Mitral valve disease Flashcards
1
Q
RA: mean pressure RV: - peak systolic pressure - EDP PA : - systolic PAP - end systolic PAPA - mean PAP
A
mmHg
1) 3-4
2) - 20-24
- 4
3) - 20-25
- 8-9
- 13-19
2
Q
PCWP LA: mean pressure LV: - peak systolic pressure - EDP
A
mmHg
1) 9
2) 9
3) - 130
- 8-12
3
Q
Aorta :
- maximum systolic pressure
- end diastolic pressure
- mean pressure
A
mmHg
- 130
- 70
- 85
4
Q
Vascular resistance ( dyne /sec/cm5)
A
- SVR = 1100
- Pulmonary resistance =70
5
Q
Mitral valve stenosis
A
Narrowing of the mitral valve orifice < 3 cm2 with consequent impairement of the LV filling
6
Q
Mitral valve stenosis can associated with
A
- Mitral valve insufficiency ( mitral valve disease)
- Aortic insufficiency
- ASD ( Lutembacher’s syndrome)
7
Q
Etiology
A
- rheumatic (90%) Rare causes: (very rare) - Congenital - Neoplastic infiltration - Inflammatory diseases: SLE,RA - Mucopolysaccharidosis - Amyloidosis - Methysergide therapy
8
Q
Pathophysiology ‘
A
- Ms => LA pressure increases =>
- Diastolic LA-LV pressure gradient => turbulent flow
- Increased pressure in pulmonary veins + capillaries => venocapillary PH
- Increase in PCP :
- 18-20 mmHg => interstitial edema
- > = 30 mmHg => alveolar edema ( acute PE)
- Chronically > 20 mmHg => at first v-c ( arterial reactive PH ) , then arteriolar wall remodeling ( fixed arteriolar Ph , DUE TO INCREASED RESISTENCE )
- PAH => RVH with consequent RV dilation => RVI ( from this point on, the risk of acute PE decreases)
9
Q
Pathophysiology ‘’
A
- There is no left ventricular insufficiency in pure mitral stenosis
- LA dilation -> RV dilation -> RA dilation +/- functional tricuspid regurgitation
- Precapillary PH ( reversible ) -> mixed PH - pre and postapillary ( partially reversible or irreversible )
10
Q
Clinical presentation I
A
Symptoms :
- can be asymptomatic (-> up until 20 years since primary lesion ) , discovered at a routine checkup
- dyspnea,embolism,hemoptysis:
- Exertional dyspnea
- Exertional cough
- Acute PE
- Fatigue
- Palpitations
- Hemoptysis
- Complications
Endocarditis
11
Q
Clinical presentation II
A
Signs:
- Inspection:
- Mitral facies
- Peripheral cyanosis
- Jugular vein distension
- Edema
- Normal chest pain palpation or :
*Hartzer’s sign
*Apical diastolic thrill - Pulmonary systolic pulsation
Palpable S1 or the P component of S2
12
Q
Clinical presentation III
A
Auscultation(= diagnosis): *loud accenuated S1 *S2 split ( P component) *Opening snap -0.04-0.12'' -Well index : ( Q-Z1)-(A2- CD) * Diastolic rumble * +- pulmonary regurgitation murmur ( Graham- Steel ) \+- functional tricuspid regurgitation murmur
13
Q
Differential diagnosis
A
- Carey - Coombs murmur
- Atria myxoma
- Large vegetation( bacterial endocarditis)
- Austin - Flint murmur
- Tricuspid Stenosis
- ASD
- Cor triatriatum
14
Q
Paraclinical investigation
A
- ECG
- Chest X ray
- Echocardiography
- Angiography and cardiac catheterization
15
Q
ECG
A
- LA hypertrophy : P mitrale
- RV hypertrophy : V1 -tall R waves , incomplete RBBB
- Supraventricular arrhythmias : SVES , AFI ,AF
16
Q
Chest Xray
A
Because of the dilatation of the atrium , the pulmonary artery the heart disappears.Normally the heart on the left side has 3 arches:superior done by aorta , inferior arch done by left ventricle ,
17
Q
pulmonary edema
A
specific aspect : butterfly aspect
18
Q
echocardiography
A
modifications at the level of mitral valve
19
Q
M mode echocardiography
A
anterior + posterior part of mitral valve is fibrotic and calcified and the openning is very reduced
20
Q
Doppler echocardiography
A
when flow linear - homogenous color
21
Q
myxoma
A
Benign tumour often developed in the LA or attached to the mitral valve.This tumour is very mobile , can engage in the mitral orifice and prosuce diastolic murmur
22
Q
Complication
A
Increased LAp and PAH: - Dyspnea -Acute PE -Hemoptysis LA dilation : - Arrhythmias ( atrial fibrilation , flutter , supraventricular arrhythmias) - Embolism Resistance PAH => RVI Abnormal valvular structure + turbulent blood flow -> risk of bacterial endocarditis
23
Q
Pathophysiological classification
A
I:mild , >2 cm2 (MVS) , < 10-12 mmHg (PCP at rest ) ,CO: N, Asymptomatic or mild symptoms
II: moderate ,1,1-2 cm2 (MVS) ,>11 -17 mmHg ( PCP at rest) , CO:N , Mild to moderate dyspnea ; acute PE
III:severe , 0.8-1 cm2 (MVS),>18 mmHg ( PCP at rest ) , CO : ↓ ,Dyspnea at rest + acute PE
IV:extreme severe , <0.8 cm2 (MSV) ,>20-25 mmHg ( PCP at rest ) , CO : ↓↓ ,Severe PAH ,RVI , Dyspnea at rest , cyanosis
24
Q
Treatment
A
Curative = interventional
- Mitral valvulopathy ( PMC)
- Valvulotomy(rarely) +/- subvalvular apparatus
- Valvular prosthesis
- If there are contraindications to valvuloplasty - Soon after failure of PMC
25
Atrial fibrilation treatment
Anticoagulant treatment
AntivitK only
for all his life
26
Definition of
| Mitral valve regurgitation
Incomplete closure of mitral valve orifice during systole with consequent LV-> LA regurgitation
27
Etiology of mitral valve regurgitation
1. Inflammatory diseases:
- RA
- SLE
- Scleroderma
2. Degenerative diseases:
- Myxomatous degenerative (Barlow's disease)
- Valvular + annular calcification (fibroelastic degeneration )
3. Post bacterial endocarditis
4. Structural changes:
- Chordae tendineae and / papillary muscles rupture
- Mitral annulus dilation
- HOCM
- Paraprosthetic
5. Ischemia
6. Congenital
28
Pathophysiology '''
Chronic progressive left ventricular insuficiency ( LV + eccentric LVH with progressive LV dilation)
* Regurgitation => LV and LA volume overload:
- Dilation , icreased compliance , moderate increase in LA pressure
- Eccentric LVH => ring expansion ( dilatation) => aggravation of Mitral regurgitation
* Severe prognosis:
- EF ( Ejection fraction) < 40 %
- LVESV > 80 ml/m2 ( critical value : > 55ml/m2)
- End diastolic diameter of RV > 70 mm
29
Clinical presentation
Symptoms :
- Asymptomatic / symptomatic due to rheumatic etiology
- Fatigue +- dyspnea
30
At examination
| Mitral regurgitation
1.Mild MR
✔ Holosystolic murmur ( grade I-III/VI)
✔ Soft S1
✔Radiates to the axilla /base of the heart
2.Severe MR :
✔Anxiety , sweating
✔Cardiomegaly
✔Grade IV-VI murmur with equivalent apical palpator
✔Soft S1
✔ ↑ or split S2
✔ ± pulmonary crackles due to stasis , late signs of RVI
31
Paraclinical investigations
1.ECG : N or LAH,LVH,FA,nonspecific ST-T wave changes
2. Chest Xray :
- LA dilation/LA appendage ± LV ( depending on the severity of MR)
- Pulmonary circulation redistribution
3. Echocardiography
4. Angiography and cardiac catheterization
32
Echocardiography
- Doppler US confirms MP
- Can suggest the etiology based on architectural abnormalities
- Appreciates dilation of heart cavities
- Estimates LV function
- Estimates severity ( the existence and degree of PAH)
33
Differential diagnosis of MR
Aortic stenosis
VSD
Tricuspid regurgitation
34
Complications of MR
- Bacterial endocarditis
- Arrhythmias (Atrial fibrilation ,flutter , supraventricular arrhythmias)
- Chronic or acute LVI -> acute PE ( pulmonary edema)
- Global HF
35
Medical Treatment
In case of chronic LVI
- Vasodilators
- Diuretics
- Tonicardiacs in case of chronic LVI
- Beta blockers
- Antibiotic prophylaxis for bacterial endocarditis, regardless of severity
36
Surgical treatment ( corrective)
- Elective in case of chronic MR
- Types of interventions:
* MV reconstruction ± annuloplasty - whenever possible , it is preferable to prosthesis
* Prosthesis ( metallic / biological valve)
* Percutaneous mitral valve repair
37
Mitral valve prolapse
| Definition
Bulging or collapse of one or both mitral leaflets in the LA during ventricular systole
38
Etiology of Mitral valve prolapse
- primar ( myxomatous degeneration of mitral valve )
- secondary
* Marfan Syndrome
* Ehler - Danlos sd
* Muscular dystrophy
* Ischemic coronary artery disease
* Collagen disease
* HCM
* Congenital cardiac diseases
* Atrial myxoma
39
Pathophysiology
| Mechanism
- Myxomatous degeneration of the valves /chordae => ↑ laxity => valves bulging in the LA
- Rupture of Chordae or pillars
- Pillars' dyskinesia
Variable mitral regurgitation ( not mandatory )
- MR can be chronic or acute
40
Clinical presentation of
| MV prolapse
```
- Asymptomatic -> different degrees of LVI:
Various and nonspecific symptoms :
- Atypical thoracic pain
-Palpitations
- Dyspnea
- Exercise intolerance
-Vertigo
- Syncope
-Panic attacks or anxiety
- Hypoesthesia / paresthesia
- Skeletal abnormalities
```
41
Synonyms of MV prolapse
- Click murmur syndrome
| - Barlow's syndrome
42
Clinical presentation
| MV prolapse
Signs :
- Mid - endsystolic click
- End/pansystolic murmur ( depending on prolapse severity )
*Radiates to the axilla
*Radiated to the base of the heart ( posterior valve prolapse) => !!!
Differential diagnosis with AS
43
Paraclinical investigation
1. ECG : N or rest/exercise changes:
- Arrhythmias
- Long QT
- Nonspecific T wave modifications ( negative in LII,LIII,aVF)
2. Chest Xray : Modified only in care of important MR
3. Echocardiography
44
Echocardiography in MV prolapse
- MV displacement from the mitral annulus plane by > 3 mm in endsystolic MVP
- MV displacement from the mitral annulus plane by > 5 mm in pansystolic MVP
- Ruptured chordae tendineae
- Mitral regurgitation ( Doppler US)
45
Complications of MV prolapse
1. Progressive MR
2. Bacterial endocarditis
3. Arrhythmias :
- PSVT
- VT ( ventricular tachycardia)
- VF ( ventricular fibrilation )
4. Sudden cardiac death ( long QT)
5. Progressive HF ( heart failure)
6. Systemic emboli ( frequently TIA)
46
Treatment
MEDICAL (phrophylaxis of complications):
- beta blockers
- Antiarrhytmic drugs
- Endocarditis prophylaxis
SURGICAL:
- Valve /subvalvular reconstruction
- Valve prosthesis
47
Acute mitral regurgitation
| Etiology
1. CUSPS - traumatic rupture , bacterial endocarditis , LA myxoma
2. CHORDAE TENDINAE - traumatic or spotaneous rupture , bacterial endocarditis , rheumatic disease
3. PAPILLARY MUSCLES - Dysfunction or rupture due to severe ischemia or AMI , traumatic rupture , acute LV dilation
4. METALLIC OR BIOLOGICAL PROSTHESIS DYSFUNCTION - Damage of the cusp tissue ,annulus or skeletal fractures , perivalvular leak through detached sutures ( fixation in open position ) , damage of the disc , cusp or ball
5. VALVULAR TUMORS
6. POST MITRAL VALVULOPLASTY
48
Acute MR
Etiology :
- Bacterial endocarditis
- Ischemia
- Trauma
Pathophysiology
- ↑ LA pressure without dilation - ↑ pulmonary capillary pressure
Clinic : Sudden onset with CPE or cardiogenic shock
Chest Xray
Massive bilateral alveolar syndrome (white lungs) or rarely unilaterally on the right side ( in case of pillars rupture of the PMV)
Treatment
Emergency surgery
Diagnosis
Made using echocardiography which highlights the lesion and the mechanism!
49
Chronic MR
```
Etiology
- Myxomatous degeneration
- Fibroelastic degeneration
-RA
- Functional
+/- Ischemia ( frequent inferior LV wall akinesia)
```
Pathophysiology
- Progressive dilation + increased pressure in the LA and in the pulmonary capillaries
- Eccentric hypertrophy + dilation of the LV
Clinic
Late onset with chronic LV insufficiency
Chest Xray
- Double contour aspect of the right lower arch + convexity of the left middle arch ( LA dilation)
- Cardiomegaly with subdiaphragmatic LV apex dilated LV)
- Interstitial then alveolar syndrome
- Esophagus imprint
- Medical/surgical ( elective surgery)
Diagnosis
Made using echocardiography which highlights the lesion and the mechanism!
