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CARDIOVASCULAR MEDICINE > MITRAL VALVE DISEASE > Flashcards

MITRAL VALVE DISEASE Flashcards

1
Q

What is the single most common cause of valvular disease in the developing world?

A

Rheumatic fever

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2
Q

What is the underlying mechanism of rheumatic fever?

A

Occurs 2-3 weeks after a pharyneal infection involving Strep pyogenes - group A streptococcal. Antibody mediated autoimmune response (antibodies against bacteria cross react with membrane antigens. Causes multi-organ disease.

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3
Q

How is the diagnosis of rheumatic fever made?

A

Duckett-Jones criteria:

Evidence for β-haemolytic streptococcus plus one major criterion or two minor criterion.

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4
Q

What are the major criteria of the Duckett-Jones criteria for diagnosing rheumatic fever?

A

Carditis
Arthritis
Sydenham’s chorea (involuntary movements of face and mouth due to inflammation of caudate nucleus)
Erythema marginatum (rash with raised red edges)
Nodules

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5
Q

What are the minor criteria of the Duckett-Jones criteria for diagnosing rheumatic fever?

A 
Fever
Previous rheumatic fever
Raised ESR or Raised CRP
Long PR interval
Arthralgia
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6
Q

What investigations would you carry out on someone with suspected rheumatic fever?

A

Blood tests - Raised ESR and CRP
Antistrptolysin O (ASO) titre - rising when taken tow weeks apart
Throat swab - positive

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7
Q

How is someone with diagnosed rheumatic fever managed?

A

High dose benzylpenicillin.
Anti-inflammatory agents - salicylates
Corticosteroids if signs of carditis
Long term follow up

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8
Q

What is the most common cause of mitral stenosis across the world?

A

Rheumatic fever

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9
Q

Apart from rheumatic fever, what are the rarer causes of mitral stenosis?

A 
Congenital - isolated lesion
Atrial septal defect (Lutembacher's syndrome)
Malignant - carnoid
Calcification
SLE
Infective endocraditis
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10
Q

What are the heart conditions that mimic mitral stenosis by obstructing inflow to the left ventricle?

A

Atrial myxoma (benign tumour of the heart)
Left atrial thrombus
Hypertrophic cardiomyopathy

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11
Q

What are the complications that can arise as a result of mitral stenosis?

A

Pulmonary hypertension and oedema
Chest infections
Atrial fibrillation
Left atrial enlargement

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12
Q

What are the clinical features of mitral stenosis?

A

Dyspnoea from pulmonary oedema
Haemoptysis from ruptured pulmonary vein due to hypertension
Palpitations and systemic emboli as a result of AF
Hoarse voice due to enlarged atrium stretching laryngeal nerve
Dysphagia due to enlarged atrium compressing oesophagus
Left lung collapse due to compression of left main bronchus

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13
Q

On examination of a patient with mitral stenosis, what might you expect to find?

A

Mid-diastolic murmur heard best with patient on their left side in expiration.
Loud S1 - mitral valve slamming shut at beginning of ventricle systole
Tapping apex beat - not displaced
Opening snap after S2
Loud P2 if there is pulmonary hypertension

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14
Q

What investigations would be ordered for someone with suspected mitral stenosis?

A

ECG
Chest X-ray
Echo
Cardiac catheterization

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15
Q

What might you see on the ECG of a patient with mitral stenosis?

A

AF

P mitrale - abnormally long p wave in lead II which may have an ‘M’ shape

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16
Q

What might a chest x-ray reveal in someone with mitral stenosis?

A

Enlarged left atrium
Calcified mitral valve
Prominent pulmonary vessels

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17
Q

What are the medical management options for someone diagnosed with mitral stenosis?

A

Small dose of beta blocker - allows for slightly longer diastolic filling time
Warfarin - in those with AF and mitral stenosis
Digoxin, beta-blockers or DC cardioversion to treat AF
Diuretics to treat any pulmonary or peripheral oedema

18
Q

Apart from medical management, what are the management options for someone diagnosed with mitral stenosis?

A

Mitral valvuloplasty - using a balloon to stretch stenosed valve
Open or closed mitral valvotomy
Mitral valve replacement

19
Q

What are the four parts of the mitral valve which can become abnormal and render the valve incompetent?

A

Valve annulus
Valve leaflets
Chordea tendineae
Papillary muscle function

20
Q

What are the cardiac complications of mitral regurgitation?

A

Dilatation of left ventricle - leading to left ventricular failure
Right ventricular failure due to pulmonary hypertension

21
Q

What are the normal presenting complaints of chronic mitral regurgitation?

A

Fatigue

Dyspnoea

22
Q

How does acute mitral regurgitation present?

A

Severe dyspnoea

23
Q

Which patients are particularly susceptible to acute mitral regurgitation?

A

MI patients

Infective endocarditis patients

24
Q

How can an MI lead to mitral regurgitation?

A

Ischaemic damage leads to papillary muscle rupture or dysfunction

25
Q

How long after an MI does papillary muscle rupture usually occur?

A

4-7 days

26
Q

What pathologies of the mitral annulus might lead to mitral regurgitation?

A

Senile calcification
Left ventricular dilatation and enlargement of the annulus
Abscess formation during infective endocarditis

27
Q

What pathologies of the mitral valve leaflets might lead to mitral regurgitation?

A 
Infective endocarditis
Rheumatic fever
Prolapsing mitral valve (floppy)
Congenital malformation
Connective tissue disorders - Marfan's syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta, pseudoxanthoma elasticium
28
Q

What pathologies of the chordae tendinae might lead to mitral regurgitation?

A

Idiopathic rupture
Myxomatous degeneration
Infective endocarditis
Connective tissue disorders - Marfan’s syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta, pseudoxanthoma elasticium

29
Q

What pathologies of the papillary muscle might lead to mitral regurgitation?

A

Myocardial infarction
Infiltration - sarcoid, amyloid
Myocarditis

30
Q

On examination of someone with mitral regurgitation, what signs might you find?

A 
Pan-systolic murmur best heard at apex
Irregularly irregular pulse - AF
Raised JVP
Displaced apex beat
Third heart sound
Loud P2
Inspiratory crepitations
Ascites
Peripheral oedema
Ventricular heave
31
Q

What is mitral valve prolapse?

A

When the valve prolapse back into the atrium.

32
Q

Does mitral valve affect more males or females?

A

Females

33
Q

How do patients with mitral valve prolapse present?

A

Often with no symptoms (diagnosed at routine medical exam)
Fatigue
Atypical chest pain
Palpitations

34
Q

Do all patients with mitral valve prolapse need prophylaxis against infective endocarditis?

A

No, only those with mitral regurgitation

35
Q

What investigations should be done in someone with suspected mitral regurgitation?

A

ECG
Chest X-ray
Echo
Cardiac catheterisation

36
Q

What might an ECG of someone with mitral regurgitation reveal?

A

Atrial fibrillation

Left-ventricular hypertrophy

37
Q

What might a chest x-ray of someone with mitral regurgation show?

A

Cardiomegaly

Calcified valve

38
Q

Why do we do cardiac catheterisation in patients with mitral regurgitation?

A

Most patients have minimal MR on echo and do not require catheterisation. It is performed to assess the severity of MR and to exclude valve lesions and coronary artery disease.

39
Q

How would you medically manage someone diagnosed with mitral regurgitation?

A

Diuretics and ACE inhibitors to treat congestive cardiac failure.

40
Q

How might you surgically manage someone diagnosed with mitral regurgitation?

A

Mitral valve repair (annuplasty or leaflet repair)

Mitral valve replacement

CARDIOVASCULAR MEDICINE (15 decks)

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