Mitral Valve disorders

Question 1

What is mitral regurgitation?

Answer 1

Incomplete closure of the mitral valve leading to blood leaking from the left ventricle to the left atrirum during systole

Question 2

What is the difference between primary and secondary mitral regurgitation?

Answer 2

1. Parimary
   
   • cuased by direct involvement of the mitral valve leaflets or the chorda tendinae
2. Secondary
   
   • caused by changed to the left ventricle that lead to valvular incompetence

Question 3

What are possible reasons for primary mitral regurgitation?

Answer 3

Primary = direct involvement of valve or chorda tendinae

• degerneration of mitral valve
• Rheumatic fever
• Infective endocarditis
• Ischemic (e.g. leading to rupture of papillary muscle due toMI)

All normally due to Mitral valve prolapse (one leaflet going back into atrium)

Question 4

What are possible reasons for secondary mitral regurgitation?

Answer 4

Secondary: due to changes of the left ventricle

• Coronary artery disease/ MI to cause rupture of papillary muscle
• dilated cardiomyopathy, left ventricular failure
  *

Question 5

What is the effect of acute Mitral regurgitation?

Answer 5

Leads to volume overload and acute symptoms of heart failure

Question 6

What is the effect of chronic Mitral regurgitation?

Answer 6

First compensated

• compensatory changes to right ventricle –> remodelling (with preserved CO)
• After time leading to heart failure (via impact on LVEF)

Question 7

What are symptoms of mitral regurgitation?

Answer 7

• SOB
• other symptoms of left-sided HF
• Palpitations
  
  • new-onset AF is common in patients with MR
• If development of cardiogenic shock
  
  • syncope
• fatigue

Question 8

What are signs of mitral regurgitation on examination?

Answer 8

• Pulmoary oedema
  
  • cyanosis
  • bine basillar, fine crackels end-inspiratory on ausculation
• poor peripheral perfusion (sign of HF)
• Tachycardia, Tachypneu, Hypotension (cardiac shock)
• displacement of apex beat

Question 9

Which cardiac murmor would you hear on auscultation in a patient with Mitral regurgitation?

Answer 9

Pansystolic murmor

• often with mid-sytolic “click”
  
  • mitral valve going back into atrium and is suddenly stoped
• roll patient on left side and listen over mitral valve
• might radiate to axilla
  
  • migh be louder with increasing after and/ or preload

Question 10

What are appropriate investigations you would order in a patient with mitral regurgitation?

Answer 10

• ECG
  
  • left ventricular hypertrophy and ?AF –> migh develop with MR
  • prior infarction?
• Echo (TTE)
• CXR
• Bloods
  
  • trop
  • bnp

Question 11

What is the epidemiology of mitral regurgitation?

Answer 11

Unknown, common (More than 5 Million World wide)

Question 12

What is mitral stenosis?

Answer 12

Hardening/ stiffness of the mitral valve

• less blood can enter the left ventricle due to reduction in opening of mitral valve

Question 13

What is the problem with mitral stenosis?

Answer 13

Reduced filling of left ventricle in diastole

Question 14

What are the most common causes for mitral stensis?

Answer 14

1. Rheumatic fever
   
   1. ​most common
2. Autoimmune diseases (SLE, RA)
3. Congenital abnormal mitral valve
4. Rare things might mimmic MS:
   
   • bacterial endocarditis of mitral valve, atrial myxoma (cancer)

Question 15

What are risk factors for developing mitral stenosis?

Answer 15

1. Female sex
2. Streptococcal infection
3. Rheumatic fever (symptom onset often 10 years after)
4. Autoimmune disease
5. Congenital abnormaliy
6. Aortic stenosis (correlation found)

Question 16

Explain the pathophysiological processes that occur in Mitral stenosis

Answer 16

1. Reduced filling of LV
   
   • leading to reduced stroke volume
   • leading to decreased CO (forward HF)
2. Congestion of blood in pulmonary circultaiton
   
   • pulmonary oedema
   • might lead to right heart failure (backwards) with right ventricular hypertrophy

Question 17

What are symptoms of Mitral stenosis?

Answer 17

• Initially asymptomatic (+compensated, oftten only 10 years after rheumatic fever)
  
  • Dyspnoea
  • Syncopes, dizziness,
  • Dyspagia
    
    • Compression of the esophagus by the enlarged left atrium

Later: signs and symptoms of RHF

Question 18

What are signs on examination of mitral stenosis?

Answer 18

• Lungs
  
  • Haemoptesis
  • bibalsal end-expiratory fine crackels
• Hoarse voice (compression of recurrent laryngeal nerve by enlarged right atrium)
• Mitral facies
  • Mauve discoloration of the cheeks due to low cardiac output and systemic vasoconstriction (picture)
• AF, embolic complications
• Cyanosis

Question 19

What are findings on auscultation in a patient with mitral stenosis

Answer 19

• Pulmonary oedema
• Murmors
  
  • Dyastolic murmor when patient lies on left
  • Loud first S1
  • Opening snap (OS) after S2
    
    • (the shorter between S2 and snap, the more sever MS)
  • All best heard over apex

Question 20

Which investigations would you order in a patient with mitral valve stenosis?

Answer 20

• ECG
  
  • look for signs of HF
• CXR
  
  • cardiomegaly? pulmonary oedema? Compression of other structures?(Picture left atrial enlargement)
• Echo (TEE)

Question 21

What is the epidemiology of mitral stenosis?

Answer 21

• More common in developing countries
  
  • mostly caused by rheumatic fever