Comprehensive Assessment of Primary Mitral Valve Disease Flashcards
What does primary mitral valve disease encompass?
Entities where disease of the valve itself causes pathophysiology leading to clinical impairment.
What are the two main types of primary mitral valve disease?
Mitral regurgitation (MR) and mitral stenosis (MS).
What has significantly improved the diagnosis of mitral valve pathology?
Advances in echocardiography, particularly 3D echocardiography.
Does medical therapy currently improve the natural history of primary MR?
No, there is currently no medical therapy that improves the natural history of primary MR.
What has improved in the surgical management of primary MR?
Better repair techniques have decreased operative mortality and improved durability.
What is a common cause of acute mitral regurgitation?
Disruption of the mitral apparatus, such as a perforated leaflet or torn chord.
What are the typical symptoms of acute MR?
Pulmonary edema, respiratory distress, hypotension, and shock.
What auscultation finding is key to diagnosing all valvular disease?
A typical murmur on physical examination.
What murmur is often associated with myxomatous degeneration of the mitral valve?
A mid-systolic click followed by a late systolic murmur.
How does chronic primary MR typically progress?
Slowly over many years, with symptoms developing insidiously.
What is the most common cause of symptomatic mitral stenosis?
Rheumatic carditis.
What is Ortners syndrome?
Hoarseness caused by extreme left atrial enlargement impinging on the left recurrent laryngeal nerve.
What is the typical auscultatory finding in mitral stenosis?
A soft diastolic rumble heard best in the left lateral decubitus position.
What does Stage A in the classification of primary MR indicate?
Patients at risk of MR.
What distinguishes primary MR from secondary MR?
Primary MR is a disease of the valve itself, whereas secondary MR is due to left ventricular disease.
What is the Carpentier classification used for?
To classify types of mitral valve pathologies.
What characterizes Type II in the Carpentier classification?
Leaflet prolapse.
What is a common imaging test for evaluating mitral regurgitation?
Two-Dimensional Transthoracic Echocardiography (TTE).
What is the definition of Stage D in the classification of primary MR?
Symptomatic severe MR.
What are the hemodynamic consequences of severe mitral regurgitation?
Moderate or severe left atrial enlargement, left ventricular enlargement, and pulmonary hypertension.
Fill in the blank: The typical murmur of mitral stenosis is a _______.
soft diastolic rumble.
True or False: Secondary MR can be cured by treating the mitral regurgitation alone.
False.
What physiological states can precipitate or worsen symptoms in mitral stenosis?
Exercise, pregnancy, fever, hyperthyroidism, atrial arrhythmia.
What is the significance of the interval history between S2 and OS in mitral stenosis?
It is a good guide to MS severity.
What is degenerative/myxomatous mitral valve disease?
A condition characterized by degeneration of the mitral valve leading to regurgitation.
What is the Carpentier classification of mitral valve regurgitation?
A classification system that includes three types:
* Type I: Normal leaflet motion with annular dilation or leaflet perforation
* Type II: Leaflet prolapse
* Type III: Leaflet restriction, further divided into IIIa (restricted opening) and IIIb (restricted closing).
How is primary mitral regurgitation diagnosed using transthoracic echocardiography (TTE)?
Diagnosis is made when mitral leaflets are displaced >2 mm into the left atrium during systole in the parasternal long view.
What does TTE assess in mitral regurgitation?
TTE assesses:
* Scallop anatomy
* Leaflet tethering
* Extent of mitral annular calcification
* Left atrial and left ventricular size
* Left ventricular function
* Pulmonary artery pressures.
What is the role of 2D transesophageal echocardiography (TEE) in evaluating mitral valve pathology?
2D TEE provides important anatomical information and helps visualize the mitral valve apparatus.
In what view are the A2 and P2 scallops visualized using 2D TEE?
In the midesophageal four chamber view at 0°.
What are the advantages of three-dimensional (3D) echocardiography over 2D echocardiography?
3D echocardiography offers:
* Better characterization of leaflet pathology
* Improved communication of valve anatomy
* Excellent spatial and temporal resolution.
What is a limitation of 3D echocardiography?
It requires familiarity with image acquisition and manipulation; errors can lead to misinterpretation.
What complementary roles do computed tomography (CT) and magnetic resonance imaging (MRI) play in assessing mitral regurgitation?
CT and MRI can help assess:
* Mitral valve anatomy
* Coronary anatomy
* Left ventricular function
* Left atrial appendage thrombus.
How is left ventriculography used to assess mitral regurgitation severity?
It qualitatively classifies severity from mild (1+) to severe (4+) based on contrast opacification of the left atrium.
What is the vena contracta method in Doppler quantitation of mitral regurgitation?
It assesses the size of the narrowest portion of the regurgitant jet, reflecting MR severity.
Fill in the blank: The effective regurgitant orifice area (EROA) can be calculated using the formula EROA = ( 2 Πr² * Va ) / PkVreg, where r is the _______.
[radius of the hemisphere].
What is the significance of using the proximal isovelocity surface area (PISA) method?
PISA helps in the quantitative assessment of MR severity based on blood flow dynamics near the regurgitant orifice.
True or False: In patients with severe MR, the E wave velocity is usually less than 1.2 m/s.
False.
What is the impact of measurement errors in the PISA radius on the EROA calculation?
Any error in measurement of the PISA radius will lead to a substantial error in the EROA calculation because the radius is squared in the flow convergence equation.
What E wave velocity indicates severe mitral regurgitation (MR)?
E wave velocity is usually greater than 1.2 m/s in patients with severe MR.
What mitral inflow pattern virtually excludes the presence of severe MR?
The presence of an A wave dominant mitral inflow pattern virtually excludes the presence of severe MR.
How can pulsed wave Doppler be used in assessing MR?
It can be used to calculate the MR regurgitant volume and fraction using the continuity equation.
What happens to forward systolic pulmonary vein flow in patients with severe MR?
Forward systolic pulmonary vein flow can be reversed or blunted.
True or False: Elevated LA pressure and atrial fibrillation can cause blunted systolic flow in the pulmonary vein.
True
What are common pitfalls in the echocardiographic assessment of MR severity?
- Relying on color Doppler with a low Nyquist limit
- Inadequate assessment with highly eccentric jets
- Limitations with eccentric jet or multiple jets
- Underestimating MR severity in TEE due to anesthesia
- Misinterpretation of EROA
- Failure to recognize imaging artifacts
- Variability of mitral gradients depending on heart rate
- Limitations of 2D TEE in diagnosing mitral clefts
- Deceptive color Doppler assessments in acute severe MR
What is the difference between calcific and rheumatic mitral stenosis (MS)?
Calcific MS involves annular calcification and is seen in elderly patients, while rheumatic MS shows commissural fusion and calcification predominating at leaflet tips.
What is the role of continuous wave Doppler (CWD) in assessing mitral stenosis?
CWD should be used to assess peak and mean mitral gradients.
What does the pressure half-time (T1/2) measure in mitral valve assessment?
It measures the time required for the maximum pressure gradient to decrease by half of its original value.
Fill in the blank: The formula to calculate mitral valve area is MVA = 220 / _______.
T1/2
What factors can affect the pressure half-time in mitral stenosis assessment?
- Changes in LV compliance
- Moderate or severe aortic regurgitation
What is the purpose of transesophageal echocardiography (TEE) before balloon valvuloplasty?
To confirm the absence of an LA appendage thrombus and assess the degree of concomitant mitral regurgitation.
What scoring system is used to predict outcomes of percutaneous balloon mitral valvuloplasty?
Wilkins score
What is the significance of a Wilkins score of 8 or less?
It predicts a suitable percutaneous valvuloplasty.
What is the primary use of invasive hemodynamics in valvular heart disease?
To clarify the clinical significance of mitral valve pathology when noninvasive assessments don’t correlate.
How does severe mitral stenosis affect LA/LV diastolic gradients?
It produces an LA/LV diastolic gradient without diastasis.
What is a common surrogate for left atrial pressure in invasive hemodynamic assessment?
Pulmonary capillary wedge pressure (PCWP)
What can cause inaccuracies in gradient assessment using PCWP?
PCWP waveforms are delayed by 40–120 ms relative to the LA waveforms.
List the strengths of 2D TTE in assessing mitral regurgitation.
- Quantify MR
- Differentiate between primary and secondary MR
- Assess LA and LV size for MR severity
What are the limitations of 2D TEE in assessing mitral stenosis?
- Detailed assessment of scallop/leaflet anatomy may not be feasible
- Requires an experienced echocardiographer
- Unreliable if 2D image quality is poor
What is the role of 3D TEE in mitral valve assessment?
It provides an integrated view of valve pathology and is more accurate for planimetry.
