Mitral valve disease Flashcards
RA: mean pressure RV: - peak systolic pressure - EDP PA : - systolic PAP - end systolic PAPA - mean PAP
mmHg
1) 3-4
2) - 20-24
- 4
3) - 20-25
- 8-9
- 13-19
PCWP LA: mean pressure LV: - peak systolic pressure - EDP
mmHg
1) 9
2) 9
3) - 130
- 8-12
Aorta :
- maximum systolic pressure
- end diastolic pressure
- mean pressure
mmHg
- 130
- 70
- 85
Vascular resistance ( dyne /sec/cm5)
- SVR = 1100
- Pulmonary resistance =70
Mitral valve stenosis
Narrowing of the mitral valve orifice < 3 cm2 with consequent impairement of the LV filling
Mitral valve stenosis can associated with
- Mitral valve insufficiency ( mitral valve disease)
- Aortic insufficiency
- ASD ( Lutembacher’s syndrome)
Etiology
- rheumatic (90%) Rare causes: (very rare) - Congenital - Neoplastic infiltration - Inflammatory diseases: SLE,RA - Mucopolysaccharidosis - Amyloidosis - Methysergide therapy
Pathophysiology ‘
- 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)
Pathophysiology ‘’
- 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 )
Clinical presentation I
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
Clinical presentation II
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
Clinical presentation III
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
Differential diagnosis
- Carey - Coombs murmur
- Atria myxoma
- Large vegetation( bacterial endocarditis)
- Austin - Flint murmur
- Tricuspid Stenosis
- ASD
- Cor triatriatum
Paraclinical investigation
- ECG
- Chest X ray
- Echocardiography
- Angiography and cardiac catheterization
ECG
- LA hypertrophy : P mitrale
- RV hypertrophy : V1 -tall R waves , incomplete RBBB
- Supraventricular arrhythmias : SVES , AFI ,AF
Chest Xray
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 ,
pulmonary edema
specific aspect : butterfly aspect
echocardiography
modifications at the level of mitral valve
M mode echocardiography
anterior + posterior part of mitral valve is fibrotic and calcified and the openning is very reduced
Doppler echocardiography
when flow linear - homogenous color
myxoma
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
Complication
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
Pathophysiological classification
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
Treatment
Curative = interventional
- Mitral valvulopathy ( PMC)
- Valvulotomy(rarely) +/- subvalvular apparatus
- Valvular prosthesis
- If there are contraindications to valvuloplasty - Soon after failure of PMC
Atrial fibrilation treatment
Anticoagulant treatment
AntivitK only
for all his life
Definition of
Mitral valve regurgitation
Incomplete closure of mitral valve orifice during systole with consequent LV-> LA regurgitation
Etiology of mitral valve regurgitation
- Inflammatory diseases:
- RA
- SLE
- Scleroderma - Degenerative diseases:
- Myxomatous degenerative (Barlow’s disease)
- Valvular + annular calcification (fibroelastic degeneration ) - Post bacterial endocarditis
- Structural changes:
- Chordae tendineae and / papillary muscles rupture
- Mitral annulus dilation
- HOCM
- Paraprosthetic - Ischemia
- Congenital
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
Clinical presentation
Symptoms :
- Asymptomatic / symptomatic due to rheumatic etiology
- Fatigue +- dyspnea
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
Paraclinical investigations
1.ECG : N or LAH,LVH,FA,nonspecific ST-T wave changes
- Chest Xray :
- LA dilation/LA appendage ± LV ( depending on the severity of MR)
- Pulmonary circulation redistribution - Echocardiography
- Angiography and cardiac catheterization
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)
Differential diagnosis of MR
Aortic stenosis
VSD
Tricuspid regurgitation
Complications of MR
- Bacterial endocarditis
- Arrhythmias (Atrial fibrilation ,flutter , supraventricular arrhythmias)
- Chronic or acute LVI -> acute PE ( pulmonary edema)
- Global HF
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
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
Mitral valve prolapse
Definition
Bulging or collapse of one or both mitral leaflets in the LA during ventricular systole
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
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
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
Synonyms of MV prolapse
- Click murmur syndrome
- Barlow’s syndrome
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
Paraclinical investigation
- ECG : N or rest/exercise changes:
- Arrhythmias
- Long QT
- Nonspecific T wave modifications ( negative in LII,LIII,aVF) - Chest Xray : Modified only in care of important MR
- Echocardiography
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)
Complications of MV prolapse
- Progressive MR
- Bacterial endocarditis
- Arrhythmias :
- PSVT
- VT ( ventricular tachycardia)
- VF ( ventricular fibrilation ) - Sudden cardiac death ( long QT)
- Progressive HF ( heart failure)
- Systemic emboli ( frequently TIA)
Treatment
MEDICAL (phrophylaxis of complications):
- beta blockers
- Antiarrhytmic drugs
- Endocarditis prophylaxis
SURGICAL:
- Valve /subvalvular reconstruction
- Valve prosthesis
Acute mitral regurgitation
Etiology
- CUSPS - traumatic rupture , bacterial endocarditis , LA myxoma
- CHORDAE TENDINAE - traumatic or spotaneous rupture , bacterial endocarditis , rheumatic disease
- PAPILLARY MUSCLES - Dysfunction or rupture due to severe ischemia or AMI , traumatic rupture , acute LV dilation
- 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
- VALVULAR TUMORS
- POST MITRAL VALVULOPLASTY
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!
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!
