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CARDIOLOGY > Mitral valve disease > Flashcards

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

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2
Q 
PCWP 
LA: mean pressure 
LV: 
- peak systolic pressure
- EDP
A

mmHg
1) 9

2) 9

3) - 130
- 8-12

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3
Q

Aorta :

  • maximum systolic pressure
  • end diastolic pressure
  • mean pressure
A

mmHg

  • 130
  • 70
  • 85
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4
Q

Vascular resistance ( dyne /sec/cm5)

A
  • SVR = 1100

- Pulmonary resistance =70

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5
Q

Mitral valve stenosis

A

Narrowing of the mitral valve orifice < 3 cm2 with consequent impairement of the LV filling

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6
Q

Mitral valve stenosis can associated with

A
  • Mitral valve insufficiency ( mitral valve disease)
  • Aortic insufficiency
  • ASD ( Lutembacher’s syndrome)
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7
Q

Etiology

A 
- rheumatic (90%)
 Rare causes: (very rare)
- Congenital 
- Neoplastic infiltration 
- Inflammatory diseases: SLE,RA
- Mucopolysaccharidosis
- Amyloidosis
- Methysergide therapy
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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)
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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 )
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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

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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
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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
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13
Q

Differential diagnosis

A
  1. Carey - Coombs murmur
  2. Atria myxoma
  3. Large vegetation( bacterial endocarditis)
  4. Austin - Flint murmur
  5. Tricuspid Stenosis
  6. ASD
  7. Cor triatriatum
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14
Q

Paraclinical investigation

A
  • ECG
  • Chest X ray
  • Echocardiography
  • Angiography and cardiac catheterization
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15
Q

ECG

A
  • LA hypertrophy : P mitrale
  • RV hypertrophy : V1 -tall R waves , incomplete RBBB
  • Supraventricular arrhythmias : SVES , AFI ,AF
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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 ,

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17
Q

pulmonary edema

A

specific aspect : butterfly aspect

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18
Q

echocardiography

A

modifications at the level of mitral valve

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19
Q

M mode echocardiography

A

anterior + posterior part of mitral valve is fibrotic and calcified and the openning is very reduced

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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

  1. Mitral valvulopathy ( PMC)
  2. Valvulotomy(rarely) +/- subvalvular apparatus
  3. Valvular prosthesis
    - If there are contraindications to valvuloplasty
  4. Soon after failure of PMC
25
Q

Atrial fibrilation treatment

A

Anticoagulant treatment
AntivitK only
for all his life

26
Q

Definition of

Mitral valve regurgitation

A

Incomplete closure of mitral valve orifice during systole with consequent LV-> LA regurgitation

27
Q

Etiology of mitral valve regurgitation

A
  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
Q

Pathophysiology ‘’’

Chronic progressive left ventricular insuficiency ( LV + eccentric LVH with progressive LV dilation)

A
  • 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
Q

Clinical presentation

A

Symptoms :

  • Asymptomatic / symptomatic due to rheumatic etiology
  • Fatigue +- dyspnea
30
Q

At examination

Mitral regurgitation

A

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
Q

Paraclinical investigations

A

1.ECG : N or LAH,LVH,FA,nonspecific ST-T wave changes

  1. Chest Xray :
    - LA dilation/LA appendage ± LV ( depending on the severity of MR)
    - Pulmonary circulation redistribution
  2. Echocardiography
  3. Angiography and cardiac catheterization
32
Q

Echocardiography

A
  • 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
Q

Differential diagnosis of MR

A

Aortic stenosis
VSD
Tricuspid regurgitation

34
Q

Complications of MR

A
  • Bacterial endocarditis
  • Arrhythmias (Atrial fibrilation ,flutter , supraventricular arrhythmias)
  • Chronic or acute LVI -> acute PE ( pulmonary edema)
  • Global HF
35
Q

Medical Treatment

A

In case of chronic LVI

  • Vasodilators
  • Diuretics
  • Tonicardiacs in case of chronic LVI
  • Beta blockers
  • Antibiotic prophylaxis for bacterial endocarditis, regardless of severity
36
Q

Surgical treatment ( corrective)

A
  • 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
Q

Mitral valve prolapse

Definition

A

Bulging or collapse of one or both mitral leaflets in the LA during ventricular systole

38
Q

Etiology of Mitral valve prolapse

A
  • 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
Q

Pathophysiology

Mechanism

A
  • 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
Q

Clinical presentation of

MV prolapse

A 
- 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
Q

Synonyms of MV prolapse

A
  • Click murmur syndrome

- Barlow’s syndrome

42
Q

Clinical presentation

MV prolapse

A

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
Q

Paraclinical investigation

A
  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
Q

Echocardiography in MV prolapse

A
  • 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
Q

Complications of MV prolapse

A
  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
Q

Treatment

A

MEDICAL (phrophylaxis of complications):

  • beta blockers
  • Antiarrhytmic drugs
  • Endocarditis prophylaxis

SURGICAL:

  • Valve /subvalvular reconstruction
  • Valve prosthesis
47
Q

Acute mitral regurgitation

Etiology

A
  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
Q

Acute MR

A

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
Q

Chronic MR

A 
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!

CARDIOLOGY (19 decks)

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