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Year 3 > Mitral valve disease (CV) > Flashcards

Mitral valve disease (CV) Flashcards

1
Q

What is mitral stenosis?

A

Narrowing of the mitral valve orifice, often caused by rheumatic valvulitis producing fusion of the valve commissures and thickening of the valve leaflets

Decreased cross-sectional area of the valve, impairing blood flow from LA–>LV

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2
Q

What is mitral stenosis most commonly due to?

A

Rheumatic heart disease (90% of cases)

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3
Q

What are some signs of rheumatic fever (main cause of mitral stenosis)? (2)

A
  • prodromal illness
  • erythema marginatum - annular (ring-like) erythematous rash affecting trunk and inner surfaces of arms and legs; rings are barely raised and non-pruritic
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4
Q

How do we treat rheumatic fever? (Main cause of mitral stenosis)

A

IM benzylpenicillin or oral penicillin V

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5
Q

How do the causes of mitral stenosis differ between countries?

A
  • rheumatic fever is the main cause in low and middle-income countries
  • mitral annular calcification is the main cause in high-income countries
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6
Q

What can mitral stenosis lead to?

A
  • causes decreased filling of LV while simultaneously increasing LA pressure –> LA hypertrophy and dilation –> pulmonary congestion & oedema
  • as disease progresses, pulmonary hypertension and right heart failure occur
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7
Q

What is mitral regurgitation?

A

Leakage of blood from LV –> LA due to incomplete closure of mitral valve during systole

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8
Q

How common is mitral regurgitation?

A

Second most common mitral disease after aortic stenosis

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9
Q

What is the difference between primary and secondary mitral regurgitation?

A
  • primary MR - caused by direct involvement of valve leaflets
  • secondary MR - caused by changes of LV leading to valvular incompetence
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10
Q

What are some causes of primary mitral regurgitation? (3)

A
  • rheumatic fever - most common
  • infective endocarditis
  • mitral valve prolapse (young females)
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11
Q

What are some causes of secondary mitral regurgitation? (2)

A
  • coronary artery disease (common post-MI due to papillary wall rupture)
  • dilated cardiomyopathy
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12
Q

What is the most common cause of mitral regurgitation?

A

Rheumatic heart disease

(Others: infective endocarditis, mitral valve prolapse, papillary muscle rupture, annular calcification)

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13
Q

What can mitral regurgitation lead to?

A
  • increased backflow of blood from LV–>LA increases pressure and results in pulmonary hypertension
  • consequent atrial dilation increases risk of atrial fibrillation
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14
Q

What are some risk factors for secondary mitral valve disease? (2)

A
  • collagen disorders - Marfan syndrome (fibrillin-1 mutation), Ehlers-Danlos syndrome
    • collagen disorders characterised by widespread joint hypermobility along with skin changes indicated by striae
  • polycystic kidney disease (associated with mitral valve prolapse and mitral regurgitation)
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15
Q

What are some clinical features of mitral stenosis? (10)

A
  • dyspnoea
  • orthopnoea
  • paroxysmal nocturnal dyspnoea
  • fatigue
  • hoarseness - compression of recurrent laryngeal nerve by enlarged LA
  • dysphagia - compression of oesophagus by enlarged LA
  • haemoptysis
  • malar flush
  • palpitations (AF)
  • symptoms of right HF in later stages
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16
Q

What may you hear on auscultation in mitral stenosis? (3)

A
  • mid-diastolic murmur - best heard on expiration on left lateral side (left lateral decubitus)
  • loud S1, opening snap –> pre-systolic accentuation
  • severe MS - length of murmur increases + opening snap becomes closer to S2
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17
Q

What do you hear in severe mitral stenosis?

A

Length of murmur increases + opening snap becomes closer to S2

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18
Q

What might you see on examination in mitral stenosis? (10)

A
  • malar flush
  • neck vein distension
  • peripheral cyanosis
  • AF = irregularly irregular pulse
  • parasternal heave (RVH secondary to pulmonary hypertension)
  • mid-diastolic murmur (loudest in left lateral decubitus on expiration)
  • loud S1 + opening snap
  • Graham Steell murmur may occur
  • evidence of pulmonary oedema on auscultation (if decompensated)
  • ascites and peripheral oedema
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19
Q

What are the clinical features of mitral regurgitation - general? (8)

A
  • dyspnoea on exertion
  • decreased exercise tolerance
  • lower extremity oedema
  • fatigue
  • palpitations (AF)
  • diaphoresis (sweating)
  • pulmonary oedema
  • left-sided HF
20
Q

How does acute mitral regurgitation present?

A

Symptoms of LV failure

21
Q

How does chronic mitral regurgitation present?

A

May be asymptomatic or present with:

  • exertional dyspnoea
  • palpitations (if AF)
  • fatigue
22
Q

What is heard on auscultation in mitral regurgitation?

A
  • pansystolic (holosystolic) blowing murmur
  • loudest at apex beat
  • radiates to left axilla
  • soft S1
  • S3 may be heard (due to rapid ventricular filling in early diastole)
23
Q

What might you see on examination in mitral regurgitation? (4)

A
  • irregularly irregular pulse in AF
  • laterally displaced apex beat with thrusting (due to LV dilation)
  • pansystolic murmur - loudest at apex beat, radiates to left axilla, soft S1, S3 may be heard
  • signs of LV failure in acute MR
24
Q

What clinical feature might you observe in post-MI acute mitral regurgitation? (1 + 3)

A

Flash pulmonary oedema

  • frothy sputum
  • breathlessness
  • coarse bilateral lung crackles developing over a couple of hours
25
Q

What are some risk factors for mitral stenosis? (5)

A
  • streptococcal infection (rheumatic fever)
  • female sex
  • ergot medications (methysergide or ergotamine)
  • serotonergic medications (fenfluramine and dexfenfluramine)
  • SLE, amyloidosis, bronchial carcinoid syndrome
26
Q

What are some risk factors for mitral regurgitation? (8)

A
  • mitral valve prolapse
  • Hx rheumatic heart disease
  • infective endocarditis
  • Hx: cardiac trauma, MI, congenital heart disease, IHD
  • LV systolic dysfunction
  • HCM
  • anorectic/dopaminergic drugs
  • elevated systolic BP
27
Q

What are the 1st-line investigations for mitral valve disease? (3)

A
  • transthoracic echocardiography
  • ECG
  • CXR
28
Q

What would a transthoracic echo show in mitral stenosis? (4)

A
  • hockey stick-shaped mitral deformity
  • reduced mitral valve area
  • LA enlargement
  • evidence of pulmonary hypertension
29
Q

What would transthoracic echo show in mitral regurgitation?

A

Presence and severity of MR; other structural and flow abnormalities

30
Q

What would CXR show in mitral stenosis vs mitral regurgitation?

A
  • MS - left atrial enlargement (double shadow in right cardiac silhouette, Kerley B lines)
  • MR - left atrial and ventricular enlargement (cardiomegaly, pulmonary oedema)
31
Q

What would ECG show in mitral stenosis? (2)

A
  • right ventricular hypertrophy
  • P-mitrale = broad notched bifid P-wave (MS –> LA enlargement –> LA makes greater contribution to P-wave contour)
32
Q

What would ECG show in mitral regurgitation? (2)

A
  • left ventricular hypertrophy
  • P-mitrale = broad notched bifid P-wave due to atrial enlargement
33
Q

What would ECG show in mitral stenosis vs regurgitation? (3)

A
  • MS - RVH
  • MR - LVH
  • both: P-mitrale (broad notched bifid P-wave due to LA enlargement); may also see AF
34
Q

How often do you repeat echo in moderate-severe mitral regurgitation?

A

Performed every 6-12 months

35
Q

What is the 1st-line management for asymptomatic mitral stenosis? (3)

A
  • no therapy required
  • monitor with regular echos
  • if severe asymptomatic (gradient>5mmHg, valve area<1.5cm2) - consider balloon valvotomy, valve replacement or repair
36
Q

What is the management for symptomatic mitral stenosis? (4)

A
  • diuretic PLUS
  • balloon valvotomy OR valve replacement OR valve repair
  • anticoagulation if valve replacement
  • consider beta-blocker (atenolol) or ivabradine
37
Q

What can you prescribe if signs of pulmonary oedema in mitral valve disease?

A

Furosemide (loop diuretic)

38
Q

What is the management for severe mitral stenosis?

A

Percutaneous mitral valve commissurotomy

39
Q

What is the management for mitral stenosis if pregnant? (2)

A
  • diuretic (furosemide)
  • consider balloon valvotomy
40
Q

What is the first-line management for acute mitral regurgitation?

A

Emergency surgery (annuloplasty = repair, mechanical valve and anticoagulation/bioprostheses, perioperative diuretics)

41
Q

What is 1st-line for asymptomatic chronic mitral regurgitation? (4)

A
  • surgery if LVEF<60% and/or LV-ESD>40mm
  • watchful waiting if not
  • ACEi (captopril)
  • BB (metoprolol)
42
Q

What is 1st-line management for symptomatic chronic mitral regurgitation? (5)

A
  • surgery if LVEF>30%
  • ACEi
  • BB
  • diuretics
  • intra-aortic balloon counterpulsation
43
Q

In general, what is the 1st-line management for symptomatic vs asymptomatic mitral regurgitation?

A

Valve repair or replacement (if not suitable for surgery, transcatheter mitral valve intervention)

Asymptomatic non-severe = watchful waiting (LVEF>60%, LV-ESD<40mm)

44
Q

What is the management for heart failure in mitral valve disease? (2)

A
  • nitrates
  • diuretics (furosemide) - can cause ototoxicity (hearing loss, tinnitus, balance issues)
45
Q

What are some complications of mitral stenosis? (4)

A
  • atrial fibrillation - all patients require anticoagulation with target INR 2.5
  • stroke
  • warfarin-induced haemorrhage
  • infective endocarditis
46
Q

What are some complications of mitral regurgitation? (7)

A
  • atrial fibrillation
  • pulmonary hypertension
  • post-operative stroke
  • prosthesis stenosis
  • heart failure + LV dysfunction
  • pulmonary oedema
  • cardiogenic shock - treated with inotropes (dobutamine)

Year 3 (210 decks)

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