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
When doing a PISA radius measurement, how do you want to change the baseline for MS vs MR?
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
What is the equation for MVA based on PISA?
MVA = A_PISA * Aliasing velocity / Peak transmitral velocity
27
What is the equation for A_PISA?
A_PISA = 2π r^2 * α/180
28
How is stroke volume calculated?
Area * VTI through that area
29
What are the ways for calculating MVA?
- 220/PHT - 760/DT - PISA - Continuity equation
30
What is the equation for calculating regurgitant volume?
Reg vol = SV_MV - SV_LVOT Remember, SV = A*VTI
31
What are the regurgitant volume cutoffs for mild, moderate and severe MR?
Mild: <30cc Moderate: 30-59cc Severe: >/= 60cc
32
How do you calculate stroke volume going through the mitral valve?
CWD through the mitral valve --> measure VTI of diastolic inflow --> multiply by MVA (need to also calculate MVA)
33
What is the equation for calculating regurgitant fraction?
RF = backwards flow / total flow RF = regurgitant volume / SV_MV inflow
34
What are the cutoffs for mild, moderate and severe MR by regurgitant fraction?
Mild: <30% Moderate: 30-49% Severe: >/= 50%
35
What is the equation for regurgitant orifice area?
Area = volume / distance ROA = regurgitant volume / VTI_MR
36
What are the cutoffs for mild, moderate and severe MR by EROA?
Mild: <0.2 cm2 Moderate: 0.2-0.39 cm2 Severe: >/=0.4 cm2
37
What two echo images are needed to calculate PISA?
CFD with Nyquist optimized to measure shell radius CWD to measure peak velocity
38
What are the cutoffs for mild, moderate and severe MR by vena contracta?
Mild: <3mm Moderate: 3-7mm Severe: >7mm
39
What are the cutoffs for mild, moderate and severe rheumatic MS by mitral valve area?
Mild: >2.5 cm3 Moderate: 2.5-1.6 cm3 Severe:
40
What are the cutoffs for mild, moderate and severe MS by PHT?
Mild: <100 msec Moderate: 100-140 msec Severe: >/= 150msec
41
What are the cutoffs for mild, moderate and severe MS by mean gradient?
Mild: <5 mmHg Moderate: 5-10 mmHg Severe: >10 mmHg
42
On 3D imaging of the MV (oriented to surgeon's view), what structure is seen to the left of the mitral valve annulus?
The LAA
43
What are the four ways you can calculate the mitral valve area?
- 220/PHT - 760/DT - PISA - Continuity equation