Lecture: Echo Assessment Mitral Valve Exam #1 Flashcards
increased stress on the MV apparatus causes disease. diseases fall under either one of these 2 categories:
the disease will either be:
1. condition that elevates LV systolic pressure
- condition that causes abnormal mitral motion
thromboembolic event also known as a
stroke
a patient’s heart rhythm goes into a fib, putting her at risk for an embolic event… the patient has an enlarged left atrium, which puts her at at risk for a blood clot (embolus and stroke to follow if not taken care of). The left atrial enlargement could have been caused by what?
Mitral Annular Calcification (MAC)
Calcific emboli from a MAC lesion can cause what
a thromboembolic event (stroke)
In SAX, MAC may be focal, extensive, or BOTH?
BOTH
symptoms:
MAC extended to base of leaflets
Motion of leaflets impaired
Narrowed diastolic flow area
Leaflet tips are thin and mobile
This is either rheumatic heart disease or Calcific Mitral Stenosis. What info from above allows you to correctly determine what disease it most likely is
Both diseases are similar, but the fact that the leaflets are THIN AND MOBILE still, point out that this is CALCIFIC MITRAL STENOSIS.
What disease can mimic other diseases (from this powerpoint)
MAC can mimic
mitral stenosis
pericardial effusion
masses
what are some examples of hemodynamic changes
regurgitation (acute or chronic)
stenosis
shunts (intracardiac)
regurgitation can lead to
congestive heart failure
A subacute (vs acute) is only an accurate diagnosis if the SOURCE of the infection (infective endocarditis) is…
BACTERIA
Patient is complaining of:
low grade fever
fatigue
weight loss
cough
weakness
could be….
SUBACUTE infective endocarditis!
This type of infection usually has a negative blood culture
Fungal infection
define “idiopathic”
relating to or denoting any disease or condition which arises spontaneously or for which the cause is unknown.
which disease process is idiopathic
MAC
Mitral Annular Calcification
arterial hypertension means the same thing as SYSTEMIC hypertension true or false
TRUE
2 causes of embolism can be caused by MAC
- MAC can cause LAE - that leads to atrial fibrillation - that leads to embolic event
- MAC lesion can form calcific emboli
patient has a high fever and a heart murmur has suddenly developed in a week - what might this be
ACUTE infective endocarditis
symptoms SUBACUTE endocarditis
low-grade fever, fatigue, cough, weight loss, weakness
what percentage of the time are blood cultures accurate?
95%
what will make blood cultures unreliable?
antibiotics
true or false patients WITH an infection and WITHOUT an infection can BOTH have vegetations?
TRUE
a vegetation in a patient without infection is called a “healed vegetation”
healed OR infected veggies are smaller and more echogenic
healed (more calcium, fibrosis)
a larger veggie or a smaller veggie has a greater chance of embolization
LARGER
valve destruction from veggies usually results in
valvular regurgitation
what side of heart veggies more common
left
what valve do veggies affect the most
mitral
right sided veggies are more common with the advent of
iv drug use, indwelling venous catheters, pacer wires
treat a veggie?
antibiotics
least destructive but also LARGEST veggie
fungal - can get so large they obstruct flow
NEW NORMAL VARIANT!
Lambl’s excrescence located on aortic valve (ventricular side) thin and linear fibroelastic protrusions (age-related - older more likely)
what view do you measure thickness of MAC (severity)
PSAX at mitral view
In NBTE, vegetations are caused by
physical trauma ex. catheter, cancer
NBTE veggie can be the origin of
infection (infective endocarditis, produce emboli, impair valve function) *embolization usually cause of symptoms
what is a lesion
any structural abnormality
A patient with lupus, they may have veggies
along valve leaflet closures (Libman-Sacks lesions or endocarditis)
Libman–Sacks endocarditis is a
form of non-bacterial endocarditis that is seen in association with systemic lupus erythematosus, antiphospholipid syndrome, and malignancies.
WHATS. THE DIFFERENCE BETWEEN infective endocarditis AND nonbacterial thrombotic endocarditis (NBTE)??????
In infective endocarditis, the body’s response is inflammation, whereas NBTE does not cause an inflammatory response.
What is another form of NBTE endocarditis seen in patients with chronic wasting diseases, mucin-producing metastatic carcinomas, and/or chronic infections such as TB, pneumonia, etc?????
Marantic endocarditis (NBTE)
an easily “friable” vegetation means what
it is “fragile” meaning EMBOLIZATION IS VERY EASY!!!
what does “marantic” mean when we talk about Marantic endocarditis (NBTE)
marantic endocarditis, which comes from the Greek marantikos, meaning “wasting away”. The term “marantic endocarditis” is still sometimes used to emphasize the association with a wasting state such as cancer.
NBTE affects more of what type of patient
chronically ill
Negative blood cultures and valvular vegetations suggest
NBTE (treated with anticoagulant)
Leaflets extend above the plane of the MV annulus in this condition
MVP - greater than or equal to 2mm beyond annulus
this is histologically identical to the myxomatous degeneration associated with this connective tissue disorder
Mitral Valve Prolapse histologically identical to Marfan’s Syndrome
abnormal collagen synthesis leads to what in MVP
lengthened chordae, abnormally large, floppy leaflets
“myxomatous” means what
“thickening”
Degenerative MV disease
Myxomatous MV disease
Both are the same disease, AKA
MVP (mitral valve prolapse)
What is the mildest form of MVP called and what is the most severe form of MVP called
mildest is “fibroelastic deficiency”
most severe is “Barlow disease”
difference between fibroelastic deficiency and Barlow disease is
fibroelastic deficiency affects mechanical integrity of leaflets due to impaired production of CT while Barlow disease is EXCESS leaflet tissue (affects whole leaflet - not just thickening at the base like fibroelastic)
“Abe Lincoln disease”
Marfan’s syndrome
Marfan syndrome is a genetic disorder that changes the proteins that help make healthy connective tissue. This leads to problems with the development of connective tissue, which supports the bones, muscles, organs, and tissues in your body.
syndrome where symptoms include hyper elastic skin and extreme joint mobility
Ehlers-Danlos syndrome
A ballet dancer or anorexic person may be prone to this
MVP
I HAVE A DIVERSE ARRAY OF SYMPTOMS BUT MY MOST COMMON SYMPTOM IS ARRYTHMIA AND HEART PALPITATIONS… WHAT AM I
MVP
can be ASYMPTOMATIC
other symptoms include:
NON-EXERTIONAL chest pain, fatigue, dyspnea, systemic emboli
Most common cause of MR in developed countries
MVP
MVP can cause MR… varying degrees of MR can cause (think about the flow of regurgitating blood)
Pulmonary hypertension,
pulmonary edema (acute),
thick MV leaflets are susceptible to disease such as
bacterial endocarditis
flail MV
ruptured chordae tendineae
an increase in MVP equals in increase in
mitral regurgitation
MVP usually associated with these sounds
systolic click and a late systolic murmur (cardiac auscultation)
“vasalva” or holding your breath and “bearing down” does what to the venous blood flow in your body
slows venous return
supine to standing, what happens to venous blood flow
when a supine person abruptly transitions to an upright position, the following events take place: The contents of the venous circulation is redistributed to the legs, decreasing the thoracic venous blood volume.
Standing to squatting VS squatting to standing (moves the click and murmur sound of an MVP patient) which way does it move with each
standing to squatting or standing to supine moves click and murmur TOWARD second heart sound (increases LV volume)
supine to standing (reduces LV volume) and moves click and murmur toward earlier in systole (pan-systolic or “hammock” prolapse)
In diagnosing MVP, use THIS view and NOT this view
Use Parasternal LAX
DO NOT use Apical view
pericardial effusion alters the overall motion of the heart in an echo, so take note if the patient has pericardial effusion if trying to diagnose this
MVP
can give a FALSE POSITIVE!
Treatments for MVP
none!
here’s what we can do
endocarditis prophylaxis
holter monitor
treadmill stress test
beta blockers for arrhythmias
stop stimulate aka caffeine/alcohol
follow up
Mitral Valve Repair when that is imperative*
In MV flail, the leaflets are where in systole and in diastole?
in systole, they are in LA
in diastole, they are in LV
What is seen in MV Flail (significant)
significant Mitral Regurgitation
is more commonly found on anterior leaflet, is generally uncommon, and is usually associated with infective endocarditis
MV Aneurysm
what is prophylaxis
Preventive healthcare, or prophylaxis is the application of healthcare measures to prevent diseases
LOOKING FOR LEFT VENTRICULAR HYPERTROPHY and finding it is a sign of what possible conditions?????
IT IS A SIGN OF ELEVATED LV SYSTOLIC PRESSURE WHICH CAN INDICATE
- hypertension
- hypertrophic cardiomyopathy
- aortic stenosis
what do you measure for MAC to determine severity? what view?
can measure THICKNESS in PSAX of the MV
Mild: 1.5 - 5mm
Moderate: 6-10mm
Severe: >10mm
Calcific Mitral Stenosis can be caused by
MAC, where MAC calcification extends to the base of the leaflets, impairing motion, restricting diastolic flow area, although the leaflet tips are still thin and mobile.
Thin/mobile leaflets differentiate this from rheumatic heart disease.
a developing perivalvular abscess (advanced by infective endocarditis) can cause what?
fistula or fistulous communications
echo appearances THIS can ALSO be laminated along the surface of the valve or valve apparatus… appearing as a more diffuse focal thickening of the leaflet…
VEGGIE!!
2 weeks following the initiation of antimicrobial treatment… what is likely to occur with a pedunculated veggie
RISK OF EMBOLIZATION!
difference between embolization of left-sided heart veggie and right-sided heart veggie
left-sided lesions: petachiae/purperic skin lesions, stroke, transient ischemic events
right-sided lesions: pneumonia-like symptoms
valve destruction from veggies usually result in valvular
REGURGITATION - easily detected by echo
type of endocarditis (specific): large thrombotic vegetations may form on valves and produce significant emboli to the brain, kidneys, spleen, mesentery, extremities, and coronary arteries. Tend to form on congenitally abnormal cardiac valves and those damaged by rheumatic fever.
NBTE Marantic Endocarditis
anticoagulants is often needed in noninfective endocarditis (NBTE) but is contraindicated in
INFECTIVE ENDOCARDITIS
patients with this type of endocarditis usually have a very severe underlying disease
Non-Bacterial Thrombotic Endocarditis
MVP is the buckling of one or both leaflets into the LA in systole or diastole?
SYSTOLE!
>2mm beyond annulus
THIS condidition is histologically identical to thickening degeneration of MV associated with Marfan’s syndrome…
MVP
all varying degrees of the SAME disease:
degenerative MV disease
myxomatous MV disease
fibroelastic deficiency
Barlow disease
MVP!
Varying degrees of mitral regurgitation (MR) can cause a few different things…
Cardiac Heart Failure
Pulmonary HTN
Acute Pulmonary Edema
TRUE or FALSE: DO NOT USE APICAL VIEWS FOR MVP diagnostics…
TRUE
only use PLAX view in 2-D and m-mode
chronically ill patients are more likely to have this TYPE of endocarditis
non-bacterial thrombotic endocarditis (check for negative blood cultures and valvular veggies) can’t be on antibiotics though… would making check for blood cultures IMPOSSIBLE
the nature and timing of MVP (in auscultation) is influenced by what? what maneuvers can help with diagnosis?
influenced by STROKE VOLUME
maneuvers that influence stroke volume are
1. vasalva
2. amyl nitrate inhalation
what is the unit to attach to any answers calculating MVA (mitral valve area)?
cm2 (squared)
what is the unit to attach to any answers calculating pressure or a pressure gradients?
mmHg
you measure the time from the peak diastolic velocity to the baseline. that is called what? you can measure mitral valve area with this information. how so?
mitral deceleration time.
MVA = 750 / deceleration time
answer in cm2 (squared)
what is Bernoulli’s equation
mva = 4v2(squared)
answer is in cm2(squared)
what is the continuity equation
MVA = (CSA)(LVOT) x (VTI)(LVOT) x (VTI)(MV)
(cross section area of left ventricular outflow tract) x (velocity time integral of left ventricular outflow tract) x (velocity time integral of mitral valve) = answer in cm2(squared)
velocity time integral is a waveform through the valve in CW.
Can you grade MS by “mean pressure gradient”?
yes, the more severe the MS the higher the pressure gradient
mild is less than 5 mmHg
moderate is 5-10 mmHg
severe is greater than 10mmHg
mean pressure gradient and MVA have an INVERSE relationship
Peak pressure gradient is not as reliable as the “mean pressure gradient” … why? what factors influence peak, making in unreliable…
Because it is influenced by other factors, namely LA compliance and LV diastolic function
what is preferred OVER valve replacement? lower incidence of MORTALITY, lower incidence of MORBIDITY, lower incidence of POSTOPERATIVE COMPLICATIONS
percutaneous balloon mitral valvotomy
where is the balloon positioned in a MV valvotomy
balloon is passed across IAS, positioned in MV orifice, inflated and splits valve on the commissures without damage to leaflets
treatment for MS
diuretics, heart controlling agents like beta blockers and calcium channel blockers (and digoxin), management of a-fib, chronic anticoagulation therapy especially with a-fib
SO many causes of MR, but can you see MR in a normal heart too? Like a completely normal heart?
yes
what’s the difference between a heart with acute MR and a heart with chronic MR?
acute won’t see any changes in LA or LV size or function
chronic will see changes in LV/LA volume and LV function will be impaired due to volume overload
Starts at leaflet TIPS and spreads toward annulus
Rheumatic Mitral Stenosis
Dome shaped hockey stick appearance (starts at tips, spreads toward annulus)
Rheumatic mitral stenosis
