Mitral regurg/stenosis Flashcards
5 components of mitral valve and heart that can result in mitral disease
- annulus (calcifies with age or disease)
- leaflets (can go bad with infection)
- two papillary muscles inserted into LV wall (each with two heads)
- chordae
- LV wall
Name the commonest etiologies of MR
- papillary muscle dysfunction
- mitral valve prolapse
- calcified mitral annulus
- Rheumatic heart disease
- infective endocarditis
what is functional mitral regurg
- no problem with the mitral valve itself, but have a problem elsewhere (papillary, LV, etc.) that causes same effect as mitral regurg
what is organic mitral regurg
- regurg that’s actually caused by a problem in the valves
Is mitral regurg a LV pressure or LV overload problem?
- volume overload (mitral valve doesn’t work, so when ventricle squeezes, blood is going through back to the left atrium
mitral regurg gives ____ hypertrophy… why?
- eccentric
- you get LV dilatation and hypertrophy to increase compliance, resulting in incrased EDV without an increase in EDP because of dilation
what is the result of mitral regurg on starling forces?
- increase SV and ejection fraction early
What is the pro and con of dilated LA
pro: prevents increase in Pulmonary artery pressure
con: over time, no forward CO, resulting in thrombi formation
carotid impulse is caused by 2 events?
so what happens with carotid impulse is MR?
- volume of blood coming out of ventricle
- speed with which volume comes out
- carotid feels normal because of our dilation, which with starling forces increases our contractility and actually increases the EF
- describe apex impulse of MR
- inferolaterally displaced and enlarged
4 types of MR murmurs and what they correspond to
- holosystolic: rheumatic heart disease
- late systolic: mitral valve prolapse
- midsystolic: papillary muscle dysfunction
- decrescendo: acute mitral regurg
if you hear murmur at apex, assume:
mitral regurg
cxr finding in chronic mr
- enlarged pericardial silhouette due to large left atrium
EKG finding of MR
- atrial dilation causes atrial dysfunction… gives us afib and potentially LVH
clinical signs of severity:
- fatigue/congestion over time
why would LV dilate?
- even though mitral regurg is sending blood back to LA, that blood is eventually going to go to LV, causing a volume overload and dilation
bedside exam indications of MR
- displaced apex
- loud systolic murmur at the apex
- potentially mid-diastolic rumble + S3
name etiologies of acute mitral regurg
- ischemia
- endocarditis
- trauma
- torn chordae (MVP)
what is acute mr and hemodynamic effect
- sudden increase in volume on unprepared LV; because LA is not compliant, the blood shot back into Left atrium cant be dealt with, causing marked PAH, with decreased SV and CO
- acute MR :
history
bedside findings
- sudden onse SOB +/- chest pain
- apex impulse is at normal location, but see parasternal lift because of that RIGHT VENTRICLE dialtion because you have backup , still hear that systolic murmur at the apex
- HEAR S4 due to atrial kick with high output
you can hear P2 and give widened splitting(?)
what is the anatomy dysfunction of MVP
- leaflets billow into LA during systole due to floppy chordae tendinae
- MVP is more common in _____(gender), but more severe in ________ (gender)
women; men(tears chordae completely)
describe mismatch idea of MVP
- your lv cavity size is normal, but you have elongated, floppy chords
What drug can you give to dilate LV?
- beta blocker (decreases contractitlity usually)
what sound is important to hear with MVP
- mid systolic CLICK (not ejection), that induces a mid systolic murmur
for MVP, increasing LV cavity size does what to murmur?
decreased cavity?
- increased cavity is going to make murmur later/shorter
- decreased cavity is going to make mumur earlier/longer
hallmark of mitral stenosis is _______
early diastolic murmur
Name some etiologies of MS
- acute rheumatic fever
- narrowing of mitral valve to give decreased area (normal is greater than 4; mild is >1.5, mod is 1-1.5, severe <1.0)
- fused commisures
what proportion of patients with rheumatic heart disease can tell you they had a history of rheumatic fever? what presents?
- 50%
- in bed with arthritis, miss a lot of school, sick
AUTOIMMUNE
Jones criteria mnemonic
CANCER
- carditis (pancarditis)
- arthritis (migratory polyarthralgia)
- nodules (subcutaneous nodules
- chorea (Syndham’s)
- erythema
- rheumatic heart disease
what is the carditis characterization of RHD
- PANCARDITIS (can affect any layer)
describe apical impulse for mitral stenosis
- decreased because of decreased LV volume
what are possible results to left atrium for mitral stenosis?
- obstruction of flow from LA-LV, creating a diastolic gradient that can eitehr increase the Left atrial pressure… potentially cause dilation
symptoms of mitral stenosis
- dyspnea: pulmonary venous HTN from backup from left atritum… see in moderate cases only with exercise, then at rest
- orthopnea, sudden acute pulmonary edema
- decreased CO from decreased lv volume is giving fatigue… definitely problem with Afib
- palpitations because of Afib because atrium can dilate or not squeeze well
characterize carotid pulse of MS
- can’t get a lot of blood out of ventricle… decrease BP systolic, narrow PP
what happens wit MS jugular venous pulse
- giant a wave (trouble getting blood into right ventricle secondary to pulmonary artery hypertension)
- giant v wave… because of increased blood going to right atrium (increased right atrial filling)
T/F you can feel a strong apical impulse… if False, what are you looking for instead?
- F; parasternal lift
Waht is the graham-steele murmur
- loud P2
how does murmur of TR vary with respiration
- inspiration makes murmur of TR louder
Explain diastolic rumble for MS
- preceded by opening snap (diseased valve like MS makes noise when it opens)
- diastolic rumble leading into presystolic afccentuation
cxr finding and ekg finding of MS
- CXR: big left atrium
EKG: afib
catheritization finding between la and lv
- gradient seen between la and lv.. with increased pressure at la due to blockage not allowing great movement to lv
5 determinants of MS clinical severity
- OS relationship to second sound (2-OS interval)
- if <0.06… higher LA pressure, severe mitral stenosis
- length of diastolic rumble
- mean gradient (<5 mild; 5-10: moderate; >10 severe
- PAP systolic (matches hypertension criteria)
Valve gradient (already seen before)
valve gradietn is _______ dependent… so it can be changed via what mechanisms?
- flow;
- HR
- BP
- contractility
Name some complications of MS
- pulmonary arterial hypertension
- Right heart failure
- afib
- thromboemboli (pooling of blood in atrium)
- Hoarsness of voice: compression of recurrent laryngeal by LA
Name 3 treatment options of MS
- medical: beta blockers and anticoagulation thearpy… only use diuretics with heart failure
- surgery (valve replacement or repair of commissurotomy)
- Percutaneous balloon valvuloplasty
