Mitral & Tricuspid valve disease Flashcards
Mitral valve anatomy
1) annulus
2) leaflets
3) chordae- attach tips of leaflets to papillary muscle
4) papillary muscles- anchor leaflets to myocardium
what does mitral valve separate?
LA and LV
when does mitral valve open and when does it close
open in diastole
close in systole (prevent backflow)
what happen in mitral stenosis
decr mitral valve open
obstruct flow from LA to LV
incr Pressure in LA, pulm vasculature, right heart
most common etiology of mitral stenosis
rheumatic MS
calcific MS (old age and renal disease)
causes of rheumatic stenosis
acute rheumatic fever (only 50%)
what is acute rheum fever
inflammation of heart, skin, CT by URI (group A strep)
2-3 wk after strep throat
effect of acute rheum fever in heaeart
inflammation of valvular endocardium –> chronic rheum heart disease
clinical effect of mitral stenosis
1) dyspnea
2) hemoptysis
3) pulm HTN
4) R sided heart failure (edema,ascites)
5) afib
6) embolic stroke
what causes dyspnea in mitral stenosis
(incr LA pressure, incr pulm venous + capillary P –> pulm edema (fluid in pulm interstitium)
what causes hemoptysis in mitral stenosis
incr pulm vascular pressure, rupture of bronchial vein into lung parenchyma
what causes right sided heart failure in mitral stenosis
RV pump against high resistance from pulm HTN
what causes afib in mitral stenosis
chronically high LA pressure –> LA dilation
what causes emb stroke in mitral stenosis
stagnant blood flow in LA –> blood clot
what heart sound with mitral stenosis
Listen over apex
1) loud S1 (high AV pressure gradient keeps MV open until last sec when systole closes valve)
2) opening snap after S2
3) diastolic rumble (low freq descrendo due to turbulence across stenotic valve)
severity of MS inversely proportional to ____
interval between S2 and opening snap
high LA pressure opens valve earlier
Mitral stenosis on ekg?
1) left atrial enlargement
2) RVH if pulm HTN present
3) afib
Mitral stenosis on echo?
1) left atrial enlarge
2) poor open of valve during diastole
3) thick leaflet, fusion of commissure
mitral stenosis treatment
1) beta blocker to slow HR so more time for blood to cross valve
2) diuretic to treat CHF sx
3) anticoag if afib = warfarin
4) mitral valve replacement
types of mitral valve stenosis interventions
percutaneous balloon mitral valvuloplasty vs. valve replacement
define percutaneous balloon mitral valvuloplasty
1) catheter into LV
2) pull balloon until against mitral valve, then expand the balloon
3) open mitral valve and relieve stenosis
indications for intervention with mitral stenosis
1) sx
2) afib
3) pulm HTN
mitral regurg define
inadeq mitral valve closure so blood flow back into LA during systole
causes of mitral regurg?
1) myxomatous degeneration (mitral valve prolapse)- MAIN
2) chordal rupture and LV dysfxn)
3) endocarditis (valve deform/perf)
4) rheum valve disease
5) LV enlargement (stretch mitral annulus/papillary)
mitral regurg physical exam
holocystolic murmur heard at apex and radiate to axilla
mitral valve prolapse
asymptomatic and benign
concern for mitral regurg
hemodynamics of mitral regurg
1) part of LV stroke volume eject backwards
2) incr LA volume/pressure –> pulm HTN + edema
3) decr fwd CO
4) stress on LV
clinical effect of mitral regurg
CHF
1) dyspnea on exertion
2) orthopnea
3) parox nocturnal dyspnea
4) edema
LA Dilation
1) afib
treatment of mitral regurg- meds
diuretics for CHF
decr afterload (ACE inhib, ARB)
treatment of mitral regurg- surgery
mitral valve repair (preferred) or replacement
surgical indication for chronic Mitral regurg
1) sx
2) LV dilation
3) decr LV systolic fxn
4) new afib
5) pulm HTN
tricuspid valve fxn
open in diastole for RA–> RV
close in systole to prevent backflow blood into RA
tricuspid regurg
during systole, blood backflow into RA
complications of tricuspid regurg
incr RA pressure –> incr venous pressure
sx of tricuspid regurg
1) LE edema
2) ascites
3) hepatic congestion (from high RA Pressure)
4) Palpitations
5) Fatigue (low CO)
6) RV enlargement and RV dysfunction
etiology of tricuspid regurg
1) 80% cases fxnal (no problems with tricuspid valve) due to annular dilation and leaflet restriction from RV P + V overload
murmur in tricuspid regurg
holocystolic murmur along sternal border
louder with inspiration b/c inspiration incr venous return to R heart
physical exam in tricuspid regurg
1) JVD with v wave (blood back up)
2) hepatomegaly
treatment of tricuspid regurg
if functional,
1) treat underlying cause of RV pressure overload
meds = diuretics surgery = tricuspid repair (more common)/replacement
tricuspid stenosis cause
rheumatic heart disease
tricuspid stenosis murmur
similar to mitral stenosis (heard near sternum)
incr with inspiration
sx of tricuspid stenosis
1) dyspnea
2) edema
3) with mitral stenosis
treatment of tricuspid stenosis
1) diuretics
2) tricuspid valve surgery
aortic insufficiency secondary to (2)
1) valvular disease
2) aortic root disease
what test to measure aortic insufficiency severity and ventricular dilation/dysfunction
echo
indications for aortic valve replacement
1) sx
2) LV dilation
3) LV dysfunction
If pulmonary hypertension has developed in mitral stenosis what happens on exam?
1) loud P2
2) RV thrill or lift
3) JVD
4) tricuspid regurgitation murmur
mitral valve prolpase define
XS mitral leaflet tissue so movement of mitral leaflets into LA during systole
mitral valve prolapse mostly sporadic or hereditary
sporadic
VERY BENIGN!!!!!!
mitral valve murmur
1) midsystolic click (sudden tensing of chordae tendinae + leaflet)
2) late systolic murmur
symptoms of mitral valve prolapse if problems arise
1) atrial arrhythmias (a-fib)
2) LV dilation, dysfunction
3) HF (dyspnea, orthopnea, edema)
symptoms of functional mitral regurgitation
1) S3, S4
2) loud P2 if pulmonary hypertension present
3) lateral displacement of apical impulse
4) edema, crackles, JVD
manuevers that make mitral valve prolapse murmur louder
decr LV size intensify and prolong murmur
1) valsalva
2) dehydration
manuevers that make mitral valve prolapse murmur quieter
1) squatting
2) hydration
treatments for functional mitral regurgitation
1) meds to treat underlying cardiomyopathy
ACE inhib beta blockers spironolactone revascularization biventricular pacing
2) Surgery with severe symptomatic MR + persistent NYHA 3-4
