Mitral Valve Disease Flashcards
What are the components of the mitral valve?
Mitral annulus Anterior and posterior leaflets Chordae tendineae Papillary muscles LV wall
What is by far the most common cause of mitral valve stenosis?
Rheumatic heart disease
What happens to the mitral valve in the case of rheumatic heart disease?
Fusion of valve cusps
Fibrosis and calcification of valve leaflets
How does the fused valve in mitral stenosis appear on echo?
Hockey stick
What occurs hemodynamically in mitral stenosis?
Increase in pressure gradient between LA and LV
Increased LA pressure –> increased pulmonary venous and capillary pressure
What symptoms occur with mitral valve stenosis?
Fatigue Dyspnea on exertion Shortness of breath Orthopnea Paroxysmal nocturnal dyspnea
Basically symptoms of congestive heart failure
What is a possible side effect due to the dilation of the LA?
Atrial fibrillation may result
What is the hemodynamic result of the increased pulmonary venous and capillary pressure in some patients?
Increased pulmonary arteriolar resistance –> increased pulmonary artery pressure –> increased RV pressure –> RV failure
What are additional clinical symptoms of mitral valve stenosis that can occur in some patients that develop RV failure?
Atrial fibrillation Pulmonary hypertension Right sided heart failure - Edema, GI , Liver congestion, ascites Hoarseness
What are physical findings of mitral stenosis?
Mitral facies (purplish, ruddy cheeks) - “classic” but never seen
Normal arterial pulse
Normal apical impulse
Normal jugular venous pressure
All normal until pulmonary hypertension develops
What will be heard on auscultation of mitral stenosis?
Opening snap
Diastolic low-pitched murmur
Loud S1
Describe what is causing the opening snap of mitral stenosis
Sudden tensing of valve leaflets during opening causes another sound after S2 (during diastole)
Describe what is causing the low-pitched diastolic murmur in mitral stenosis
Low pressure gradient between LA and LV
May crescendo right before S1 with LA contraction
Describe what is causing the Loud S1 in mitral stenosis
Presystolic accentuation of the low-pitched murmur
Caused by contraction of the LA
What sign of mitral stenosis can you see on an xray?
Left atrial enlargement
What causes primary mitral valve regurgitation?
Problems with any of the mitral valve components, not one specifically
What causes secondary mitral valve regurgitation?
Dilation of the LV and the annulus
What occus hemodynamically in mitral valve regurgitation
Elevation of LA volume and pressure –> LA dilation
Reduction in forward output
Volume-related stress on LV –> LV dilation
What is the difference between chronic and acute mitral regurgitation?
Chronic - occurs over time, LA dilates - increased compliance, less elevated pressure in LA
Acute - occurs acutely, LA doesn’t have time to dilate - normal compliance, sudden high pressure in LA –> pulmonary edema
What are clinical manifestations of mitral regurgitation?
Heart failure
Fatigue Dyspnea on exertion Shortness of breath Orthopnea Paroxysmal nocturnal dyspnea
What are physical findings of mitral regurgitation?
Holosystolic murmur
S3
Hyperdynamic apex with palpable thrill
What is causing the holosystolic murmur hear in mitral regurgitation?
Regurgitation throughout systole
Stays the same, no crescendo
What is causing the S3 in mitral regurgitation?
Large volume going into ventricle stops suddenly
What is a phrase that can be used to remember the sounds heard in mitral regurgitation?
“slush-ing in”
Slush = S1, ing = S2, in = S3
What is a summation gallop?
When S3 and S4 exist very close together, they sound like a murmur
What happens to the valve in mitral valve prolapse?
Billowing of leaflets into LA (looks like parachute) due to loose myxomatous tissue replacing the normal dense collagen and elastin matrix of the valve leaflets
What causes the myxomatous degeneration of the leaflets?
Inherited as autosomal dominant disorder
OR
Associated with connective tissue diseases like Marfan’s or Ehlers-Danlos
What are symptoms of mitral prolapse?
None, unless develop some mitral regurgitation
What can you hear upon auscultation in mitral prolapse?
Mid to late systolic click - when leaflets billow back up
Late systolic murmur
MOST IMPORTANT: the timing of these changes with maneuvers
Will you hear the click and murmur of mitral prolapse earlier when standing or lying down?
Standing
Less volume (pressure) in left ventricle when standing - won’t need to contract as much to reach pressure when click occurs
Will you hear the click and murmur of mitral prolapse earlier when squating or lying down?
Lying down
Squat causes left ventricle to expand - will need to contract more to reach pressure when click occurs than if lying down
What can occur if the elongated chordae in mitral prolapse rupture?
Get severe acute mitral regurgitation
Flail leaflet
