CVPR 04-02-14 11am-Noon Mitral & Tricuspid Valve Disease - Dorosz Flashcards
Mitral & tricuspid valve – timing of opening
Open in diastole (to allow blood to flow into ventricles from atria)
Valve diseases
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
Mitral valve anatomy - parts
Annulus ….. Leaflets…. Papillary muscles…. Chordae tendonae
Mitral valve annulus
Fibrous ring structure that supports the valve in the atrial ventricular grove…. Not planar (Hyperbolic paraboloid – saddle-shaped for efficiency & preserved throughout species)
Mitral valve leaflest
Posterior = smaller but more connected to annulus… Anterior = larger
Mitral valve pathology
Regurgitation/insufficiency OR Stenosis
Primary mitral valve disease (regurgitation) – causes
Myxomatous mitral valve disease (Primary MV disease) OR Functional/Acquired Mitral valve disease (Endocarditits, Chordae Rupture)
Myxomatous mitral valve disease causing regurgitation
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
Mitral valve prolapsed – sequlae
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
Mitral valve prolapse – characteristics on physical exam
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)
Myxomatous mitral valve – treatment
No great medial treatment (Afterload reduction by reducing systemic BP, HF symptoms treatment via diuretics) …. Surgical treatment is usually the best option (repair/replace)
Mitral valve regurgitation – Functional Mitral Valve disease
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
Functional Mitral Valve Regurgitation – characteristics on physical exam
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)
Functional Mitral Valve disease – treatment
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)
Mitral stenosis – defn
Restricted opening of the mitral valve from a chronically thickened valve
Mitral stenosis –causes
Rheumatic heart disease (Abs produced during rheumatic fever attack the valve many years later)….. Rarely, senile calcification (age, renal disease)
Rheumatic fever & Mitral stenosis
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
Mitral stenosis – sequlea
Long asymptomatic period —> Left atrial enlargement (can be massive; atrial arrhythmias, clots, strokes)—> HF symptoms (dyspnea, edema, orthopnea…)—> Pulmonary HTN (RV dysfunction, tricuspid regurgitation)
Mitral stenosis – characteristics on physical exam
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)
Measuring stenosis
Measure velocity of blood through the valve… stenosis = “thumb over the hose” = blood comes out faster the more restrictive/stenotic the valve is
Mitral stenosis – treatment
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)
Tricuspid valve anatomy
Little sister of the mitral valve; 3 leaflets + 3 papillary muscles
Tricuspid valve disease
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
Tricuspid Regurgitation - Sequlae
Associated w/underlying RV disease & Pulmonary HTN – Edema, JVD, Hepatic congestion
Tricuspid regurgitation – characteristics on physical exam
Holosystolic murmur – left lower sterna border, increases w/inspiration, loud P2 (w/pulmonary HTN)
Tricuspid stenosis – cause
Rare – Carcinoid syndrome (via tumor-produced serotonin; stuck open = stenosis & regurgitation)
Tricuspid stenosis – sequlea
Right heart symptoms – JVD, edema, hepatic congestion
Tricuspid stenosis – characteristics on physical exam
Diastolic murmur at left lower sterna border, increasing w/inspiration (hard to hear)
