Mitral Regurgitation Flashcards

1
Q

MR Etiology

A
  • Rheumatic
  • Degenerative
  • Ischemic
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2
Q

MR Mechanisms

A
  • Leaflet retraction (fibrosis or calcification)
  • MV annular dilation
  • Chordal changes (rupture, elongation, shortening or tethering)
  • LV dysfunction +/- papillary muscle involvement
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3
Q

MR Presentation of Sx

A
  • Asymptomatic
  • DOE
  • CHF
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4
Q

Classic PE finding of MR

A

Holosystoic murmur heard at apex, radiating to axilla

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5
Q

Characteristics of Myxomatous MR

A
  • Acquired: fibroelastic deficiency in older patients
  • Congenital: excessive, weak fibroelastic connective tissue
  • Leaflets: thickened and spongy
  • Annulus: thickented and dilated
  • Changes more pronounced in younger patients (Barlow syndrome)
    • Less obvious is older patients
  • Chordal rupture likely due to:
    • Defective collagen
    • Underlying papillary muscle fibrosis and dysfunction
    • Posterior chorde most likely to rupture
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6
Q

MR and Echocardiography

A
  • Best overall diagnostic modality, can visulaize mechanism
  • Quantitate regurgitation
  • MV prolapse
  • Directon of jet:
    • Anterior (septal): posterior leaflet prolapse
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7
Q

MR and Cardiac Catheterization

A
  • Quantitate regurgitation
  • Assess function of pulmonary hypertension
  • Assess coronaries for CAD
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8
Q

MCC of MR

A

MV prolapse

(2-6% of poplulation)

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9
Q

Natural History of MR

A
  • Prolonged asymptomatic phase
  • Accelerated phase
  • Ruptured chordae tendinae
  • Men age > 45 subject to complications
  • Sudden death rate: <1%/year
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10
Q

Annual sudden death rate for MR

A

<1% per year

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11
Q

MR indications for operation

A
  • Acute symptomatic MR
  • Symptomatic or Asymptomatic MR with LV dysfunction
    • Mild (EF 50-60%, Systoic Dimension 45-50 mm)
    • Moderate (EF 30-50%, Systolic Dimension 50-55 mm)
    • Severe (EF < 30%, Systolic Dimension > 55 mm)
  • Asymptomatic with AFib or Pulmonary Hypertension
    • PA > 50 (rest) or >60 (with exercise)
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12
Q

Surgical Approaches to MV

A
  • Left thoracotomy (rare, mostly historical)
  • Right thoracotomy
    • Redo MVR or TV repair
  • Median sternotomy
    • Interatrial groove
    • Interatrial groove + SVC detachment
    • Superior via dome of LA
    • Trans-septal
      • Associated TV repair, Afib
  • Partial sternotomy
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13
Q

Techniques of MV Repair

A
  • Reduction annuloplasty
  • Triangular resection
  • Quadrangular resection
  • Sliding posterior leaflet repair
  • Artificial chordae
  • Posterior leaflet transfer
  • Combined anterior leaflet augmentation and posterior reduction
  • Anterior leaflet augmentation
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14
Q

Operations for MR

A
  • MV Repair
    • Likely with posterior leaflet prolapase or ruptured chordae
    • Less likely with anteiror leaflet prolapse
  • Choradal Sparing MVR
    • Bioprosthesis
    • Mechanical
    • Mitral homograft
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15
Q

MV Repair Outcomes

A
  • Hospital mortality (non-ischemic MR): 0-1%
  • Mortality for IMR:
    • Low-risk patients have improved hospital mortality with Repair over replacement
    • No surival benefit for repair over replacement
    • Survival after MVR/Repair + CABG worse for IMR compared to rheumatic or degenerative MR
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16
Q

3 key factors to consider for chronic, IMR

A
  1. Presence/severity of CAD
  2. Severity of MR
  3. Presence of LV dysfunction
17
Q

Treatment principles of chronic IMR

A
  • Mild (1+) MR: can be left alone
  • Modeate (2+) MR: surgical tx controversial
    • If CHF, will benefit most form CABG+MV Repair
  • Severe (3-4+) MR: needs surgery
18
Q

Outcome after MV Repair

A
  • Freedom form reoperation: 80-95% at 10-15 years
  • Repair more effective for myxomatous (rather than rheumatic) disease
  • Residual MR is usually immediately present after repair (rather than developing later)
  • Recurrent regurgitation after repair:
    • Inadequate operation
    • Progression of disease
19
Q

Factors that may increase ris of late reopeation after MV Repair

A
  • Rheumatic diease
  • Anterior leaflet degenerative changes
  • Residual MR after initial operation