Mitral valve disease

Question 1

What is mitral regurgitation?

Answer 1

Mitral regurgitation (MR), also known as mitral insufficiency, occurs when blood leaks back through the mitral valve during systole.

Question 2

How common is mitral regurgitation?

Answer 2

It is the second most common valve disease after aortic stenosis.

Question 3

What are the consequences of mitral regurgitation?

Answer 3

Regurgitation leads to a less efficient heart, as less blood is pumped through the body with each contraction.

Question 4

What are the risk factors for mitral regurgitation?

Answer 4

Risk factors include female sex, lower body mass, age, renal dysfunction, prior myocardial infarction, prior mitral stenosis or valve prolapse, and collagen disorders such as Marfan’s Syndrome and Ehlers-Danlos syndrome.

Question 5

What are some causes of mitral regurgitation?

Answer 5

Causes include coronary artery disease, mitral valve prolapse, infective endocarditis, rheumatic fever, and congenital factors.

Question 6

What symptoms are associated with mitral regurgitation?

Answer 6

Most patients are asymptomatic; however, symptoms may include fatigue, shortness of breath, and edema due to left ventricle failure, arrhythmias, or pulmonary hypertension.

Question 7

What signs can be observed in mitral regurgitation?

Answer 7

A pansystolic murmur described as ‘blowing’ is typically heard at the apex and radiates into the axilla. Severe MR may cause a widely split S2.

Question 8

What investigations are used for diagnosing mitral regurgitation?

Answer 8

Investigations include ECG (which may show a broad P wave), chest x-ray (showing cardiomegaly), and echocardiography (crucial for diagnosis and assessing severity).

Question 9

What are the treatment options for mitral regurgitation?

Answer 9

Treatment options include medical management with nitrates, diuretics, positive inotropes, and surgery in acute severe cases. Repair is preferred over replacement when possible.

Question 10

What is mitral stenosis?

Answer 10

Mitral stenosis describes the obstruction of blood flow across the mitral valve from the left atrium to the left ventricle.

Question 11

What are the consequences of mitral stenosis?

Answer 11

It leads to increases in pressure within the left atrium, pulmonary vasculature, and right side of the heart.

Question 12

What are the primary causes of mitral stenosis?

Answer 12

The primary cause is rheumatic fever.

Question 13

What are some rarer causes of mitral stenosis?

Answer 13

Rarer causes include mucopolysaccharidoses, carcinoid, and endocardial fibroelastosis.

Question 14

What are common features of mitral stenosis?

Answer 14

Common features include dyspnoea, pulmonary venous hypertension, haemoptysis, mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, and atrial fibrillation.

Question 15

What does a mid-late diastolic murmur indicate?

Answer 15

It is best heard in expiration and indicates mitral valve leaflets are still mobile.

Question 16

What are features of severe mitral stenosis?

Answer 16

In severe MS, the length of the murmur increases and the opening snap becomes closer to S2.

Question 17

What might a chest x-ray show in a patient with mitral stenosis?

Answer 17

Left atrial enlargement may be seen.

Question 18

What is the normal cross-sectional area of the mitral valve?

Answer 18

The normal cross-sectional area is 4-6 sq cm. A ‘tight’ mitral stenosis implies a cross-sectional area of < 1 sq cm.

Question 19

What is the management for patients with atrial fibrillation and mitral stenosis?

Answer 19

Patients require anticoagulation, with warfarin still recommended for moderate/severe MS.

Question 20

What is the management for asymptomatic patients with mitral stenosis?

Answer 20

They are monitored with regular echocardiograms, and percutaneous/surgical management is generally not recommended.

Question 21

What are the treatment options for symptomatic patients with mitral stenosis?

Answer 21

Treatment options include percutaneous mitral balloon valvotomy and mitral valve surgery (commissurotomy or valve replacement).

Question 22

What is mitral valve prolapse?

Answer 22

Mitral valve prolapse is common, occurring in around 5-10% of the population. It is usually idiopathic but may be associated with a wide variety of cardiovascular disease and other conditions.

Question 23

What are some associations of mitral valve prolapse?

Answer 23

Associations include congenital heart disease (PDA, ASD), cardiomyopathy, Turner’s syndrome, Marfan’s syndrome, Fragile X, osteogenesis imperfecta, pseudoxanthoma elasticum, Wolff-Parkinson White syndrome, long-QT syndrome, Ehlers-Danlos Syndrome, and polycystic kidney disease.

Question 24

What are the features of mitral valve prolapse?

Answer 24

Patients may complain of atypical chest pain or palpitations. Features include a mid-systolic click (occurs later if patient squatting) and a late systolic murmur (longer if patient standing).

Question 25

What are the complications of mitral valve prolapse?

Answer 25

Complications include mitral regurgitation, arrhythmias (including long QT), emboli, and sudden death.

Question 26

What are the most common heart valves that need replacing?

Answer 26

The most common valves which need replacing are the aortic and mitral valve.

Question 27

What are the two main options for heart valve replacement?

Answer 27

The two main options for replacement are biological (bioprosthetic) or mechanical.

Question 28

What is the origin of biological (bioprosthetic) valves?

Answer 28

Biological (bioprosthetic) valves are usually bovine or porcine in origin.

Question 29

What is a major disadvantage of biological (bioprosthetic) valves?

Answer 29

The major disadvantage is structural deterioration and calcification over time.

Question 30

Which patients typically receive bioprosthetic valves?

Answer 30

Most older patients (> 65 years for aortic valves and > 70 years for mitral valves) receive a bioprosthetic valve.

Question 31

Is long-term anticoagulation usually needed for bioprosthetic valves?

Answer 31

Long-term anticoagulation is not usually needed for bioprosthetic valves.

Question 32

What anticoagulant may be given for the first 3 months for bioprosthetic valves?

Answer 32

Warfarin may be given for the first 3 months depending on patient factors.

Question 33

What is given long-term for patients with bioprosthetic valves?

Answer 33

Low-dose aspirin is given long-term.

Question 34

What is the most common type of mechanical valve now implanted?

Answer 34

The most common type now implanted is the bileaflet valve.

Question 35

What is a major disadvantage of mechanical valves?

Answer 35

The major disadvantage is the increased risk of thrombosis, meaning long-term anticoagulation is needed.

Question 36

What anticoagulant is preferred for patients with mechanical heart valves?

Answer 36

Warfarin is still used in preference to DOACs for patients with mechanical heart valves.

Question 37

When is aspirin normally given for patients with mechanical valves?

Answer 37

Following the 2017 European Society of Cardiology guidelines, aspirin is only normally given in addition if there is an additional indication, e.g. ischaemic heart disease.

Question 38

What is the target INR for aortic valves?

Answer 38

The target INR for aortic valves is 3.0.

Question 39

What is the target INR for mitral valves?

Answer 39

The target INR for mitral valves is 3.5.

Question 40

Are antibiotics recommended for common procedures to prevent endocarditis?

Answer 40

Following the 2008 NICE guidelines for prophylaxis of endocarditis, antibiotics are no longer recommended for common procedures such as dental work.