin of the mitral leaflets and ______ inserting on the ventricular (rough zone) surface of the leaflets pre- venting billowing while reducing tension on the leaflet tissues

Answer 7

Marginal or primary

Secondary

Question 8

_____ chordae are thicker, secondary chordae and attach to the anterior MV leaflet with a broad, muscular base. These chordae have greater viscoelasticity than marginal chordae and may play a role in determining dynamic ventricular shape and function due to their contribution to ventricular-valve continuity

Answer 8

“Strut” chordae

Question 9

______ chordae insert on the posterior leaflet base and mitral annulus.

Answer 9

Tertiary or basal

Question 10

There are two papillary muscles; the _____ arises from the apicolateral third of the LV, and the _____ arises from the middle of the LV inferior wal

Answer 10

Anterolateral

Posteromedial

Question 11

The anterolateral papillary muscle is composed of an _____ head, and the posteromedial papillary muscle is usually composed of _____.

Answer 11

AL: Anterior and posterior heaed

PM:Anterior, intermediate, posterior

Question 12

The posteromedial papillary muscle gives chordae to the _____ half of both leaflets (i.e., posteromedial commissure, A3, P3, A2M, and P2M).

Similarly, the anterolateral papillary muscle chordae attach to the _____ half of the MV leaflets (i.e., anterolateral commissure, A1, P1,A2L,and P2L)

Answer 12

PM: Medial

AL: Lateral

Question 13

Carpentier classification of MR

Answer 13

Type I: Normal leaflet motion
Type II: Increased leaflet motion (leaflet prolapse)
Type III:
IIIA: Restricted leaflet motion (restricted opening)
IIIB: Restricted leaflet motion (restricted closure)

CARPENT - NEROc

Question 14

Type of MR: ICMP

Answer 14

Type I, II, IIIB

Question 15

Type of MR: RHD

Answer 15

Type II, IIIA

Question 16

Type of MR: DCMP

Answer 16

Type I and IIIB

Question 17

Type of MR: Endocarditis

Answer 17

Type I and II

Question 18

Type of MR: EDS

Answer 18

Type II

Question 19

Type of MR:

Carcinoid disease
Radiation
Lupus erythematosus Ergotamine use Hypereosinophilic syndrome Mucopolysaccharidosis

Answer 19

Type IIIA

Question 20

Type of MR: Degenerative disease

Answer 20

Type II

Question 21

Palpation of the arterial pulse is helpful in differentiating aortic stenosis (AS) from MR, both of which may produce a prominent systolic murmur at the base of the heart and apex.

The carotid arterial upstroke is ____ in severe MR and ____ in AS; the volume of the pulse may be normal or reduced in the presence of HF.

Answer 21

Carotid upstroke:

MR: Sharp
AS: Delayed

The cardiac impulse, like the arterial pulse, is brisk and hyperdynamic. It is displaced to the left, and a prominent LV filling wave is frequently palpable in thin patients.

Question 22

S1 , produced by MV closure, is often _____ in patients with primary MR and defective valve leaflets

Answer 22

Diminished

Question 23

_____ splitting of S2 is common and results from shortening of LV ejection and an earlier A2 as a consequence of reduced resistance to LV ejection

Answer 23

Wide

Question 24

The _____ is the most prominent physical finding; it must be differentiated from the systolic murmur of AS, tricuspid regurgitation, and ventricular septal defect.

In most patients with severe MR, the systolic murmur commences immediately after the soft S1 and continues beyond and may obscure A2 because of the persisting pressure difference between the LV and LA after aortic valve closure.

Answer 24

Systolic murmur

Question 25

The holosystolic murmur of chronic MR is usually constant in intensity, blowing, high-pitched, and loudest at the apex, with frequent radiation to the _____ area, particularly with posteriorly directed jets.

Radiation toward the _____, however, may occur with abnormalities of the posterior leaflet associated with an anteriorly directed regurgitant jet and is particularly common in patients with MVP and flail involving this leaflet

Answer 25

Posterior jet: left axilla and left infrascapular area

Anterior jet: sternum or aortic area

Question 26

The murmur shows _____ change, even in the presence of large beat-to-beat variations of LV stroke volume, as in AF.

Answer 26

Little change

This finding contrasts with that in most midsystolic (ejection) murmurs, such as in AS, which vary greatly in intensity with stroke volume and therefore with the duration of diastole.

Question 27

The murmur of MR may be holosystolic, late systolic, or early systolic.

When the murmur is confined to late systole, the regurgitation usually is secondary to _____ and may follow one or more mid-systolic clicks and typically is not severe.

Answer 27

MVP

Such late systolic MR is often associated with a normal S1 because initial closure of the MV cusps may be unimpaired.

Question 28

A midsystolic click preceding a mid- to late-systolic murmur, and the response of that murmur to a number of maneuvers helps establish the diagnosis of _____.

Answer 28

MVP

Question 29

Early systolic murmurs are typical of _____ MR.

Answer 29

Acute MR

Question 30

When MR is holosystolic, it typically varies little during respiration. However, sudden standing usually _____ the murmur, whereas squatting _____ it.

Answer 30

Standing: Diminished

Squatting: Augment

Question 31

The late systolic murmur of MVP behaves in the opposite direction, _____ in duration with squatting and _____ in duration with standing.

Answer 31

MVP:
Standing: Increased duration

Squatting: Decreased duration

Question 32

Similarly, with the Valsalva maneuver,
MVP clicks may occur earlier in systole with lengthening of the murmur.

Holosystolic MR murmur is often _____ during the strain of the Valsalva maneuver and shows a left-sided response (i.e., a transient overshoot that occurs six to eight beats after release of the strain)

Answer 32

Valsalva maneuver:

MVP clicks: Earlier, with lengthening of murmur

Holosystolic MR: softer during strain phase

Question 33

The murmur of MR usually is intensified by isometric exercise, differentiating it from the systolic murmurs of valvular AS and obstructive hypertrophic cardiomyopathy, both of which are reduced by this intervention.

Answer 33

Isometric exercise:

MR: Intensified

AS/HOCM: Reduced

Question 34

In primary MR, the jet may be late systolic with a direction typically _____ from the most significant anatomic lesion, so posterior prolapse or flail typically produces an anterior jet and vice versa.

With secondary MR, regurgitation is frequently bimodal, peaking in both early and late systole, ____ directionality depending on the presence of anterior leaflet override of a tethered posterior leaflet.

Answer 34

Primary: Away

Secondary: With or without directionality

Question 35

The _____ method is perhaps the most practical quantitative method for daily use. It exploits the predictable flow acceleration leading into the MV, which forms roughly hemispheric isovelocity shells that can be highlighted by shifting the aliasing velocity of the color display and identified where the color changes from blue to red

Answer 35

PISA

There are some important caveats to use of the PISA equation,the most critical of which involves nonholosystolic jets, such as those occurring with MVP in which the MR does not begin until the latter half of systole.In this case, the MR is much less severe than a single frame showing either the largest jet, vena contracta, or convergence zone would imply. Additional pitfalls include situations in which there are two or more regurgitant jets. Finally, the PISA method quantifies EROA with calculation of the Rvol. Regurgitant fraction requires a measure of total LV stroke volume and thus cannot be directly measured by this technique.

Question 36

Supportive evidence for MR severity can be found in pulmonary venous flow.

The normal pattern of systolic (S) wave greater than diastolic (D) wave generally indicates _____ MR, frank sytolic reversal indicates ____ MR, but the common “blunted” pattern (S < D) may be seen in all degrees of MR.

Answer 36

Mild MR: S > D

Severe MR: Frank systolic reversal (S < D)

Question 37

A transmitral E-wave >1.2 m/sec is supportive of _____ MR, whereas a pattern with E < A virtually excludes severe MR.

Answer 37

> 1.2. m/s: Severe MR

Question 38

Exercise echocardiography

This is a useful objective means to evaluate symptomatic patients who appear to have less than severe MR at rest; determine functional status and dynamic changes in hemodynamics in patients who otherwise appear stable and asymptomatic with severe MR

Late-systolic MR may become _____ holosystolic with exercise, particularly if PA pressure rises significantly.

Answer 38

More holosystolic

Question 39

Calcification of the mitral annulus, an important cause of MR in older adults, is most prominent in the _____ of the cardiac silhouette. The lesion is best visualized on chest films exposed in the lateral or right anterior oblique projections, in which it appears as a dense, coarse, C-shaped opacity.

Answer 39

Posterior third

Question 40

_____ is the most common cause of chronic primary MR in developed countries and is defined by an overriding of the annulus by a leaflet edge with displacement of the coaptation point into the atrium

Answer 40

MVP

Question 41

Leaflet _____ implies coaptation failure with eversion of the free edge of a leaflet into the LA, usually consequent to chordal rupture

Answer 41

Flail

Question 42

Because of the normal saddle shape of the annulus, diagnostic criteria for MVP were refined to include single-leaflet or bileaflet displacement >_____ mm beyond the long-axis annular plane, with >_____ mm leaflet thickening.

Answer 42

> 2 mm - Displacement

> 5 mm - leaflet thickening

Using this more specific criteria, the prevalence of echocardiographically diagnosed MVP is #2% to 3%

Question 43

In addition to severity of MR,outcomes are associated with LV size,with mortality risk increasing linearly with LV end-systolic dimension (ESD) >_____ mm (HR, 1.15; 95% CI 1.04 to 1.27 per 1-mm increment) or LVESD index ≥_____ mm/m2 (adjusted HR 1.12; 95% CI, 1.01 to 1.23 per 1-mm/m2 LVESD increment; p = 0.01).

Answer 43

LVESD: > 40 mm
LVESD index: ≥ 22 mm/m2

Although surgery was associated with reduced mortality (adjusted HR, 0.62; 95% CI, 0.45 to 0.86; p = 0.0035), LVESD ≥40 mm was an independent predictor of reduced postsurgical survival.

Question 44

A measure of longitudinal LV mechanics, global longitudinal strain (GLS) may be a more sensitive and accurate measurement of LV func- tion than LVEF. In a study of 593 patients with severe primary MR (Barlow disease, fibroelastic deficiency, or forme fruste) who underwent MV surgery, LV-GLS ≥____% (more impaired) showed significantly worse survival than did patients with LV-GLS <–20.6% (p < 0.001) and GLS LV-GLS had incremental prognostic value over clinical risk factors for long-term survival

Answer 44

≥ -20.6%

Question 45

_____ has received growing awareness as a marker for risk of ventricular arrhythmias and sudden death in patients with MVP.

This term describes abnormal spatial displacement of the point of insertion of the posterior MV leaflet, which results in a wide separation between the LA wall and MV junction and the LV attachment.

Answer 45

Mitral annular disjunction (MAD)

Question 46

The _____ in patients with severe chronic primary MR, regardless of LV function, is also associated with poor outcomes.

Answer 46

Onset of symptoms

Question 47

MIDA score parameters

Answer 47

Age ≥65 years (3 points)
Symptoms (3 points)
RV systolic pressure >50 mm Hg (2 points)
AF (1 point)
LA diameter ≥55 mm (1 point)
LV end-systolic diameter ≥40 mm (1 point)
LVEF </= 60% (1 point)

Question 48

Reduced preload and/or afterload may actually worsen _____ in MVP.

Answer 48

MR in MVP

Question 49

In the setting of reduced LVEF (<____%), however, standard guideline-directed medical therapy is indicated.

Answer 49

< 60%

Question 50

With acute, hemodynamically significant primary MR (i.e., flail), _____therapy can increase forward flow but is often limited by systemic hypotension. In these instances, _____ can be helpful to treat acute severe MR.

Answer 50

Vasodilator therapy

IABP

Question 51

Surgical intervention is warranted in patients with:

Answer 51

Severe primary MR
+
Symptoms
+
LV systolic dysfunction (LVEF <60% or LVESD >40 mm)

Question 52

Repair success increases with surgical volume and expertise, which should be considered when referring a patient for surgery. In addition, MV repair has _____ outcomes to biological or mechanical MV replacement.

Answer 52

Superior

Question 53

The two main etiologies of secondary MR are:

Answer 53

Annular dilation or atriogenic MR (Carpentier type I)

Leaflet tethering from a ventricular disease (Carpentier IIIA)

Question 54

Recent studies suggest the underlying mechanism
of atriogenic MR is related to _____.

Answer 54

Insufficient leaflet growth
LA dilation
Annular dilation with altered annular dynamics

Question 55

Secondary MR stemming from LV dilation and systolic dysfunction, often with concomitant mitral annular dilation, is a common consequence of _____.

Answer 55

Ischemic and nonischemic cardiomyopathies

Question 56

A number of mechanisms may contribute to malcoaptation of the MV leaflets in secondary MR:

Answer 56

(1) global and/ or regional LV dilation/dysfunction that decreases the closing forces of the leaflets

(2) displacement of the papillary muscles with tethering of the leaflets into the ventricular cavity, which outweighs the closing forces

(3) dilation and dysfunction of the annulus

(4) inadequate leaflet adaptation to ventricular or atrial enlargement

Question 57

ACC AHA class I indications for intervention of chronic primary MR

Answer 57

In symptomatic patients with severe primary MR (Stage D), mitral valve intervention is recommended irrespective of LV systolic function

In asymptomatic patients with severe primary MR and LV systolic dysfunction (LVEF ≤60%, LVESD ≥40 mm) (stage C2), mitral valve surgery is recommended.

In patients with severe primary MR for whom surgery is indicated, mitral valve repair is recommended in preference to mitral valve replacement when the anatomic cause of MR is degenerative disease, if a successful and durable repair is possible.

Question 58

The anatomic features associated with these mechanisms thus predict the severity of MR and recurrence after surgical repair:

Answer 58

(1) Mitral leaflet tethering and restricted closure
(2) Asymmetric displacement and abnormal contraction of the LV wall underlying the papillary muscles
(3) Decreased shortening of the distance between the papillary muscles
(4) Increased LV sphericity

Question 59

The revised 2020 ACC/AHA guidelines indicate that it is reasonable to perform _____ (Class IIa) in severely symptomatic patients with primary MR who are considered at high or prohibitive surgical risk, if MV anatomy is favorable for the repair procedure and patient life expectancy is at least 1 year

Answer 59

Transcatheter MV edge-to-edge repair

Studies of the MV clip have demonstrated improved symptoms and a reduction in MR by 2 to 3 grades leading to reverse remodeling of the LV.

Question 60

The ideal anatomy for edge-to-edge repair for nonrheumatic primary MR come from the EVEREST trial and include

Answer 60

Involvement limited to the A2/P2 scallop
Absence of calcium in the grasping zone
Baseline MV area ≥4 cm2
Fail width <15 mm
Flail gap <10 mm

Question 61

PE findings of secondary MR

Answer 61

• Apical S3 - common finding.
• Systolic murmur of secondary MR related to LV dilation may be soft and barely audible, particularly in those patients with nonholosystolic MR that becomes minimal in midsystole. (can be misleading regarding the presence and severity of secondary MR).
• The murmur of papillary muscle dysfunction may occur in late systole and is highly variable, often accentuated or holosystolic during acute myocardial ischemia and absent when ischemia is relieved.

Question 62

Spline-curve analyses showed a linearly increasing risk enabling the ability to stratify patients into:

In the intermediate-risk group, a regurgitant fraction ≥50% was an indicator of hemodynamic severe secondary MR associated with poor outcome (p = 0.017)

Answer 62

Low-risk
EROA <20 mm2
Rvol <30 mL

Intermediate-risk
EROA 20 to 29 mm2
Rvol 30 to 44 mL

High-risk
EROA ≥30 mm2
Rvol ≥45 mL

Question 63

Patients with a more impaired _____ experienced higher mortality rates than those with a more preserved LV GLS (</= –7.0%).

Answer 63

More impaired LV GLS (> –7.0%)

Question 64

Patients with secondary MR stemming from LV dilation and dysfunction should undergo aggressive evidence-based medical management for _____.

Answer 64

LV systolic dysfunction

Question 65

Medical therapies have been shown to reduce MR in up to _____ % of patients and are associated with improved outcomes.

Answer 65

40%

GDMT including inhibitors of the renin-angiotensin-aldosterone system (RAAS) and beta-adrenergic blockers can significantly reduce secondary MR in 30-40% of patients with HF.

Other:
ARNI
CRT

Question 66

_____ is recommended at the time of coronary artery bypass surgery (CABG) in patients with LV dysfunction and severe ischemic MR.

Answer 66

MV surgery

Question 67

MV repair of secondary MR is often not durable because of _____ of the underlying LV myocardial disease.

Answer 67

Progression

Question 68

The _____, which randomized patients with LV dysfunction and secondary MR to GDMT alone versus GDMT plus transcatheter edge-to-edge repair showed a significant reduction in the primary endpoint, rehospitalization for HF, and secondary end- points of reduction in mortality, and combined endpoints of mortality and rehospitalization for HF.

Answer 68

Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Func- tional Mitral Regurgitation (COAPT) trial

This seminal trial led the U.S. Food and Drug Administration to approve the edge-to-edge repair device for severe secondary MR as well as a Class IIa recommendation in the revised guidelines

Randomization for COAPT occurred only after aggressive GDMT was achieved, including CRT as indicated, and stable for 3 months, and the primary efficacy outcome was rehospitalization for heart failure within 24 months; a relatively low percent of patients received ARB or ARNI therapy.

All-cause mortality rates at 1 year were similar for both treatment groups between the two trials. However, by 2 years the mortality rate for the GDMT arm in COAPT was worse (46% in COAPT versus 34% in MITRA-FR).

Question 69

The _____ trial, which also randomized patients with LV dysfunction and secondary MR to GDMT alone versus GDMT plus transcatheter edge-to-edge repair, reported no significant benefit to edge-to-edge repair in the primary combined endpoint of survival or rehospitalization for HF

Answer 69

Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation (MITRA-FR)

Randomization for the MITRA-FR trial, however, occurred after identification of appro- priate LVEF and MR criteria, and GDMT could continue to be fine-tuned during the course of the trial for both randomized cohorts; and a higher percentage of patients in both arms were treated with RAAS blockers

Question 70

ACC AHA Recommendations for Intervention for Chronic Secondary Mitral Regurgitation

Answer 70

Class IIA

In patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) who have persistent symptoms (NYHA class II, III, or IV) while on optimal GDMT for HF (Stage D), TEER is reasonable in patients with appropriate anatomy as defined on TEE and with LVEF between 20% and 50%, LVESD ≤70 mm, and pulmonary artery systolic pressure ≤70 mm Hg

In patients with severe secondary MR (Stages C and D), mitral valve surgery is reasonable when CABG is undertaken for the treatment of myocardial ischemia

Question 71

ESC Recommendations on indications for intervention in severe primary mitral regurgitation

Answer 71

Mitral valve repair is the recommended surgical technique when the results are expected to be durable.

Surgery is recommended in symptomatic patients who are operable and not high risk.

Surgery is recommended in asymptomatic patients with LV dysfunction (LVESD >_40 mm and/or LVEF <_60%).

Class IIA
**Surgery should be considered in asymptomatic patients with preserved LV function (LVESD <40 mm and LVEF >60%) and AF secondary to mitral regurgitation or pulmonary hypertensionc (SPAP at rest >50 mmHg).

Class IIB - TEER

Question 72

Causes of acute MR

Answer 72

Spontaneous rupture of chordae tendineae
Infective endocarditis with disruption of valve leaflets or chordal rupture
Ischemic dysfunction or rupture of a papillary muscle
Malfunction of a prosthetic valve

Question 73

Hemodynamic consequences of Acute severe MR

Answer 73

Marked reduction in forward stroke volume
Slight reduction in ESV
Increase in EDV

Question 74

One major hemodynamic difference between acute and chronic MR derives from the differences in ____

Answer 74

LA compliance

Patients who develop acute severe MR usually have a normal-size LA, with normal or reduced LA compliance.

The LA pressure rises abruptly, which often leads to pulmonary edema, marked elevation of pulmonary vascular resistance, and right-sided heart failure.

Question 75

Because the ______ is markedly elevated in patients with acute severe MR, the reverse pressure gradient between the LV and LA declines at the end of systole, and the murmur may be ______ rather than holosystolic, ending well before A2.

Answer 75

v wave

Decrescendo

Question 76

It usually is _____ and ____ than the murmur of chronic MR.

Answer 76

Lower pitched

Softer

Question 77

A left-sided S4 frequently is found.

______ which is common in patients with acute MR, may increase the intensity of P2 , and the murmurs of pulmonary regurgitation and tricuspid regurgitation also may develop, along with a right-sided S4.

In patients with severe, acute MR, a v wave (late systolic pressure rise) in the pulmonary artery pressure pulse may rarely cause premature closure of the pulmonary valve, an early P2 , and ____

Answer 77

Pulmonary hypertension

Paradoxical splitting of S2.

Question 78

Characteristic features on Doppler echocardiography are the severe jet of MR and elevation of the _____.

Similar to the physical examination, the high atrial v wave can lead to early cessation of MR and a triangular CW Doppler profile

Answer 78

Pulmonary artery systolic pressure

Question 79

______ is particularly important in treating patients with acute MR.

Answer 79

Afterload reduction

Intravenous nitroprusside may be lifesaving in patients with acute MR caused by rupture of the head of a papillary muscle complicating an acute myocardial infarction

Question 80

In patients with acute MR who are hypotensive, an inotropic agent such as _____ should be administered with the nitroprusside.

_____ may be necessary to stabilize the patient while preparations for surgery are made.

Answer 80

Dobutamine

Intra-aortic balloon counterpulsation

Question 81

In patients with papillary muscle dysfunction, initial treatment should consist of hemodynamic stabilization, usually with the aid of an intra-aortic balloon pump, and surgery should be considered for those patients who do not experience improvement with aggressive medical therapy.

If patients with MR can be stabilized by medical treatment, it is preferable to defer operation until _______ after the infarction if possible.

Answer 81

4 to 6 weeks

Emergency surgical treatment may be required for patients with acute LV failure caused by acute severe MR.

Acute papillary muscle rupture requires emergency surgery with MV repair or replacement.