Cardiology #15 (Mitral Valve Disorders)

Question 1

What is the pathophysiology of mitral stenosis?

Answer 1

Obstruction of flow from LA to LV secondary to narrowed mitral orifice –> blood back up into the LA

Question 2

What happens when the left atrial pressure becomes too much?

Answer 2

There is volume overload –> pulmonary HTN –> CHF

Question 3

MCC of mitral stenosis

Answer 3

Rheumatic heart disease

Question 4

Other causes of mitral stenosis

Answer 4

-Congenital
-Thrombus
-Valvulitis (SLE, amyloid, carcinoid)

Question 5

Symptoms of mitral stenosis

Answer 5

-Dyspnea (MC symptom)
-Hemoptysis, cough
-Pulmonary HTN
-Atrial fibrillation: secondary to atrial enlargement
-Mitral facies: flushed cheeks with facial pallor

Question 6

In addition, another symptom of Mitral Stenosis is Ortner’s Syndrome. What is this?

Answer 6

Recurrent laryngeal nerve palsy due to compression by the dilated left atrium –> hoarseness

Question 7

Describe the murmur of a patient with mitral stenosis

Answer 7

-Prominent S1 (forceful closure of the mitral valve)
-Opening snap (forceful opening of the valve)
-Loud P2
-Low-pitched, diastolic rumbling best heard at the apex

Question 8

What actions or positions increase the murmur intensity of mitral stenosis and mitral regurgitation?

Answer 8

-Left lateral decubitus position
Expiration
Increased venous return (squatting, leg raise, laying supine)

Question 9

What will be seen on ECG in a patient with mitral stenosis

Answer 9

Left atrial enlargement
Atrial fibrillation
Pulmonary HTN (RVH, right axis deviation)

Question 10

what is the most useful noninvasive diagnostic, and most commonly used diagnostic, for mitral stenosis?

Answer 10

Echocardiogram

Question 11

What’s the most accurate diagnostic for mitral stenosis?

Answer 11

Cardiac catheterization

Question 12

What is the best treatment for symptomatic mitral stenosis in younger patients?

Answer 12

Percutaneous balloon valvuloplasty

Question 13

If percutaneous balloon valvuloplasty is not an option for the patient with mitral stenosis, what is another treatment option that can be pursued?

Answer 13

Mitral valve replacement
Diuretics and sodium restriction for edema and volume overload
Anticoagulation for atrial fibrillation, BB, CCB, Digoxin as well

Question 14

What is the pathophysiology of Mitral Regurgitation

Answer 14

Abnormal, retrograde blood flow from the LV to LA, leading to left atrial dilation and increased pulmonary pressure

Question 15

What is the MC etiology of mitral regurgitation in the US?

Answer 15

Mitral valve prolapse

Question 16

However, the MCC of mitral regurgitation in developing countries is

Answer 16

Rheumatic fever

Question 17

Other causes of mitral regurgitation

Answer 17

-Endocarditis
-Valvulitis
-Annulus dilation (LV dilation)
-Marfan syndrome

Question 18

Symptoms of mitral regurgitation

Answer 18

-Dyspnea (MC)
-Heart failure symptoms (fatigue)
-Atrial fibrillation
-Hemoptysis
-HTN

-Acute: Hypotension, pulmonary edema

Question 19

Describe the murmur of mitral regurgitation

Answer 19

-Blowing holosystolic murmur best heard at the apex with radiation to the axilla

Question 20

What actions or positions increase the intensity of mitral regurgitation?

Answer 20

Left lateral decubitus position
Expiration
Handgrip
Squatting, leg raise, lying supine

Question 21

What actions DECREASE mitral regurgitation?

Answer 21

Valsalva, standing
Amyl nitrate
Inspiration

Question 22

How do you initially diagnose mitral regurgitation?

Answer 22

Echo

Question 23

Medical treatment for mitral regurgitation

Answer 23

Symptom control with after load reducers (ACEi, ARBs, Nitrates, or diuretics)

Question 24

If surgical intervention is preferred with mitral regurgitation, what options are available?

Answer 24

Repair preferred over replacement
–If EF < 60% or refractory to medical therapy

Question 25

What is the pathophysiology of Mitral Valve Prolapse?

Answer 25

The leaflets of the mitral valve bulge (prolapse) into the left atrium during systole

Question 26

MVP is the MCC of ______ in the US

Answer 26

Mitral regurgitation

Question 27

Mitral valve prolapse is MC in what population?

Answer 27

Young women (15-35 years of age)

Question 28

Name some common etiologies of MVP

Answer 28

-Myxomatous degeneration of the mitral valve
-Connective tissue diseases: Marfan syndrome, Osteogenesis imperfecta, Ehlers-Danlos syndrome

Question 29

Symptoms of MVP

Answer 29

-Most are asymptomatic
-atypical chest pain, panic attacks, palpitations, dizziness, fatigue (autonomic dysfunction)

Question 30

Describe what a patient with MVP may look like on physical examination

Answer 30

narrow AP diameter
low body weight
Hypotension
scoliosis
pectus excavatum

Question 31

How do you diagnose MVP

Answer 31

Echocardiogram

Question 32

Describe the murmur of MVP

Answer 32

-Mid-late systolic ejection click best heard at the apex

Question 33

Which maneuvers make the MVP murmur increase?

Answer 33

-Anything that makes the LV smaller (decreases preload): results in an earlier click. Valsalva, standing

Question 34

Which maneuvers make the MVP murmur decrease?

Answer 34

Anything that makes the LV bigger (increases preload). Delayed click and shorter murmur duration. Squatting, leg raise, supine. Handgrip.

Question 35

Treatment for MVP

Answer 35

Reassurance in most patients (good prognosis)
BB if autonomic dysfunction
Mitral valve repair or replacement if severe or to prevent CHF