Cardiology Lecture 4 -- Mitral Valve Lesions

Question 1

What is the ultimate diastolic dysfunction?

Answer 1

Fixed obstruction to filling of LV (mitral stenosis)

Question 2

Most common cause of mitral stenosis

Answer 2

Rheumatic heart disease leading to hockey stick pattern of mitral valve leaflets

Question 3

When do symptoms of mitral stenosis typically manifest?

Answer 3

In 30’s or 40’s

Question 4

Heart changes due to mitral stenosis

Answer 4

LA dilates = increase in left atrial P to overcome obstruction to LV filling (slow filling)

Question 5

Mitral stenosis: Effect on P graph

Answer 5

Shallow y descent (atrial P) since atrial emptying is prolonged P gradient throughout diastole with increased gradient at atrial kick

Question 6

2 symptoms associated with mitral stenosis

Answer 6

Acute pulmonary edema

Sudden dyspnea (often associated with pulmonary edema)

Question 7

Explain why acute pulmonary edema occurs in mitral stenosis

Answer 7

Sudden tachycardia = no time to fill LV = increased LAP

+

Sudden tachycardia –> atrial fib –> no atrial kick due to fib –> increase LAP

= sudden P backup –> acute pulmonary edema

Question 8

Describe the behavior of the murmur in mitral stenosis

Answer 8

Pandiastolic rumble

Mild stenosis = initial gradient to filling with an increase gradient at kick

Severe stenosis = duration of rumble increases with accentuation at kick

Question 9

Describe the behavior of S1 in mitral stenosis

Answer 9

Opening snap = increase intensity of S1 since dp/dt is increased

Question 10

Where do you listen for mitral stenosis

Answer 10

Bring apex forward, best if patient lies in left lateral decubitus position (best heard with bell)

Question 11

Management of mitral stenosis

Answer 11

• Diuretics to decrease LAP
• Beta blockers to keep HR low to decrease LAP
• Surgery is not required (valvuloplasty an option)

Question 12

Define valvuloplasty

Answer 12

Catheter inserted to balloon open the valve (split commissures)

Question 13

What is the benefit of valvuloplasty for mitral stenosis

Answer 13

Long term (11 - 12 years)

Question 14

2 types of mitral regurgitation

Answer 14

Acute

Chronic

Question 15

Common cause of chronic mitral regurgitation

Answer 15

Mitral valve prolapse (into the left atrium)

Question 16

What kind of overload is chronic mitral regurgitation associated with?

Answer 16

VOlume overload condition

Question 17

Heart sound associated with chronic mitral regurgitation

Answer 17

S3

Question 18

Why isn’t mitral regurgitation a pressure overload condition?

Answer 18

When LV contracts, the blood can go either forward through the aortic valve or backwards through the mitral valve (which is easier since LAP is already so low), so afterload is not increased since preload is either normal or decreased

Question 19

Decscribe the isovolumetric phases in chronic mitral regurgitation

Answer 19

Non-existent

Question 20

Describe the murmur associated with chronic mitral regurgitation

Answer 20

Pansystolic murmur due to gradient between LV and LA

Question 21

Where do you listen for mitral regurgitation?

Answer 21

Heard best at apex (displaced)

Question 22

Describe the behavior of the murmur of chronic mitral regurgitation post PVC (early contraction). Why is this significant?

Answer 22

Compensatory increase in intensity DOES NOT occur in the next beat, so you can differentiate from aortic stenosis in this way

Question 23

Most common symptom associated with chronic mitral stenosis

Answer 23

dyspnea

Question 24

What is a sign that the chronic mitral regurgitation is severe?

Answer 24

Diastolic rumble due to increased flow through the mitral valve (flow murmur)

Question 25

Treatment for chronic mitral regurgitation

Answer 25

Reparative surgery (instead of replacement)

Question 26

What would one expect the EF to be in chronic mitral regurgitation?

Answer 26

Brisk (very high)

Question 27

When should a patient with chronic mitral regurgitation get surgery?

Answer 27

Symptomatic

OR

Asymptomatic with decreased or normal EF

Question 28

2 potential causes for acute mitral regurgitation

Answer 28

Blow out one of papillary muscles, i.e. by inferior MI = flailing cusp

Endocarditis

Question 29

Pressure behaviors during acute mitral regurgitation

Answer 29

No time to accomodate increased volumes in LA so LAP increases precipitously

Question 30

P graph behavior during acute mitral regurgitation

Answer 30

Huge v wave since atrial filling is increased

Question 31

What is a very concerning symptom in acute mitral regurgitation

Answer 31

Acute pulmonary edema

Question 32

Describe the murmur in acute mtiral regurgitation

Answer 32

Early to mid short systolic