Mitral and Tricuspid Valve Disease Flashcards
Mitral valve anatomy
- Annulus - ring:helps seat the valve
- Leaflet
- Chordae
- Papillary muscle - Anchor into myocardium
Role of mitral valve
Opens in diastole, allow blood to flow from LA to LV
Closes in systole to prevent blood from flowing backwards from LV to LA
Main etiologies of mitral stenosis (MS)
MAINLY Rheumatic MS (80-99%), only 1/2 report rheumatic fever Calcific MS (3%), advanced age & renal disease
Jones criteria (how many major and minor?)
2 major or 1 major + 2 minor -> high risk
Clinical presentation of mitral stenosis (6)
- Dyspnea
- Hemoptysis
- Pulmonary hypertension/CHF
- Right sided heart failure (edema, ascites)
- Atrial fibrillation (because of LA dilation)
- Thromboembolic event - stroke (because stagnant blood in LA leads to clot formation)
Physical exam findings of mitral stenosis
Loud S1: High AV pressure keeps MV open until ventricular systole forcefully closes valve
Snap: Follows S2, due to opening of stenotic leaflets (hearing it open!) Can assess severity by listening to timing of snap - inversely proportional. Higher LA pressure forces valve to open earlier
Diastolic rumble: Low frequency decrescendo murmur due to turbulent flow across stenotic valve during diastole.
Pulm hypertension physical exam (4)
- Loud P2
- RV thrill or lift
- JVD
- Tricuspid regurg
EKG findings for MS
- Left Atrial Enlargment
- RVH if pulm hypertension exists
- Possible atrial fibrillation
ECHO findings for MS (4)
- Left atrial enlargement
- Restricted opening of MV in diastole
- Thickened mitral valve leaflets, fusion of commissures
- MS severity estimated by Doppler or direct visualization
Drug Tx for MS
- MOST IMPORTANT: Beta blockers slow HR and allow more time for blood to cross the MV in diastole
- Diuretics to treat CHF symptoms
- Anticoagulants if aFib is present (MV can cause stasis)
Mechanical Tx for MS
- Mitral valve replacement (biprosthetic or mechanical valves)
- Percutaneous Ballon Miral Valvuloplasty
Indications for intervention of MS
- Symptoms
- Atrial Fib
- Pulmonary hypertension
What is mitral regurgitation? What causes it?
Inadequate mitral valve closure such that blood flows backwards, from the LV to the LA during systole
Mitral valve prolapse is the most common cause of primary mitral regurg.
May be caused by abnormality of any of the components of the MV anatomy
Etiology of mitral regurgitation
- Myxomatous degeneration: MV prolapse
- Ischemic heart disease: papillary muscle dysfunction or rupture
- Endocarditis: valve deformity, perforation
- Rheumatic valve disease
- LV enlargement: stretches mitral annulus and/or papillary muscles
What physical exam finding do you have for mitral regurgitation?
Holosystolic murmur best heard at apex with radiation to the axilla
What physical exam finding do you have for mitral valve prolapse?
Midsystolic click (between S1 and S2)- due to the sudden tensing of the chordae tendinae and mitral leaflet, followed by a late systolic murmur
What is the clinical course of mitral valve prolapse?
Usually benign with good prognosis.
Primary concern is development of mitral regurgitation
Primary mitral valve disease vs Functional mitral valve disease
- Primary mitral valve disease - Issues with the MV itself
2. Functional disease - mitral valve iself doesn’t have a problem, but LV puts extra stress on valve and causes issues.
Hemodynamics of mitral regurgitation
Part of LV stroke volume is ejected backwards into LA.
- Leads to LA elevated volume and pressure = pulmonary edema, pulmonary HTN
- Decreased forward CO
- Volume related stress on the LV which may lead to LV dysfunction over time
Clinical presentation of mitral regurgitation
CHF:
- Dyspnea on exertion
- Orthopnea
- PND
- Edema
Tx of mitral regurg:
- Medications
- diuretics for CHF
- Afterload reduction (ACE-I, and ARBs) - Surgery
- mitral valve repair or replacement - Mitraclip (transcatheter valve repair)
Indications for surgery for MR
1. Symptoms 2 LV dilation 3. Decreased LV systolic function 4. New onset atrial fibrillation 5. Pulmonary hypertension
Fxn of tricuspid valve
Opens in diastole to allow blood to flow from RA to RV
Closes in systole to prevent blood in RV from flowing backwards into the RA
Tricuspid regurgitation mechanism
During systole, tricuspid doesn’t close adequately and blood flows backwards into RA
- elevated RA pressure leads to INCREASED venous pressure
- L extremity edema, ascites, hepatic congestion
Etiology of tricuspid regurgitation
- 80% of cases are functional; secondary to annular dilation and leaflet tethering in the setting of RV dilation from volume and/or pressure overload
- Other causes can be: rheumatic disease, congenital disease, endocarditis, radiation, carcinoid, trauma, pacemaker leads
Physical findings of tricuspid regurgitation
- JVD with a visible systolic “v” wave
- Hepatomegaly in 90% of patients, and less common systolic pulsation of liver
- Classically the holosystolic murmur is heard along the sternal border and increases intensity with inspiration
Symptoms of TR
- Fatigue from low CO
- Abdominal fullness
- Edema
- Palpitations (if atrial arrhythmias pressent)
- Hepatic congestion
Tx of TR
- If functional TR, treat underlying cause of RV pressure/overload
- Medications = diuretics
- Surgery = Tricuspid repair or replacement
Indications for TR surgery
- Severe TR undergoing Left-sided valve surgery
- TV repair with less severe TR with annular dilation or R sided HF
- Symptomatic severe TR unresponsive to medical therapy
- Asymptomatic severe TR and progressive RV dilation or dysfunction
BEST IF PATIENT IS ALREADY HAVING SURGERY FOR SOME OTHER HEART ISSUE
Triscupid stenosis
- Rare!
- Usually from rheumatic heart disease!
- Murmur similar to MS but close to the sternum and intensifies with inspiration
- Symptoms of dyspnea and edema. Usually occurs simultaneously with mitral stenosis
- Tx: Diuretics or surgery (for isolated, symptomatic severe TR)
What type of murmur becomes louder with inspiration?
Tricuspid murmur from tricuspid regurgitation.
