MHD: Clinical valvular heart disease

Question 1

What is the predominant cause of mitral stenosis?

Answer 1

Rheumatic fever

Question 2

In rheumatic fever, what determines whether MS or MR is the predominant pathology?

Answer 2

Location of affected tissues. Fusion of leaflets results in MS, whereas involvement of the chordae tendinae with little fusion results in MR

Question 3

What are the primary clinical manifestations of mitral stenosis?

Answer 3

Dyspnea due to reduced lung compliance
Pulmonary edema
Thromboembolism
Infective endocarditis
Hoarse voice due to laryngeal nerve compression

Question 4

What sign seen on 2D echocardiograms indicates mitral stenosis?

Answer 4

Hockey stick deformity showing thickened, calcified leaflets

Question 5

How is pressure half time used to quantify mitral valve stenosis?

Answer 5

You can calculate the pressure half time from doppler readings
Mitral area = 220/PressureHalfTime (msec)

Question 6

What is the definitive treatment for mitral stenosis?

Answer 6

Valvuloplasty

Question 7

What are the causes of acute mitral regurgitation?

Answer 7

Infectious endocarditis
Trauma
Myxomatous Degeneration
Libman-Sacks lesions (SLE)
CAD
LV dysfunction, MI, myocarditis
Prosthetic valve dysfunction

Question 8

What are the causes of chronic mitral regurgitation?

Answer 8

Inflammatory (rheumatic, SLE)
Degenerative (MVP, Marfans, MAC)
Infective subacute endocarditis
Structural: ruptured chordai, CAD, LV dilatation, HCM, prothetic valve dysfunction
Congenital

Question 9

What is the difference between pressure overload and volume overload?

Answer 9

Pressure overload occurs with HOCM, aortic stenosis and involves hypertrophy
Volume overload occurs with mitral regurgitation and aortic regurgitation and involves acute processes (no time for remodeling)

Question 10

Does end-systolic diameter predict the post-operative death probability for mitral regurgitation patients?

Answer 10

Yes. If the ESD is above 45mm, there are poor outcomes because the actin/myosin become permanently damaged due to overdilatation

Question 11

What is the major structural difference seen between acute and chronic mitral regurgitation?

Answer 11

In acute, the LA is small, but at a high pressure.

In chronic, the LA is dilated

Question 12

What is the hallmark physical exam sign for mitral regurgitation?

Answer 12

Holosystolic murmur

Question 13

When do symptoms develop in patients with chronic MR?

Answer 13

When the left ventricle fails

Serious damage has often occurred before symptoms present

Question 14

Which is more problematic clinically: mitral regurgitation or mitral stenosis?

Answer 14

Mitral regurgitation is often silent during progression, whereas stenosis is associated with early symptoms leading to better detection

Question 15

What is the major medical treatment for mitral regurgitation?

Answer 15

Same as treating heart failure: afterload reduction

If it is easier to pump out, then less blood will regurgitate into the left atrium

Question 16

What physiologic parameter of heart function predicts surgical outcome for mitral regurgitation patients?

Answer 16

Ejection fraction predicts surgical outcome

Question 17

Physical exam finding of mitral valve prolapse

Answer 17

Mid systolic click

Question 18

What are the two causes of aortic stenosis?

Answer 18

Bicuspid valve caused by either:
Genetics
Degenerative process

Question 19

Describe the location of calcification in aortic stenosis in the elderly

Answer 19

In senile aortic stenosis, calcifications are at the flexion lines of the valve leaflets, with minimal consequences on valve function

Question 20

What are the physical exam findings in aortic stenosis?

Answer 20

Aortic ejection sound (E) louder than S1

Systolic murmur crescendo-decrescendo

Question 21

What symptoms decrease survival rate in aortic stenosis?

Answer 21

Angina, Syncope and Failure (most severe)

Question 22

What is the main treatment for aortic stenosis?

Answer 22

Aortic valve replacement

*Valvuloplasty not successful due to restenosis

Question 23

What is aortic regurgitation caused by?

Answer 23

Disease of valve leaflets, or wall of aortic root

Question 24

What is the main treatment for aortic regurgitation?

Answer 24

Symptomatic: valve replacement
Asymptomatic: Depends on end-systolic diameter, ejection fraction

Question 25

What is the most commonly used prosthetic valve today?

Answer 25

Bi-Leaflet tilting disc valve

“St. Judes valve”

Question 26

What is the most common cause of tricuspid regurgitation?

Answer 26

Dilatation of the right ventricle and the tricuspid annulus

Question 27

Which 3 conditions can a holosystolic murmur be heard in?

Answer 27

Tricuspid regurge: heard at suprasternal notch
Mitral regurge: heard left lateral 5th ICS, axilla
Ventricular septal defect: heart right 5th ICS