Mitral Valve Disease

Question 1

What are the components of the mitral valve?

Answer 1

Mitral annulus
Anterior and posterior leaflets
Chordae tendineae
Papillary muscles
LV wall

Question 2

What is by far the most common cause of mitral valve stenosis?

Answer 2

Rheumatic heart disease

Question 3

What happens to the mitral valve in the case of rheumatic heart disease?

Answer 3

Fusion of valve cusps

Fibrosis and calcification of valve leaflets

Question 4

How does the fused valve in mitral stenosis appear on echo?

Answer 4

Hockey stick

Question 5

What occurs hemodynamically in mitral stenosis?

Answer 5

Increase in pressure gradient between LA and LV

Increased LA pressure –> increased pulmonary venous and capillary pressure

Question 6

What symptoms occur with mitral valve stenosis?

Answer 6

Fatigue 
Dyspnea on exertion
Shortness of breath
Orthopnea
Paroxysmal nocturnal dyspnea

Basically symptoms of congestive heart failure

Question 7

What is a possible side effect due to the dilation of the LA?

Answer 7

Atrial fibrillation may result

Question 8

What is the hemodynamic result of the increased pulmonary venous and capillary pressure in some patients?

Answer 8

Increased pulmonary arteriolar resistance –> increased pulmonary artery pressure –> increased RV pressure –> RV failure

Question 9

What are additional clinical symptoms of mitral valve stenosis that can occur in some patients that develop RV failure?

Answer 9

Atrial fibrillation
Pulmonary hypertension
Right sided heart failure
- Edema, GI , Liver congestion, ascites
Hoarseness

Question 10

What are physical findings of mitral stenosis?

Answer 10

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

Question 11

What will be heard on auscultation of mitral stenosis?

Answer 11

Opening snap
Diastolic low-pitched murmur
Loud S1

Question 12

Describe what is causing the opening snap of mitral stenosis

Answer 12

Sudden tensing of valve leaflets during opening causes another sound after S2 (during diastole)

Question 13

Describe what is causing the low-pitched diastolic murmur in mitral stenosis

Answer 13

Low pressure gradient between LA and LV

May crescendo right before S1 with LA contraction

Question 14

Describe what is causing the Loud S1 in mitral stenosis

Answer 14

Presystolic accentuation of the low-pitched murmur

Caused by contraction of the LA

Question 15

What sign of mitral stenosis can you see on an xray?

Answer 15

Left atrial enlargement

Question 16

What causes primary mitral valve regurgitation?

Answer 16

Problems with any of the mitral valve components, not one specifically

Question 17

What causes secondary mitral valve regurgitation?

Answer 17

Dilation of the LV and the annulus

Question 18

What occus hemodynamically in mitral valve regurgitation

Answer 18

Elevation of LA volume and pressure –> LA dilation
Reduction in forward output
Volume-related stress on LV –> LV dilation

Question 19

What is the difference between chronic and acute mitral regurgitation?

Answer 19

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

Question 20

What are clinical manifestations of mitral regurgitation?

Answer 20

Heart failure

Fatigue 
Dyspnea on exertion
Shortness of breath
Orthopnea
Paroxysmal nocturnal dyspnea

Question 21

What are physical findings of mitral regurgitation?

Answer 21

Holosystolic murmur
S3
Hyperdynamic apex with palpable thrill

Question 22

What is causing the holosystolic murmur hear in mitral regurgitation?

Answer 22

Regurgitation throughout systole

Stays the same, no crescendo

Question 23

What is causing the S3 in mitral regurgitation?

Answer 23

Large volume going into ventricle stops suddenly

Question 24

What is a phrase that can be used to remember the sounds heard in mitral regurgitation?

Answer 24

“slush-ing in”

Slush = S1, ing = S2, in = S3

Question 25

What is a summation gallop?

Answer 25

When S3 and S4 exist very close together, they sound like a murmur

Question 26

What happens to the valve in mitral valve prolapse?

Answer 26

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

Question 27

What causes the myxomatous degeneration of the leaflets?

Answer 27

Inherited as autosomal dominant disorder
OR
Associated with connective tissue diseases like Marfan’s or Ehlers-Danlos

Question 28

What are symptoms of mitral prolapse?

Answer 28

None, unless develop some mitral regurgitation

Question 29

What can you hear upon auscultation in mitral prolapse?

Answer 29

Mid to late systolic click - when leaflets billow back up
Late systolic murmur

MOST IMPORTANT: the timing of these changes with maneuvers

Question 30

Will you hear the click and murmur of mitral prolapse earlier when standing or lying down?

Answer 30

Standing

Less volume (pressure) in left ventricle when standing - won’t need to contract as much to reach pressure when click occurs

Question 31

Will you hear the click and murmur of mitral prolapse earlier when squating or lying down?

Answer 31

Lying down

Squat causes left ventricle to expand - will need to contract more to reach pressure when click occurs than if lying down

Question 32

What can occur if the elongated chordae in mitral prolapse rupture?

Answer 32

Get severe acute mitral regurgitation

Flail leaflet