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Cardiology > Mitral Regurgitation > Flashcards

Mitral Regurgitation Flashcards

1
Q

What causes mitral regurgitation?

A

Problems with MV parts (leaflet, chords, papillary muscle, annulus) will lead to failure of MV closing and cause MR

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2
Q

What problem can occur with leaflet overlap leading to MR?

A

decreased leaflet mobility = scarred, tied down

normal leaflet mobility = hole in leaflets

increased leaflet mobility = hypermobile / flail (ie. prolapse)

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3
Q

What are the two types of MR?

A

Leaflet / Chords abnormal = 1° mitral valve problem

LV distorted –> pulls mitral valve apart = 2° mitral regurgitation (leaflets / chords normal)

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4
Q

What is the most common cause of primary mitral valve problem?

A

Rheumatic mitral valve

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5
Q

What causes leaflet perforation?

A

Perforation due to leaflet destruction / degeneration

almost always from valve infection = endocarditis

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6
Q

What is another term for primary MR where there is increased leaflet mobility?

A

MV prolapse

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7
Q

What happens in MV prolapse?

A

Leaflet + chords stretch, billow into LA –> leaflet margins fail to coapt –> MR

OR

Flail leaflet = leaflet tip points into LA –> always has to be rupture of chords
(ie. still primary MV problem)

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8
Q

What is the most common cause of severe MR?

A

MVP

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9
Q

T or F: MVP show symptoms

A

F:
usually no symptoms, benign!
can be associated with vague chest pain / palpitations
sudden tensing of MV apparatus in mid-systole –> ‘click’

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10
Q

T or F: ECG and CXR are normal in MVP

A

T

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11
Q

What does echo show for MVP?

A

shows leaflet morphology, severity of prolapse + MR

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12
Q

What is the usual treatment for MVP?

A

usually none needed (NO endocarditis prophylaxis)
if severe MR develops –> consider MV repair
if MV irreparable –> replace MV

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13
Q

T or F: Ischemic papillary muscle is common

A

F: very rare

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14
Q

What happens in 2o MR involving ischemic papillary muscle?

A

Papillary muscle fails to ‘pull’ on chords / leaflet leaflet prolapses, billows into LA

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15
Q

What happens in 2o MR involving ischemic scarred LV?

A

Scarred papillary muscle (from old infarct) ‘pulls’ on chords / leaflet –> leaflet pulled open

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16
Q

What happens in 2o MR involving LV dilation?

A

Annulus dilates (usually because LV dilates) –> leaflet cannot cover area of annulus +pap. muscles move out of place

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17
Q

What are the top three common causes of MR?

A

Mitral valve prolapse syndrome = 1° MV disease
‘stretchy’ chords +leaflets (‘floppy valve’)
2° MR = 1° LV problem:
‘Ischemic’ MR = LV scar (old infarct) / (almost never true ischemia of papillary muscle)
Functional = LV dilates –> annulus stretches (from ischemic or non-ischemic LV dilation / dysfunction)

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18
Q

What is pathophysiological in MR?

A

Increased LA volume leads to:

  • increased diastolic MV flow
  • increased LV filling
  • increased LVP +/or LV volume

LV needs to accommodate both forward volume + volume of MR ejected backwards into LA
–> so need 2x ↑LV Output to maintain normal forward flow

LV contracts –> LVP > LAP –> lead to MR into LA because less afterload
–> more pressure builds up (LVP and BP) –> more MR

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19
Q

T or F: Acute MR is a severe illness

A

T

20
Q

What happens in acute MR?

A

No time for LA or LV to dilate (still ‘stiff’)
MR –> but stiff LA –> very high LAP –> very high pulmonary P’s –> severe pulmonary edema +/- poor forward output –> low BP

LA fills both from pulmonary veins and MR –> increased LV filling in diastole
–> increased LV filling in diastole –> increases potential LV output/contractility BUT LV stiffness limits amount of LV volume

21
Q

What kind of heart sounds are heard in acute MR?

A

S1 / S2 maybe normal
S3 = sound from loaded LV filling early in diastole
S4 = sound from stiff LV filling late in diastole
murmur = from turbulent LV to LA flow—tapers off

22
Q

T or F: you can expect cardiogenic shock in MR

A

T

23
Q

What are symptoms of cardiogenic shock?

A

BP may be very low
increased HR
apex non-displaced
lungs: severe edema –> +++ crackles

24
Q

T or F: in chronic MR there is also a rise pressure in lungs

A

F:
Chronic illness –> LA & LV dilate (less stiff)
Compliant (stretchy) LA / LV –> no ↑↑↑ pressures into lungs until late in time course

25
Q

What is the pathophysiology of chronic MR?

A

increased LV filling –> increased LV volume –> increased LV wall stress
–> compensatory increase in LV wall thickness
= lengthening & thickening of muscle fibers
= ‘ECCENTRIC’ LV HYPERTROPHY

26
Q

T or F: in chronic MR the LV can accept more volume without increase in LVP

A

T: because had more time to become compliant

27
Q

Without any further change to mitral valve, what would worsen chronic MR?

A

very high systLV Pressure

		- high Aortic blood pressure
		- narrowed aortic valve (aortic stenosis)
28
Q

How does chronic MR leads to worsened MR?

A

Longterm increased LV volume –> gradual, insidious decrease in LV systolic function AND
Both increase LV size + reduced LV function –> increased annulus dilation / papillary muscle stretch –> increased MR

29
Q

What happens as a result of reduced LV function in chronic MR?

A 
--> decompensation 
	decreased forward output
        fatigue
AND
	increased back- pressures
	increased LAP
	increased pulmonary P’s
	--> systolic heart failure
30
Q

How does chronic MR lead to conduction issues?

A

Long-standing drastically increases LA volume –> pulls wiring apart

- -> risk of atrial fibrillation (short circuits)
- -> risk of blood clots +  increased LAP --> systolic heart failure
31
Q

What may happen as a result of increased LAP in chronic MR?

A

Long-standing increased pulmonary venous pressures

- pulmonary hypertension
- right ventricular failure / dilation
- peripheral edema, low forward output
32
Q

What are some early symptoms of chronic MR?

A 
Symptoms of  increased backward pressure:
LEFT HEART FAILURE
		dyspnea
		orthopnea
		paroxysmal nocturnal dyspnea
33
Q

What are some later symptoms of chronic MR?

A

Symptoms of long-standing ↑↑LA back-pressure:
atrial fibrillation –> increased palpitations +/or clots / emboli

RIGHT HEART FAILURE (late)
peripheral edema + ascites, liver pain from venous backpressure
(decreased forward RV output, increased fatigue, weakness, +decreased dyspnea)

34
Q

What kind of heart sounds would be in chronic MR?

A

S1 variable, S2 early

S3: LV volume load

pansystolic (ie. holosystolic) murmur from turbulent MR flow, lasts through all of systole

diastolic murmur from torrential flow across MV in diastole = ‘flow rumble’

35
Q

What phys findings would be associated with chronic MR?

A

BP , HR normal
lungs: clear
LV apex enlarged, displaced, diffuse, hyperdynamic
palpable MR ‘thrill’

36
Q

What is a holosystolic murmur?

A

High-pitched (high pressure gradient)
Usually loudest at mitral area / apex
Radiates widely, but usually into axilla (usual central or posterior jet of MR)
tends to remain same intensity even if heart rate variability (unlike Aortic stenosis)

37
Q

What would one see in decompensated chronic MR?

A

BP maybe low
lungs: decreased edema ?
RV enlarged –> RV ‘heave’ , increased JVP, pulsating tender liver

38
Q

What may show in ECG for chronic MR?

A

may show LVH, LA enlargement

may show atrial fibrillation

39
Q

What may show in CXR for chronic MR?

A

enlarged LV, LA
may show prominent pulmonary veins
if decompensated –> pulmonary edema
–> RV enlarges

40
Q

What may show in echo for chronic MR?

A

can define leaflet, chord, annulus morphology
can assess severity of MR (+ other valve lesions)
can assess LA size, LV size, LV function
test of choice to assess MR

41
Q

What may show in cath for chronic MR?

A

can (crudely) estimate severity of MR
can assess LV function and pressures
only way to assess coronaries before surgery

42
Q

How to prevent MR?

A
  1. NO Antibiotics before dental work (NO more endocarditis prophylaxis)
  2. Maintain good dental hygiene (reduce risk infective endocarditis)
  3. Careful follow-up of asymptomatic patients with MR, counselling about main symptoms
  4. Regular echo exams to assess for LV size & function
43
Q

What is treatment of MR?

A

lower BP –> decrease LV pressure
–> decrease mitral regurgitation
Useful in acute MR
No proven benefit to BP lowering drugs (e.g. ACE inhibitors) if no hypertension in chronic MR (high BP would worsen MR)

Diuretics and nitrates (ie. venous dilator):
may help alleviate heart failure symptoms from excessive volume loading

Rate-slowing drugs:
if go into atrial fibrillation, best to prevent excessive tachycardia (+ need anticoagulant)

Anti-arrhythmic and rate-slowing drugs:
may help keep patient in normal rhythm (not routinely used), but need HR slowing

44
Q

T or F: dysfunctional LV’s tend to get WORSE after valve replacement

A

T because no longer can empty into low pressure LA, have to pump entirely into high pressure aorta

45
Q

Does a MV repair or replacement have better outcomes?

A

MV repair –> better outcomes than replacement

46
Q

When to have surgery (ie. replacement) for MR?

A

BP lowering drugs unproven to slow progression or delay need for surgery

Surgery if major symptoms OR if LV shows asymptomatic decrease in function / increase in size

Cardiology (29 decks)

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