Mitral and tricuspid disease

Question 1

Mitral valve anatomy

Answer 1

1. Annulus is fibrous structure that supports the valve in the AV groove. Saddle shaped structure 2. leaflets (anterior and posterior) 3. Chordae tendinae which connect leaflets to papillary muscles

Question 2

Mitral valve regurgitation causes

Answer 2

primary mitral valve problems (only mitral valve is affected) :Myxomatous or functional (endocarditis, chordae rupture)

Question 3

What is myxomatous mitral valve?

Answer 3

hereditary disease in which Annulus is replaced with mucin. Results in prolapse, redundancy, and incompetence of the valve

Question 4

Describe mitral valve prolapse

Answer 4

mitral valve crosses into plane of atrium and a murmur results

Question 5

time course of mitral valve prolapse

Answer 5

asymptomatic > left atrial enlargement (atrial arrhythmias, fibrillation) > left ventricle volume overload (left ventricular dilation and dysfunction) > heart failure symptoms (dyspnea, orthopnea, edema) > risk of endocarditis

Question 6

Mitral valve prolapse physical exam

Answer 6

Mid-systolic click, late diastolic or holosystolic murmur at apex, Maneuvers that Decrease LV size intensify and prolong the Murmur Valsalva, dehydration, Maneuvers that Increase LV size decrease murmur (Squatting, Hydration)

Question 7

Myxomatous mitral valve treatment

Answer 7

surgical repair or replacement, Reduce systemic BP (reduce after load), treat CHF symptoms (diuretics)

Question 8

mitral valve regurgitation- Functional mitral valve disease

Answer 8

Left ventricle problem: restriction of leaflets, tethering of chordae or dilation/flattening of annulus. The left ventricle is dilating and it brings the mitral valve with it

Question 9

Functional mitral valve regurgitation physical exam

Answer 9

Holosystolic murmur at apex (quiet S1), signs of LV dysfunction (S3, S4, loud P2 (second part of S2) from pulmonary HTN, lateral displacement of apical impulses, edema, crackles, jugular distension)

Question 10

Functional mitral regurgitation treatment

Answer 10

surgery is controversial. Treat underlying cardiomyopathy (ACEI, B blockers, spironolactone, revascularization, bi-ventricular pacing, transplant)

Question 11

Mitral stenosis causes

Answer 11

Rheumatic heart disease, rarely senile calcification. Both limit the opening of the mitral valve due to thickening and/or calcification

Question 12

What is rheumatic fever and how is it prevented

Answer 12

Immune response to strep throat results in Abs that attack the mitral valve years later. Prophylatic treatment with penicillin used until 18-21 yrs old

Question 13

Time course of mitral stenosis

Answer 13

long asymptomatic period > left atrial enlargement (arrhythmias, clots, strokes) > heart failure symptoms (dyspnea, edema, orthopnea) > pulmonary hypertension (RV dysfunction and tricuspid regurgitation)

Question 14

Mitral stenosis physical exam

Answer 14

loud S2, opening snap (S2-OS time shorter if more severe), diastolic rumble at apex, signs of pulmonary hypertension (loud P2, RV thrill or lift, jugular venous distension, tricuspid regurgitation murmur)

Question 15

Mitral stenosis treatment

Answer 15

Mitral balloon valvuloplasty, surgical replacement, medical (beta blockers, diuretics, anticoag, antibiotics)

Question 16

Tricuspid valve anatomy

Answer 16

3 leaflets, 3 papillary muscles

Question 17

Causes of tricuspid valve disease

Answer 17

Tricuspid regurgitation (almost always secondary to right heart failure or pulmonary hypertension) and Primary tricuspid valve disease (rare- Congenital heart disease, endocarditis from IV drugs, carcinoid which results in serotonin that attacks the valve, rheumatic less often than mitral valve)

Question 18

Symptoms associated with tricuspid regurgitation

Answer 18

Symptoms due to RV disease and pulmonary hypertensions (edema, jugular distention, hepatic congestion)

Question 19

Tricuspid regurgitation physical exam

Answer 19

holosystolic murmur at left lower sternal border, increases with inspiration b/c more blood is brought into RV and loud P2 if pulmonary hypertension

Question 20

What causes tricuspid stenosis

Answer 20

rare- carcinoid syndrome (thickened valve due to attack by serotonin)

Question 21

Tricuspid stenosis symptoms

Answer 21

jugular distension, edema, hepatic congestion

Question 22

tricuspid stenosis physical exam

Answer 22

diastolic murmur at left lower sternal border that increases with inspiration

Question 23

Epsteins disease

Answer 23

congenital disease of tricuspid valve: septal leaflet doesn’t grow and the anterior leaflet grows apically so the functional RA is large and the functional RV is very small