Mitral Valve disease questions

Question 1

What is natural history of mitral stenosis

Answer 1

Symptomatic on exertion when MVA becomes <2.5cm

Symptomatic at rest when <1.5

Natural progression of MS causes valve area reduction at 0.1 to 0.3 per year

Progression from onset of RF to onset of signs of MS takes 10 to 20 years

Pulmonary hypertension >50mmHg the mean survival is 3 years

Question 2

What is natural history of Mitral stenosis

Answer 2

exertional symptoms at MVA < 2.5cm2
rest symptoms at MVA < 1.5 cm2
natural progression of MS is about 0.1 to 0.3 cm2
The progression from onset of RF to signs of MS takes about 10 to 20 years
the progression from signs of MS to mild symptoms of MS takes 10 to years
the 10 year survival is 80% in pts with NHYA I or II
10 year survival in NHYA III or NHYA IV is 10 to 15%
Pulmonary hypertension the mean survival is 3 years

Question 3

List poor prognostic features of MR include

Answer 3

1) symptoms for > 1 year
2) atrial fibrillation
3) age > 60 years
4) EF < 50%

Question 4

What are symptoms of MR

Answer 4

Fatigue, weakness–related to low cardiac output
Dyspnea, orthoponea and PND
Pulmonary hypertension and right heart failure

Question 5

What are the signs of MR

Answer 5

Displaced volume-loaded apex beat
Apical thrill
3rd heart sound
Apical pansystolic murmur–radiating to the axilla
Apical diastolic flow murmur
Right ventricular heave and an increased pulmonary compliance of the 2nd heart sound

Question 6

What are the causes of mitral stenosis

Answer 6

1) Rheumatic fever (Lancefield group A beta-haemolytic streptococcus
2) Congential parachute mitral valve
3) Endocardial fibroelasosis
4) Carcinoid syndrome
5) Cor triatriatum
6) left atrial myxoma
7) pulmonary vein stenosis

Question 7

Symptoms of Mitral stenosis

Answer 7

Long latent period
Fatigue
Dyspnea, orthopnea, PND
Left atrial distention resulting in
a) atrial fibrillation and subsequent thrombo-embolic events
b) left recurrent laryngeal nerve compression presenting with hoarseness (Ortner’s syndrome)
c) esophageal compression producing dysphagia
d) rarely, left main bronchus compression causing left lung collapse
Pulmonary hypertension
a) peripheral edema and ascities
b) hemoptysis due to distention and rupture of bronchial veins

Question 8

What are the signs of mitral stenosis

Answer 8

Low volume pulse
irregular pulse
opening snap
loud S1
Mid-diastolic rumbling murmur loudest at the apex
Pulmonary hypertension
a) mitral facies
b) central cyanosis
c) loud P2
d) tricuspid regurgitation-pan-systolic murmur at the right sternal edge
f) pulmonary regurgitation–Graham steel early diastolic murmur on inspiration

Question 9

What is etiology of ischemic MR

Answer 9

infarcted, ruptured or non-ruptured papillary muscles (type II)

Chronic —restricted movement of P2 and P3 scallops of the posterior MV due to left ventricular dilation displacing the papillary muscles (Type IIIb)—functional dilation of the annulus (Type I).

Question 10

Carpentiers’ classification of MR

Answer 10

Type I: Normal leaflet motion

Type II: excess leaflet motion

Type III: restricted leaflet motion

           a) during diastole 
           b) during systole

Question 11

Classification of different degrees of MR

Answer 11

Factor Mile Moderate Severe
Jet area (% of LA area) <20 20-40% > 40%
Vena contracta < 0.3 0.3 to 0.7 > 0.7
Regurgitant volume (ml) <30 30 to 60 > 60
Regurgitant fraction(%) < 30 30 to 50 >50
Effective regurgitant <0.2 0.2 to 0.4 > 0.4
orifice aea

Question 12

Describe Barlows diseasae

Answer 12

Prolapse is defined as >2mm billowing of the anterior or posterior leaflet beyond the annular plane into the left atrium with or without MR

familial, non-familial, associated with Marfan Syndrome

Histological analysis–myxomatous proliferation of acid mucopolysaccharides withing the zona spongiosa of the mitral valve leafletsthinning and elongation of the chordae tendinae.

Question 13

What are methods to measure Mitral valve Area

Answer 13

1) Planimetry: short axis view on 2D echocardiography
2) pressure half-time: MVA = 220/PHT
3) continuity equation:
4) Gorlin equation MVA = CO/ 38 x HR x DFO x square root of mean gradient

Question 14

What are determinants of the Wilkins mitral stenosis score

Answer 14

Leaflet mobility
Leaflet thiickening
Leaflet calcification
subvalvular thickening

Each scores between 0 and 4 with max score at 16

A Wilkins score of > 9 suggests the lesion unlikley to be amenable to PMBV

Question 15

List different surgical repair techniques for mitral valve disease

Answer 15

Posterior MVL prolapse
     1) quadrangular or triangular resection 
     2) sliding annuloplasty
     3) artificial chord implantation 
Anteior MVL prolapse
    1) triangular resection 2) artificial chord implantation/ chordal transfer
Bileaflet MV prolapse
    1) leaflet resection
    2) artificial chord implantation
    3) Alfieri stitch 
    4) MV replacement 
Partial papillary muscle rupture
    1) reimplantation of the papillary muscle
Complete papillary muscle rupture
    1) MVR

Question 16

What are the surgical approaches to the mitral valve

Answer 16

1) Standard left atriotomy
Mobilise the pericardial reflections around the inferior and superior pulmonary veins
Sondergards groove is developed by reflecting the right atrium back over the left atrium
incision is made in the left atrium anterior and medial the right superior pulmonary vein and
and continued inferiorly
2) Bi-atrial trans-septal incision
3) Superior roof incision
4) Bi-atrial Dubost incision
vertical incision is made between the RSPV and Inferior pulmonary vein, which extends across the left atrium, right atrium, and interatrial septum

Question 17

What is systolic anterior motion

Answer 17

SAM occurs when the tips of the mitral leaflets are displaced anteriorly into the left ventricular outflow tract

results in a venturi effect pulling on the mitral leaflets causing MR and left ventricular outflow tract obstruction.

During diastole the left ventricular outflow diameter is normal

Question 18

What is physiology of SAM

Answer 18

Due to forward displacement of elongated mitral valve relative to the septum during systole

Venturi effect of the high-velocity blood stream carries the protruding edge of the anterior mitral leaflet toward the aortic annulus in early systole

Question 19

What are consequences of SAM

Answer 19

Variable degree of mitral regurgitation

intraventricular gradient due to obstruction of the LVOT

Question 20

What are risk factors for SAM

Answer 20

Excess height of posterior mitral valve leaflet (>1.5cm) 
undersized annuloplasty ring
Narrow -aortic angle (130degree) 
Excessively high PL/AL
Small LV cavity
inappropriate filling
rhytm disturbances
prominent septal bulge (HOCM)

Question 21

What is intra-operative management of SAM

Answer 21

Increase preload
Increase afterload (partial aortic cross clamp) (increase MA 80-90 mmHg)
Stop inotropes
treat rhythm disturbances (avoid tachcardiac)
Check the LVOT peak gradient (it’s critical…if < 40 its ok to go back to ICU if > 50 then go back on
also check for degree of MR (no more then mild)
CPB and do one of the following
add neochordae to displace posterior leaflet into ventricle
confirm appropriate annuloplasty ring size
check coptation depth < 12

Question 22

What are advantages of repairing the mitral valve over replacing it

Answer 22

Greater freedom from mortality (operative and long term)
less Structural valve deterioration compared to bio
Less rates of re-operation
lower rates of infective endocarditis
decreased post op thrombo-embolism
lower rates of post operative hemorrhage complications related to anticoagulation
improved LV ejection fraction

Question 23

What is Freedom from re-intervention for patients older then 70 for different mitral valve surgery

Answer 23

Repair of anterior mitral valve leaflet 78% at 10 years
Repair of posterior mitral valve leaflet 98% at 10 years
open mitral valve commissurtomty 80% at 10 years
close mitral valve comussurotomy 70% at 10 years
Porcine bioprosthesis 75% at 10 years
Bovine pericardial bioprosthesis 80% at 10 years
Mechanical prosthesis 98% at 10 years

Question 24

List 5 echocardiographic findings of ischemic MR

Answer 24

Annular dilation
leaflet tenting
Leaflet coaptation below the plane of the annulus
papillary muscle displacement
regional wall motion abnormality (LV dilation
Failure of leaflet coptation during systole (loitering)
Papillary muscle rupture (acute)

Question 25

list ecocardiographc findings of chronic MR

Answer 25

``` LV posterolateral wall motion abnormality LV dilation Normal leaflet morphology restricted leaflet motion plan of coaptation below the annulus annular dilation central jet of MR ```

Question 26

What echo features should be assessed with ischemic MR

Answer 26

Valve tenting--valve being pulling towards in the ventricle Tenting area position/displacement of papillary muscle left ventricular function/wall motion abnormalities direction of jet (eccentric) assess closure near medial commissure MR severity

Question 27

What would you accept as minimally acceptable indexed EOA for mitral valve?

Answer 27

> 1.2 cm2/m2 page 869 of Cohn states EOAI of 1.3 to 1.5 as measured by continuuity equation may increase the risk of PPM

Question 28

List 5 methods for repairing anterior mitral valve leaflet prolapse

Answer 28

transfer of secondary chord to the unsupported free edge limited resection of a triangular wedge of anterior leaflet alfieri stitch chordal shortening: the papillary muscle is split and the chord is shortened by embedding it in the muscle chordal replacement withe PTFE (size 5-0) quandrangular resection of the posterior leaflet and transferring that portion of the posterior leaflet with its supporting chord--to the anterior leaflet.

Question 29

What are techniques to repair anterior mitral leaflet

Answer 29

``` triangular resection chordal shortening chordal transfer new chordae alfieri stich ```

Question 30

What is classification of AV groove disruption

Answer 30

Type 1: Dissociation at annulus Type 2: Dissociation at the base of the papillary musclee Type 3 dissociation between annulus and PM

Question 31

What are risk factors for AV groove disruption

Answer 31

1% decreased by preservation of PML age, female, annular calcification, annular abscess, complete resection of mitral valve leaflets, deep sutures, manipualtion after insertion, small LV, large valve size

Question 32

How is atrioventricular disruption following mitral valve replacement treated

Answer 32

Patient back on CPB remove the prosthetic valve Implant a bovine pericardial patch across the atrioventricular groove implant a smaller prosthetic valve with a low profile avoid lifting the heart with the prosthesis in situ

Question 33

What are intra-operative risk factors for AV groove separation in Mitral valve replacement

Answer 33

``` Oversizing of valve Aggressive debridement of posterior annulus/posterior leaflet Vigourous retraction De-airing maneuvers Bioprosthetic valve Papillary muscle resection ```

Question 34

List 3 essential anatomic components of myxomatous mitral valve prolapse

Answer 34

Diffuse leaflet thickening annular dilation interchordal ballooning of the mitral leaflets--- with or without elongated thinned or ruptured chords.

Question 35

What are pathologic features of Fibroelastic deficiency

Answer 35

Occurs in Elderly Short history of symptoms Leaflets are thin and there is no excess tissue except in the prolapsing areas annulus maybe dilated and/or calcified

Question 36

What is pathologic features of Barlows disease

Answer 36

``` Younger patients Long history of MR entire valve is thickened and prolapsing excess leaflet tissue Chordae are elongated Papillary muscles maybe elongated Annulus is dilated and occasionally calcified Generalized myxomatous degeneration ```

Question 37

What are indications for tricuspid valve annuloplasty when performing left sided sirgery

Answer 37

``` Severe TR (functional) Tricuspid annulus dilation > 40mm ```

Question 38

When do asymptomatic pts with MR usually develop symptoms

Answer 38

5-10 years after diagnosis | High event rates were seen when quantitatively graded severe degenerative MR (EROA >40mm2) occurs.

Question 39

What are difference between European and North American Guidelines for mitral valve surgery

Answer 39

Europeans recommend surgery with LVESD > 45mm | North American recommend surgery with LVESD > 40mm

Question 40

Why even bother with asymptomatic mitral valve surgery

Answer 40

Rosenhek--132 pts with severe asymptomatic in 8 year period 45% had cardiac event Kang et al. 161 pts showed that 99% of pts who underwent surgery and 85% of pts who were watched were cardiac event free at 9 years Montant in 67 pts 10 year survival was significantly lower in conservative vs those operated

Question 41

What are predictors of severe MR in pts who are asymptomatic

Answer 41

High levels of brain natriuretic peptide (>105)) were assoicated with unfavourable outcomes LVESD >40mm is independently associated with increased mortality under medical management and after surgery Suri and collegues at mayo showed that ejection fraction of >65% is associated with superior recovery of left ventricular function

Question 42

Atrial fibrillation and Systolic pulmonary pressure at rest of > 50mmhg are what class of indication for mitral valve repair

Answer 42

Class IIa

Question 43

What is current indication for minimally invasive mitral valve repair

Answer 43

Class IIb

Question 44

What are potential benefits of minimally invasive

Answer 44

``` Reduced sternal complication reduced blood transfusion reduced atrial fibrillation reduced ventilation times reduced ICU length of stay reduced hospital length of stay improved cosmesis ```

Question 45

What are potential negatives of minimally invasive mitral valve repair

Answer 45

increased risk of stroke increase risk of aortic dissection prolonged cross clamp, cardiopulmonary bypass and procedure time

Question 46

What are the comparable outcomes for minimally invasive and traditional approach to mitral valve repair

Answer 46

comparable short and long term mortality

Question 47

What are contraindications to minimally invasive access

Answer 47

Severe calcification of annulus Severe lung pathology (adhesions) small peripheral vessels

Question 48

List additional surgical options for Functional MR

Answer 48

``` 2 size downsizing restricted annuloplaty (sized for a 30 so you place a 26) string and a ring concept secondary chordal cutting posterior leaflet extension septal-lateral banding posterior LV wall plication PPM relocation-(Dr. Kron) CorCap ```

Question 49

What is data for cutting secondary chords in Ischemic MR

Answer 49

In 2007 they found a reduced frequency of early recurrence (15% vs 37%) of ischemic MR by adding this technique

Question 50

List contraindications to balloon vavotomy

Answer 50

Heavily calcified valve MS with more then mild MR Nodular calcifications of both commissures MV obstruction without commissural fusion

Question 51

List contraindications to percutaneous balloon mitral valvotomy based on echo

Answer 51

Moderate to severe MR Mild MS Presence of LA thrombus Calcified and non-pliable valve (low risk surgical candidates)

Question 52

List rare cases of double valve disease

Answer 52

``` Ergotamine toxicity Radiation injury Q-fever Blunt trauma Lymphoma Relapsing polychondritis Ectodermal anhydrotic dysplasia Werner syndrome SLE Maroteaux-Lamy syndrome ```

Question 53

What papillary muscle is more likely prone to ischemia

Answer 53

posterior medial papillary muscle is more likely because it is supplied by just the PDA in 63% of cases The Anterior lateral papillary muscle is supplied by LAD and circumflex

Question 54

When does papillary muscle rupture occur

Answer 54

usually occurs 2 to 7 days after MI. without urgent surgery, approximately 50 to 75% die in 24 hours

Question 55

List genes associated with mitral valve prolapse

Answer 55

3 different Loci-Chromosomes 16, 11, and 13 (automomial dominant) are linked to mitral valve prolapse.

Question 56

What is X-linked myxomatous mitral dystrophy

Answer 56

Locus on chromosome X cosegrates a rare form of mitral valve prolapse Some degree of mitral prolapse is seen in 5 to 6% of the female population

Question 57

What are the outcome of mitral valve PPM

Answer 57

Independently associated with persisting pulmonary hypertension increased incidence of CHF reduced survival

Question 58

What are Guidelines on reporting morbidity on prosthetic valves

Answer 58

``` Structural valve deteriorgation Non Structural valve degenerations Valve thrombosis Embolism Bleeding event Operated Valve endocarditis ```

Question 59

List 5 predictors of recurrent MR post ischemic MR repair

Answer 59

``` LVEDD >65 Posterior leaflet angle >45 Anterior leaflet angle >25 Tenting area >2,5 cm2 Coaptation distance >10mm End systolic interpapillary muscle distance >20mm Systolic shericity index >7 ```

Question 60

What are ways to distinguish post MI VSD with papillary muscle rupture

Answer 60

1. murmur of septal rupture is more prominent @ the left sternal border and is louder and associated with a thrill. 2. murmur of pap muscle rupture is best heard at apex and is softer with no thrill. 3. VSD rupture is most likely associated with anterior infarction and conduction abnormality while a pap muscle is likely posterior with no conduction ***bonus criteria** septal rupture show > 9% step up in oxygen saturation between RA and PA papillary muscle shows classic V waves in the pulmonary artery wedge tracing

Question 61

What are rates of recurrent MR after ring annuloplasty post IMR repair

Answer 61

Conventional ring annuloplasty is prone to failure in these patients, with recurrent severe MR in 25% of patients as early as 1 year after surgery

Question 62

List available mitral valve prosthesis

Answer 62

``` St. Jude Medical Epic Medtronic Mosaic Carpentier Edwards Carptentier Edwards Magna Sorin Mitroflow Medtronic Hancock II ```

Question 63

What is operative mortality for Mitral Valve Surgery in degenerative disease A. Replacement B. Repair

Answer 63

a. | b. <1% for mitral repair

Question 64

What is Operative mortality for Mitral valve surgery in IMR for repair or replacement

Answer 64

range 4 to 30%

Question 65

List type of chordae

Answer 65

a. First Order: Originate near the papillary muscle tips and insert on the leading edge of the leaflets b. Secondary/Strut: originate in same location, thicker, few in the number, insert on the ventricular side of the leaflets. most important in ventricular function c. Third order: originate directly from ventricular wall, fan shaped.

Question 66

What is pathophysiology of Rheumatic fever

Answer 66

Group A beta-hemolytic strep antigens cross-react with human tissues "molecular mimicry" and stimulate immune response. This mimicry on heart tissue proteins, combined with inflammatory cytokines, and low IL-4 production leads to autoimmun reactions and damage. mitral most common (40%)

Question 67

What is pathoanatomical features of mitral RF

Answer 67

commisural fusion leaflet fibrosis with stiffening and retraction chordal fusion and shortening

Question 68

List all components of valvular-ventricular complex

Answer 68

``` Mitral annulus Leaflets Chordae tendineae Papillary muscles left atrium left ventricle ```

Question 69

How often does IMR occur

Answer 69

40% of pts in heart failure 15% of pts with acute MI in anterior territory 40% of pts with acute MI in posterior territory

Question 70

What is physiology of mitral annular calcification

Answer 70

pts older 60, women > men Stress-induced feature associated with systemic HTN, hypertrophic cardiomyopathy, aortic stenosis, and occasionally Barlows. Chronic renal failure, DM, and advanced AS are associated features

Question 71

What occurs with mitral valve replacement when the chords ARE divided

Answer 71

a. no post operative change in LVEDV b. increase in LVESV c. increases in LV end-systolic stress d. Decrease in LV ejection fraction

Question 72

What occurs in mitral valve sparing chordal replacement (chords are SAVED)

Answer 72

Smaller LVEDV and smaller LVESV Decreased LV ESS (systolic stress) unchanged ejection fraction A smaller chamber size, reduced systolic after load, and preservation of contractile function act in concert to maintain ejection fraction. increased chamber size, increased systolic afterload and reduction in contraction around papillary muscles may be the reasons why chordal division outcomes are worse

Question 73

List two ways to measure the annuluplasty ring

Answer 73

Height of the anterior leaflet | Inter-trigonal distance

Question 74

What is the durability of the prosthetic mitral valves?

Answer 74

Much less then aortic position Maybe b/c of higher ventricular systolic pressures against the mitral cusps compared to the diastolic pressured resisted by the aortic cuspus. directly related to age, hyperca+, chronic renal.

Question 75

What are rates of Freedom from SVD after mitral replacement with Bioprosthesis

Answer 75

5 years = 98% 1- years= 70-85% 15 years = 50% 20 years = minimal data

Question 76

What is survival at 10 years for mitral valve replacement for bioprosthetic valve?

Answer 76

about 50-60%

Question 77

List some predictors of mortality after mitral valve surgery

Answer 77

``` Overall age New York Heart association III or IV presence of CAD ventricular dysfunction BMI Pre-existing pulmonary hypertension prosthesis type ```

Question 78

List predisposing factors for Infective endocarditis in mitral position

Answer 78

``` rheumatic valvular disease intravenous drug abuse immunosuppression degenerative valve disease intravascular prosthesis and devices hemodialysis catheters nosocomial infections ```

Question 79

What is patholophysiology of IE and locations in mitral position

Answer 79

NVE---endocardial trauma resulting in alteration of valvular endocardial surface---deposition of fibrin and platelets with attachment of bacteria Usual site on mitral valve is at the base of the atrial aspect of the leafets/ Annular or subannular invasion can cause separation at the AV junction. Occasionally "drop lesion" from Aortic valve land on anteior mitral leaflet or the tensor apparatus of the mitral valve.

Question 80

What are differences in prevalence of IE for mitral and aortic

Answer 80

For NVE mitral valve more likely to get infected then aortic. for PVE it is more common for aortic then the mitral risk is greatest 5 weeks post surgery then declines < 1 year is early and > 1 year is late incidence of early is 1% and 0.5 to 1%/year is late

Question 81

What are most common pathogens

Answer 81

Endocarditis of native valves is most likely Streptococcus viridans

Question 82

List the HACEK organisms

Answer 82

``` Haemophilis Actinobasillis Cardiobacterium hominis Eikennal corrrodens Kingella ``` account for 3% of culture negative PVE

Question 83

What is normal surface area of mitral valve? what mitral valve area does a pressure gradient occur? what mitral valve area do symptoms of severe MS occur

Answer 83

a. 4-6 cm2 b. 2cm2 c. 1 cm2