CVPR 04-02-14 11am-Noon Mitral & Tricuspid Valve Disease - Dorosz

Question 1

Mitral & tricuspid valve – timing of opening

Answer 1

Open in diastole (to allow blood to flow into ventricles from atria)

Question 2

Valve diseases

Answer 2

Regurgitation/insufficiency (valve stays a bit open when it’s not supposed to, allowing blood flow backwards) OR Stenosis (valve won’t open enough, not allowing blood to flow forward)….. May be aortic, pulmonic, tricuspid, mitral

Question 3

Mitral valve anatomy - parts

Answer 3

Annulus ….. Leaflets…. Papillary muscles…. Chordae tendonae

Question 4

Mitral valve annulus

Answer 4

Fibrous ring structure that supports the valve in the atrial ventricular grove…. Not planar (Hyperbolic paraboloid – saddle-shaped for efficiency & preserved throughout species)

Question 5

Mitral valve leaflest

Answer 5

Posterior = smaller but more connected to annulus… Anterior = larger

Question 6

Mitral valve pathology

Answer 6

Regurgitation/insufficiency OR Stenosis

Question 7

Primary mitral valve disease (regurgitation) – causes

Answer 7

Myxomatous mitral valve disease (Primary MV disease) OR Functional/Acquired Mitral valve disease (Endocarditits, Chordae Rupture)

Question 8

Myxomatous mitral valve disease causing regurgitation

Answer 8

Primary mitral valve disease….. Leaflets are myxomatous (leafles no longer fibrous & pliable, but floppy & redundant)….. Associated w/CT disease… Hereditary … Results in prolapsed, redundancy, and incompetence of the valve

Question 9

Mitral valve prolapsed – sequlae

Answer 9

Long asymptomatic course —> Left atrial enlargement (atrial arrhythmias – fibrillation) w/leakiness —> Left ventricle volume overload (LV dilation/dysfunction) —> HF symptoms (dyspnea, orthopnea, edema, etc.) & Risk of endocarditis

Question 10

Mitral valve prolapse – characteristics on physical exam

Answer 10

Mild systolic click (when valve opens suddenly)….. Late diastolic or holosystolic murmur (classically at apex)….. Maneuveurs that decrease LV size —>intensify/prolong murmur (valsalva, dehydration)….. Maneuveurs that increase LV size —> decrease murmur (squatting, hydration)

Question 11

Myxomatous mitral valve – treatment

Answer 11

No great medial treatment (Afterload reduction by reducing systemic BP, HF symptoms treatment via diuretics) …. Surgical treatment is usually the best option (repair/replace)

Question 12

Mitral valve regurgitation – Functional Mitral Valve disease

Answer 12

Primarily a LV problem (thus secondarily a valve problem) – dilating LV dilates the mitral valve w/it and pulls the chordae/papillary muscles down, which restricts the valve from closing… restriction of leaflets, tethering of chordea, dilatation & flattening of annulus

Question 13

Functional Mitral Valve Regurgitation – characteristics on physical exam

Answer 13

Holosystolic murmur at apex (quiet S1)….. Signs of LV dysfunction (S3, S4… Loud P2, associated w/pulmonary HTN… Lateral displacement of apical impulse… Edema, crackles, JVD (HF)

Question 14

Functional Mitral Valve disease – treatment

Answer 14

Medical treatment is the best option (Since the primary problem is the LV, treat underlying cardiomyopathy) – ACEIs, BBs, Spironolactone, Revascularization, Bi-ventricular pacing, Transplant….. Primary mitral valve surgery (controversial b/c valve isn’t the 1st problem & has mixed results)

Question 15

Mitral stenosis – defn

Answer 15

Restricted opening of the mitral valve from a chronically thickened valve

Question 16

Mitral stenosis –causes

Answer 16

Rheumatic heart disease (Abs produced during rheumatic fever attack the valve many years later)….. Rarely, senile calcification (age, renal disease)

Question 17

Rheumatic fever & Mitral stenosis

Answer 17

Childhood illness….. Immune response to strep throat…. Acute disease: chorea (jerky movements of limbs, trunk, facial muscles), rash, fever, arthritis for 2-4 weeks after strep infection….. Valvulopathy can happen years later ….. Prophylactic treatment w/Penicillin until 18-21 yo or risk of strep throat low (longer for those w/valvulopathy or with increased exposure to strep – at least age 40) – once you have demonstrated that you produce antibodies, each time you get strep you’ll produce more, so this is prevented prophylactically

Question 18

Mitral stenosis – sequlea

Answer 18

Long asymptomatic period —> Left atrial enlargement (can be massive; atrial arrhythmias, clots, strokes)—> HF symptoms (dyspnea, edema, orthopnea…)—> Pulmonary HTN (RV dysfunction, tricuspid regurgitation)

Question 19

Mitral stenosis – characteristics on physical exam

Answer 19

Louds S2….. Opening snap (S2-OS time shorter w/more severe stenosis)….. Diastolic rumble at apex w/pt lying on left size….. Signs of pulmonary HTN (loud P2, RV thrill/lilt, JVD, Tricuspid regurgitation murmur)

Question 20

Measuring stenosis

Answer 20

Measure velocity of blood through the valve… stenosis = “thumb over the hose” = blood comes out faster the more restrictive/stenotic the valve is

Question 21

Mitral stenosis – treatment

Answer 21

Valvuloplasty (balloon to crack open; can’t use if there is regurgitation or if too calcified that they crack like an egg)….. Surgical replacement….. Medical (not curative): BBs (more time for blood to flow during diastole), Diuretics (for HF), Anticoagulation, Antibiotics (prophylactic)

Question 22

Tricuspid valve anatomy

Answer 22

Little sister of the mitral valve; 3 leaflets + 3 papillary muscles

Question 23

Tricuspid valve disease

Answer 23

Almost always a secondary functional valvular disease due to right HF or pulmonary HTN….. Primary Tricuspid Valve disease is rare, and occurs in the setting of (1) Congenital Heart Disease - Epstein’s Abnormality where posterior leaflet grows down instead of across; (2) Endocarditis - esp. in IV drug users; (3) Carcinoid (serotonin produced w/carcinoid tumor in liver —> goes to right heart & attack tricuspid/pulmonic valves —> lungs metabolize, spare left valves; OR (4) Rheumatic - caused much less often than mitral valve disease

Question 24

Tricuspid Regurgitation - Sequlae

Answer 24

Associated w/underlying RV disease & Pulmonary HTN – Edema, JVD, Hepatic congestion

Question 25

Tricuspid regurgitation – characteristics on physical exam

Answer 25

Holosystolic murmur – left lower sterna border, increases w/inspiration, loud P2 (w/pulmonary HTN)

Question 26

Tricuspid stenosis – cause

Answer 26

Rare – Carcinoid syndrome (via tumor-produced serotonin; stuck open = stenosis & regurgitation)

Question 27

Tricuspid stenosis – sequlea

Answer 27

Right heart symptoms – JVD, edema, hepatic congestion

Question 28

Tricuspid stenosis – characteristics on physical exam

Answer 28

Diastolic murmur at left lower sterna border, increasing w/inspiration (hard to hear)