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1. PTE Masters > Mitral Valve > Flashcards

Mitral Valve Flashcards

1
Q

What is the most common cause of MS in adults?

A

Rheumatic fever

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2
Q

Which papillary muscle is more likely to rupture?

A

The posteromedial papillary muscle (receives blood supply from only RCA in 70% of patients)

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3
Q

What is the short axis of the mitral valve and where is it best measured? What is its normal value?

A

The anterior-posterior axis; best measured in the ME LAX view.

It is the highest point in the annulus (the “high axis”).

Normal <3.6cm

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4
Q

What is the commissural axis of the mitral valve and where is it best measured?

What is the normal size?

A

The long axis; best measured in the ME commissural view.

It is the lowest point in the annulus (the “low axis”).

Normal <46mm

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5
Q

Which TEE view shows the high axis of the mitral valve?

A

ME LAX (gives us the AP diameter)

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6
Q

Which view is best for looking at the subvalvular apparatus?

A

TG 2C
Shows the posteromedial papillary muscle (closest to probe)

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7
Q

What is billowing, prolapse, and flail?

A

Billowing: body of leaflet above annular plane, tip below annular plane

Prolapse: leaflet tip above annular plane

Flail: ruptured chord, entire leaflet above annular plane

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8
Q

What is Carpentier’s classification of MR?

A

Type I: normal leaflet motion (annular dilation or perforation)
Type II: excessive leaflet motion (prolapse or flail)
Type IIIa: restricted in both systole and diastole (Rheumatic heart disease)
Type IIIb: restricted in systole (LV/LA dilation)

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9
Q

What are possible etiologies of MR?

A
  • Myxomatous degeneration (most common in developed countries)
  • Rheumatic disease (most common in developing nations)
  • Ischemia (PM dysfunction/rupture)
  • Cardiomyopathy (dilated, IHSS)
  • Endocarditis
  • Congenital
  • Connective tissue disease
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10
Q

What is the cutoff for mild, moderate and severe MR by vena contracta?

A

Mild: <0.3cm
Moderate: 0.3-0.7cm
Severe: >0.7cm

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11
Q

What is the cutoff for severe MR by MR jet area?

A

> 10cm2

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12
Q

What is the cutoff for severe MR by EROA?

A

> /= 0.4cm2

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13
Q

What echo sign is seen in rheumatic mitral stenosis?

A

Diastolic doming of the anterior mitral valve leaflet forming a “hockey stick” appearance and immobile posterior leaflet

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14
Q

Risk factors for SAM after MVr

A

Small:
- Mitral-aortic angle <120 degrees
- C-sept <2.5cm
- AL/PL ratio <1.3
- Small, non-dilated LV (LVIDd <4.5cm)
- Small annuloplasty ring

Big:
- AMVL length >20mm
- PMVL length >15mm
- Basal septal thickness >1.5cm

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15
Q

When will the MR jet will be directed away from a restricted leaflet?

A

SAM

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16
Q

Causes of mitral stenosis

A
  • Rheumatic heart disease (most common in developed and undeveloped countries both)
  • Left atrial myxoma
  • Severe MAC
  • Thrombus
  • Parachute MV
  • Congenital MS
  • Subvalvular mitral ring
  • Cortriatriatum sinister
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17
Q

How does severe AR or decreased LV compliance affect mitral valve area by pressure half time?

A

Will cause the degree of MS to be underestimated because of a rapid rise in LV diastolic pressure leading to more rapid equilibration of pressures between the LA and LV

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18
Q

Factors that can cause the mitral valve mean gradient to be over- or underestimated

A
  • Severe MR: overestimate
  • Angle of incidence is off: underestimate
  • Decreased LV compliance: overestimate
  • Impaired LV active relaxation: underestimate
  • Increased HR: increases mean gradient
  • Increased stroke volume: increases mean gradient
19
Q

How does severe MR affect the MV mean gradient?

A

Increases the LAP leading to higher gradient across the mitral valve (more volume through the same area = higher pressure)

20
Q

How does decreased LV compliance affect the MV mean gradient?

A

Causes restrictive inflow pattern on transmitral doppler inflow velocities = overestimation of the mean graident

21
Q

How does impaired LV active relaxation affect the MV mean gradient?

A

Impaired active relaxation leads to decreased LV filling = less volume through the same area = lower pressure (underestimation)

22
Q

How does HR affect the MV mean gradient?

A

Higher HR = higher MG
Lower HR = lower MG

23
Q

How do changes in stroke volume affect the MV mean gradient?

A

Larger SV = higher MG
Smaller SV = lower MG
Due to changes in diastolic inflow across the MV

24
Q

What general equation is PISA based on?

A

The continuity equation!

25
Q

When doing a PISA radius measurement, how do you want to change the baseline for MS vs MR?

A

Move the baseline towards the lesion

For MS, move the baseline down (flow is away from probe)

For MR, move the baseline up (flow is towards the probe)

26
Q

What is the equation for MVA based on PISA?

A

MVA = A_PISA * Aliasing velocity / Peak transmitral velocity

27
Q

What is the equation for A_PISA?

A

A_PISA = 2π r^2 * α/180

28
Q

How is stroke volume calculated?

A

Area * VTI through that area

29
Q

What are the ways for calculating MVA?

A
  • 220/PHT
  • 760/DT
  • PISA
  • Continuity equation
30
Q

What is the equation for calculating regurgitant volume?

A

Reg vol = SV_MV - SV_LVOT

Remember, SV = A*VTI

31
Q

What are the regurgitant volume cutoffs for mild, moderate and severe MR?

A

Mild: <30cc
Moderate: 30-59cc
Severe: >/= 60cc

32
Q

How do you calculate stroke volume going through the mitral valve?

A

CWD through the mitral valve –> measure VTI of diastolic inflow –> multiply by MVA (need to also calculate MVA)

33
Q

What is the equation for calculating regurgitant fraction?

A

RF = backwards flow / total flow

RF = regurgitant volume / SV_MV inflow

34
Q

What are the cutoffs for mild, moderate and severe MR by regurgitant fraction?

A

Mild: <30%
Moderate: 30-49%
Severe: >/= 50%

35
Q

What is the equation for regurgitant orifice area?

A

Area = volume / distance

ROA = regurgitant volume / VTI_MR

36
Q

What are the cutoffs for mild, moderate and severe MR by EROA?

A

Mild: <0.2 cm2
Moderate: 0.2-0.39 cm2
Severe: >/=0.4 cm2

37
Q

What two echo images are needed to calculate PISA?

A

CFD with Nyquist optimized to measure shell radius

CWD to measure peak velocity

38
Q

What are the cutoffs for mild, moderate and severe MR by vena contracta?

A

Mild: <3mm
Moderate: 3-7mm
Severe: >7mm

39
Q

What are the cutoffs for mild, moderate and severe rheumatic MS by mitral valve area?

A

Mild: >2.5 cm3
Moderate: 2.5-1.6 cm3
Severe: </= 1.5 cm3

40
Q

What are the cutoffs for mild, moderate and severe MS by PHT?

A

Mild: <100 msec
Moderate: 100-140 msec
Severe: >/= 150msec

41
Q

What are the cutoffs for mild, moderate and severe MS by mean gradient?

A

Mild: <5 mmHg
Moderate: 5-10 mmHg
Severe: >10 mmHg

42
Q

On 3D imaging of the MV (oriented to surgeon’s view), what structure is seen to the left of the mitral valve annulus?

43
Q

What are the four ways you can calculate the mitral valve area?

A
  • 220/PHT
  • 760/DT
  • PISA
  • Continuity equation

1. PTE Masters (14 decks)

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