Chapter 286 - Multiple and Mixed Valvular Heart Disease Flashcards
Which valves might be involved in rheumatic disease?
Any valve might be involved in rheumatic disease.
In order of frequency, it might involve the mitral valve, aortic valve, tricuspid valve or rarely the pulmonic valve.
“For example, rheumatic heart disease can involve the mitral (mitral stenosei [MS], mitral regurgitation [MR], or MS and MR), aortic (aortic stenosis [AS], aortic regurgitation [AR], or AS and AR), and/or tricuspid (tricuspid stenosis [TS], tricuspid regurgitation [TR], or TS and TR) valve, alone or in combination.”
How does one explain the fact that severe mitral calcification can result in either stenosis, regurgitation or both?
“Severe mitral annular calcification can result in regurgitation (due to decreased annular shortening during systole) and mild stenosis (caused by extension of the calcification onto the leaflets resulting in restricted valve opening).”
In infetive endocarditis involving the aortic valve should one expect a possible mitral valve involvement?
Yes.
“Aortic valve infective endocarditis may secondarily involve the mitral apparatus either by abcess formation and contiguous spread via the intervalvular fibrosa or by “drop metastases” from the aortic leaflets onto the anterior leaflet of the mitral valve.”
Chordal rupture has been described infrequently in patients with severe aortic stenosis.
True or False?
True.
Which valves are usually involved in carcinoid heart disease?
Right-sided valves (tricuspid and pulmonic).
(there are two exceptions, which include carcinoid syndrome with a lung neoplasia, and the existent of a previous left-to-right shunting).
Name the drugs that have been rarely associated with mixed valve disease involving the aortic and/or mitral valves.
Ergotamines, and the previously used combination of fenfluramine and phentermine.
A patient with myxomatous degeneration that causes prolapse of multiple valves (mitral, aortic, tricuspid) might not have an identifiable connective tissue disorder.
True or False?
True.
Bicuspid aortic or pulmonic valve disease doesn’t lead to mixed stenosis and regurgitation.
True or False?
False.
How does one explain that a more proximally located valve disease might mask a more distal one? Give examples of such a phenomenon.
“In patients with multivalvular heart disease, the pathophysiologic derangements associated with the more proximal valve disease can mask the full expression of the attributes of the more distal valve lesion. For examples, in patients with rheumatic mitral and aortic valve disease, the reduction in cardiac output (CO) imposed by the mitral valve disease will decrease the magnitude of the hemodynamic derrangements related to the severity of the aortic valve lesion (stenotic, regurgitant, or both). Alternatively, the development of atrial fibrilation (AF) during the course of MS can lead to sudden worsening in a patient whose aortic valve disease was not previously felt to be significant. The development of reactive pulmonary vascular disease, sometimes referred to as a “secondary obstructive lesion in series,”, can impose an additional challenge in these settings. As CO falls with progressive tricuspid valve disease, the severity of any associated mitral or aortic disease can be underestimated.”
Which valvulopathy is frequently associated with mitral stenosis, due to its natural history course?
“One of the most common examples of multivalve disease is that of functional tricuspid regurgitation (TR) in the setting of significant mitral valve disease. Functional TR occurs as a consequence of right ventricular and annular dilation; pulmonary artery hypertension is often present.”
One of the features of tricuspid regurgitation is a large c-v systolic wave. Does the height of this wave have any correlation with other variables? If so, which ones?
“The hight of the c-v wave is dependent on right atrium compliance and the volume of regurgitant flow.”
What are the two most common valvulopathies in rheumatic fever?
Mitral stenosis with aortic regurgitation.
Explain the hemodynamic pathophysiology of rheumatic mitral valve disease associated with aortic valve disease.
“In isolated mitral stenosis (MS), left ventricular (LV) preload and diastolic pressure are reduced as a function of the severity of inflow obstruction. With concomitant aortic regurgitation, however, LF filling is enchanced and diastolic pressure may rise depending on the compliance characteristics of the chamber. Because the cardiac output falls with progressive degrees of MS, transaortic valve flows will decline, masking the potential severity of the aortic valve lesion (AR, AS, or its combination).”
Atrial fibrilation might be especially deleterious in patients with either mitral stenosis and tricuspid regurgitation or mitral stenosis and aortic regurgitation,
True or False?
True.
How does one explain mitral regurgitation (MR) in a patient with severe aortic stenosis (AS)? How should it be treated?
“Functional MR may complicate the course of some patients with severe AS. The mitral valve leaflets and chordae tendinae are usually normal. Incompetence is realted to changes in LV geometry (remodeling) and abnormal systolic tethering of the leaflets in the context of markedly elevated LV systolic pressures. Relief of the excess afterload with surgical or transcatheter aortic valve replacement often, but not always, results in reduction or elimination of the MR. Persistence of significant MR following AVR is associated with impaired functional outcomes and reduced survival. Identification of patients who would benefit from concomitant treatment of their functional MR at time of AVR is quite challenging. Most surgeons advocate for repair of moderate-to-severe or servere functional MR at time of surgical AVR.”
If a patient suffers from aortic regurgitation and aortic stenosis, it is expected to find an increased murmur and transaortic flow velocity, which might lead to lower orifice estimations in comparison to planimetry.
True or False?
True: the sentence is only true if the patient has a preserved left ventricle systolic function.
False: if the left ventricle systolic function is decreased, the estimation might be compensated or even decreased to the aortic orifice measurement in planimetry.
The Gorlin formula is an accurate way to measure the orifice area in mixed valvular disease.
True or False?
False.
This formula relies on the forward cardiac output (which might be affected by mixed valvular disease).
How would you expect to find the left ventricular chamber size in aortic regurgitation (AR) or mitral regurgitation (MR)? And in aortic stenosis (AR) or mitral stenosis (MS)?
“When either AR or MR is the dominant lesion in patients with mixed aortic or mitral valve disease, respectively, the LV is dilated. When AS or MS predominates, LV chamber size will be normal or small.”
Paravalvular regurgitation is a significant risk factor for short- to intermediate-term death following transcatheter aortic valve replacement.
True or False?
True.
How does one explain the fact that a patient with aortic stenosis might not tolerate as well an acute aortic regurgitation in comparison to a patient without previous valve disease?
“Patients with significant AS, a nondilated LV chamber, and concetric hypertrophy will poorly tolerate the abrupt development of aortic regurgitation, as may occur, for example, with infective endocarditis or after surgical or transcatheter AVR complicated by paravalvular leakage. The noncompliant LV is not prepared to accomodate the sudden volume load, and a result, LV diastolic pressure rises rapidly and severe heart failure develops.”
Which conditions might be associated with incapacity for compensatory dilation of the left ventricle in the setting of aortic or mitral valve regurgitation?
“Conditions in which the LV may not be able to dilate in response to chronic AR (or MR) include radiation heart disease and, in some patients, the cardiomyopathy associated with obesity and diabetes.”
Angina might occur due to oxygen supply/demand mismatch either to an hypertropied right or left ventricle or due to pressure/volume overload to either of these chambers, either in the presence or not of coronary artery disease.
True or False?
True.
A meso-systolic murmur in a patient with suspected aortic regurgitation is always a sign of concomitant aortic stenosis/sclersosis.
True or False?
False.
An ejection click is usually present in bicuspid aortic stenosis, especially in the young. If one has a mixed aortic valve disease, do you expect to find this phenomenon?
No.
“An early ejection click, which usually defines bicuspid aortic valve disease in young adults, if often not present in patients with congenital, mixed, AS and AR.”
