MITRALKLAPPENINSUFFIZIENZ (MI) Flashcards
Was ist die Definition der Mitralklappeninsuffizienz?
Akut oder chronisch auftretende Schlussunfähigkeit der Mitralklappe zwischen dem linken Vorhof und linken Ventrikel durch Veränderungen im Bereich des Klappenanulus, der beiden Segel, der Chordae tendineae oder der Papillarmuskeln.
Wie hoch ist die Inzidenz der Mitralklappeninsuffizienz?
2 %/J. (zweithäufigstes Klappenvitium bei Erwachsenen)
Nenne die primären Ursachen der Mitralklappeninsuffizienz.
- Degenerative, myxomatöse Veränderungen der Klappensegel
- Elongation oder Ruptur von Chordae tendineae
- Mitralklappenringverkalkung bei älteren Patienten
- Nach perkutaner Mitralklappen-Kommissurotomie (PMC)
- Rheumatische und/oder bakterielle Endokarditis
Was ist ein Mitralklappenprolaps (MKP)?
Systolische Vorwölbung von Mitralsegelanteilen in den linken Vorhof (> 2 mm), ggf. mit zusätzlicher Verdickung der Segel (≥ 5 mm = klassischer MKP, M. Barlow).
Wie häufig tritt der Mitralklappenprolaps in der westlichen Welt auf?
Bei etwa 2 - 3 % der erwachsenen Bevölkerung; familiäre Häufungen; w > m.
Wie präsentiert sich der Mitralklappenprolaps klinisch?
Ein oder mehrere hochfrequente systolische Klicks am linken unteren Sternalrand oder über der Herzspitze.
Was sind mögliche Assoziationen des Mitralklappenprolaps-Syndroms?
- Neuroendokrine Störungen
- Supraventrikuläre und ventrikuläre Herzrhythmusstörungen
- Arterielle Embolien
- Plötzlicher Herztod
Wie oft sollten kardiologische Kontrollen ohne Mitralklappeninsuffizienz empfohlen werden?
In 5-Jahres-Intervallen.
Nenne die Ursachen der sekundären (funktionellen) Mitralklappeninsuffizienz.
- Dilatation des Mitralklappenanulus
- Hineinziehen der Klappensegel in den Ventrikel durch Verlagerung der Papillarmuskeln bei LV-Dilatation
- Dysfunktionen eines Papillarmuskels bei Myokardischämie
Fülle die Lücke: Die häufigste Klappenanomalie in der westlichen Welt ist der _______.
[Mitralklappenprolaps]
Was sind die Verlaufsformen einer Mitralinsuffizienz (MI)?
Akute MI bei bakterieller Endokarditis oder nach Myokardinfarkt; Chronische MI.
Wann schließen die Mitralklappensegel?
In der frühen Systole, wenn der Druck im linken Ventrikel (LV) den Druck im linken Vorhof (LA) erreicht.
Welche Strukturen bewirken das Schließen der Mitralklappensegel?
Papillarmuskeln und Chordae tendineae.
Was passiert bei einer Schlussunfähigkeit der Mitralklappe?
Entleerung des LV in zwei Richtungen: Ein Teil des HZV in die Systemzirkulation, der andere Teil als Regurgitationsvolumen in den LA.
Was geschieht mit dem regurgitierten Blut in den LA?
Es gelangt bis in die Lungengefäße, was zu Lungenstauung und reaktiver pulmonaler Hypertonie führt.
Welche Folgen hat eine chronische Mitralinsuffizienz auf das Herzzeitvolumen?
Um das Herzzeitvolumen aufrechtzuerhalten, muss das Schlagvolumen gesteigert werden.
Was sind die klinischen Zeichen einer Mitralinsuffizienz?
Resultieren aus dem kleinen Minutenvolumen im großen Kreislauf und dem Blutrückstau in die Lungenzirkulation.
Wie kann der Organismus auf eine chronische MI reagieren?
Durch Adaptationsmechanismen kann sie längere Zeit toleriert werden.
Was zeigen Verlaufsbeobachtungen über 10 Jahre bei Patienten mit chronischer MI?
Eine erhöhte Inzidenz von Herzinsuffizienz und Mortalität, auch bei zunächst asymptomatischen Patienten.
Welche Beschwerden können sich bei Versagen des linken Ventrikels entwickeln?
Dyspnoe, Palpitationen, nächtliche Hustenanfälle u.a.
Wie ist die Klinik bei akuter Mitralinsuffizienz?
Ähnlich wie bei Mitralstenose, jedoch mit rascher linksventrikulärer Dekompensation und Lungenödem.
Was kann eine kardiale Dekompensation auslösen?
Vorhofflimmern.
Welche Komplikationen können bei Vorhofflimmern auftreten?
Thromboembolien und bakterielle Endokarditis.
Was ist bei der Inspektion und Palpation selten zu beobachten?
Periphere Zyanose.
Wie ist der Puls bei Vorhofflimmern?
Normal oder absolute Arrhythmie.
Was zeigt sich bei Trikuspidalinsuffizienz?
Systolischer Venenpuls.
Was ist der Spitzenstoß bei exzentrischer Linkshypertrophie?
Verbreitert und nach unten/außen verlagert.
Was sind hebende Pulsationen?
Über dem rechten Ventrikel.
Wie ist die Auskultation in Linksseitenlage?
Verschmolzen mit dem 1. HT, der leise ist, hochfrequentes, bandförmiges (Holo) Systolikum.
Wo ist der Punktus maximum (P.m.) bei der Auskultation?
Über der Herzspitze, Fortleitung in die Axilla.
Was zeigt sich bei höhergradiger Mitralinsuffizienz?
Kurzes Intervall-Diastolikum zur Zeit der raschen Ventrikelfüllung, evtl. 3. HT.
Was zeigt das PTEkg bei Mitralinsuffizienz?
P-sinistroatriale = P-mitrale (P > 0,11 sec., doppelgipflig und betonter zweiter Anteil).
Was kann bei schwerer Mitralinsuffizienz beobachtet werden?
Linkshypertrophie (Volumenbelastung), später auch Rechtsherzbelastung (bei pulmonaler Hypertonie).
Was zeigt das Echo zur Bestimmung des Insuffizienzgrades?
Farbdopplersignal (Vena contracta, effektive Regurgitationsöffnungsfläche, Berechnung von Regurgitationsvolumen und -fraktion).
Was ist der natürliche Verlauf bei asymptomatischer primärer Mitralinsuffizienz?
5-Jahresüberlebensrate bei 80 %, 10-Jahresüberlebensrate bei 60 %.
Was gilt als Hinweis auf ein fortgeschrittenes Krankheitsstadium?
Verminderung der Kontraktilität.
Wie hoch ist die 10-Jahresmortalität bei sekundärer Mitralinsuffizienz?
Zwischen 30 - 70 %.
Wie erfolgt die Verlaufskontrolle bei Mitralinsuffizienz?
Klinische Untersuchung, EKG, Echokardiografie, Ergometrie, BNP.
Nach welchem Schweregrad richten sich die Kontrollintervalle?
Z.B. alle 6 - 12 Monate.
What is the prognostic benefit of medical therapy for primary mitral insufficiency (MI)?
The prognostic benefit of medical therapy is not established and should not delay surgical therapy.
What is the focus of therapy for secondary mitral insufficiency (MI)?
The focus is on heart failure therapy (medication + possibly CRT).
How is the decision for intervention or surgical therapy made?
The decision is made in an interdisciplinary Heart Team considering the individual patient’s situation.
What are the surgical options for mitral valve intervention?
Options include mitral valve reconstruction with/without ring, or replacement with mechanical or biological prosthesis.
What is the most common percutaneous intervention for mitral insufficiency?
The most common is mitral leaflet clipping (Edge-to-Edge procedure).
What is the indication for mitral valve surgery in primary mitral insufficiency?
Indications include symptomatic patients and asymptomatic patients who are suitable for surgery without increased perioperative risk.
What are the criteria for catheter-based repair in high-risk patients?
Catheter-based repair is indicated for high-risk patients or those not suitable for surgery.
What are the criteria for mitral valve intervention in secondary mitral insufficiency?
Indications include persistent symptoms despite optimized guideline-directed medical therapy and simultaneous indication for bypass or other valve surgery.
What is the recommendation for isolated secondary mitral insufficiency?
Catheter-based repair is recommended for patients who meet criteria for good therapeutic response.
What is the recommendation for patients not suitable for surgery?
Catheter-based repair or another interventional procedure is recommended for symptomatic therapy or as a bridge to heart transplantation.
What is the recommendation for intervention in symptomatic patients with mitral valve issues?
Intervention is recommended for symptomatic patients with contraindications or increased risk for surgery as assessed by the Heart Team.
What is the significance of left ventricular ejection fraction (LVEF) and left ventricular end-systolic diameter (LVESD)?
LVEF ≤ 60% and/or LVESD ≥ 40 mm indicate higher surgical risk, while LVEF > 60% and LVESD < 40 mm with certain conditions may allow for surgery.
What are the risks associated with mitral valve procedures?
Hospital mortality is approximately 2% for mitral valve reconstruction and 6% for mitral valve replacement.
What is the anticoagulation requirement for mechanical and biological prostheses?
Oral anticoagulation is required for life with mechanical prostheses and for at least 3 months with biological prostheses.
What is necessary after mitral valve surgery?
Endocarditis prophylaxis is necessary after surgery.
What is transcatheter aortic valve replacement (TAVR)?
A procedure in which a diseased aortic valve is replaced via an endovascular or transthoracic approach, using a bioprosthetic valve delivered via a catheter.
What condition is TAVR primarily used to treat?
Severe aortic stenosis (AS).
What is the traditional standard comparator to TAVR?
Surgical aortic valve replacement (SAVR).
Who can receive TAVR treatment?
Patients with severe AS irrespective of their risk once anatomic suitability for delivery and deployment has been ascertained.
How is risk assessed for patients considering aortic valve replacement (AVR)?
Evaluation by a ‘Heart Valve Team’ consisting of healthcare professionals with experience in valvular heart disease.
What scoring systems are commonly used to estimate operative mortality for AVR?
Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) Calculator and European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II Risk Calculator.
What factors are considered in the risk assessment for AVR?
Age, renal function, lung disease, cardiac function, and prior cardiac surgeries.
What is a contraindication for TAVR based on life expectancy?
A life expectancy of less than 1 year based on noncardiac factors.
What aortic annulus sizes preclude TAVR?
Less than 17 mm or larger than 29 mm.
What are the relative contraindications for TAVR?
Bicuspid aortic valve, severe aortic regurgitation without severe AS, emergency AVR, myocardial infarction, cardiogenic shock, recent stroke, hypertrophic cardiomyopathy, LVEF less than 20%, severe right ventricular dysfunction, severe dementia, severe mitral regurgitation.
What are the indications for aortic valve replacement (AVR)?
Symptomatic patients with severe AS, severe AS if LVEF is less than 50%, symptomatic patients with low-flow/low-gradient severe AS, asymptomatic severe AS with decreased exercise tolerance, critical AS, severely elevated B-type natriuretic peptide (BNP).
In the context of AVR, what defines low flow?
A stroke volume index less than 35 mL/m2.
What does aortic velocity greater than 4 m/s indicate?
Severe aortic stenosis (AS).
What does mean pressure gradient greater than 40 mm Hg indicate?
Severe aortic stenosis (AS).
True or False: TAVR is contraindicated in the setting of endocarditis.
True.
What is necessary for a successful TAVR procedure?
A careful analysis of preprocedural/baseline aortic root morphology.
What is the typical threshold for severe AS in males based on calcium score assessment?
Greater than 2000 HU.
What is the typical threshold for severe AS in females based on calcium score assessment?
Greater than 1200 HU.
What is recommended for symptomatic and asymptomatic patients with severe AS who are <65 years of age or have a life expectancy >20 years?
SAVR is recommended
SAVR stands for Surgical Aortic Valve Replacement.
For symptomatic patients aged 65–80 years with severe AS and no anatomical contraindications to transfemoral TAVI, what is recommended?
Either SAVR or transfemoral TAVI is recommended after shared decision-making
Decision-making should consider expected patient longevity and valve durability.
What is recommended for symptomatic patients >80 years of age or younger patients with a life expectancy <10 years and no anatomical contraindications to transfemoral TAVI?
Transfemoral TAVI is recommended in preference to SAVR
In asymptomatic patients with severe AS and an LVEF <50% who are ≤80 years of age, what should guide the decision between TAVI and SAVR?
The same recommendations as for symptomatic patients in the first three categories should be followed
What is recommended for asymptomatic patients with severe AS and an abnormal exercise test, very severe AS, rapid progression, or elevated BNP?
SAVR is recommended in preference to TAVI
For patients preferring a bioprosthetic valve but unsuitable for transfemoral TAVI, what is the recommendation?
SAVR is recommended
Factors may include valve or vascular anatomy.
What is recommended for symptomatic patients of any age with severe AS and high or prohibitive surgical risk?
TAVI is recommended if predicted post-TAVI survival is >12 months with acceptable quality of life
What is recommended for symptomatic patients with severe AS for whom predicted survival is <12 months?
Palliative care is recommended after shared decision-making
This includes discussion of patient preferences and values.
What may be considered as a bridge to SAVR or TAVI in critically ill patients with severe AS?
Percutaneous aortic balloon dilation may be considered
What are the two broad categories of mitral regurgitation (MR)?
Primary and secondary MR
What causes primary mitral regurgitation?
Disease of the mitral valve
Common causes include mitral valve prolapse (MVP), calcific degeneration, infective endocarditis, rheumatic heart disease, and collagen vascular disease.
What is the effect of primary MR on the left ventricle (LV)?
Imparts a volume overload on the LV
What adaptations occur in the left ventricle due to primary MR?
Dilation and increased end-diastolic volume, leading to increased stroke volume
What are the potential consequences of primary MR on heart function over time?
Impaired LV contractility despite preserved ejection fraction
What are the effects of primary MR on the left atrium (LA) and lungs?
Increased LA pressure, pulmonary congestion, symptoms of dyspnea, pulmonary hypertension, right ventricular failure
What clues indicate mitral regurgitation during physical examination?
Holosystolic murmur radiating to the axilla, displaced apical beat, S3 heart sound
What is the primary diagnostic tool for confirming mitral regurgitation?
Transthoracic echocardiography (TTE)
What additional echocardiographic technique can be useful if TTE quality is suboptimal?
Transesophageal echocardiography (TEE)
How is the severity of MR traditionally graded?
Mild, moderate, or severe
What echocardiographic methods are used to evaluate the severity of MR?
Color Doppler to assess MR jet size, vena contracta width, effective regurgitant orifice area, regurgitant volume
What are some secondary findings of chronic, severe MR visible on echocardiography?
LA and LV enlargement, elevated pulmonary artery pressures, systolic flow reversal in pulmonary veins
Fill in the blank: The Carpentier classification for MR includes Type I, Type II, and Type ___.
III
What does Type II in the Carpentier classification refer to?
Excessive leaflet motion
What causes secondary mitral regurgitation?
Disease of the left ventricle leading to wall motion abnormalities, ventricular dilation, annular dilation
What conditions can lead to secondary MR?
Coronary artery disease, myocardial infarction, dilated cardiomyopathy, atrial fibrillation
True or False: An S3 heart sound in severe MR always indicates heart failure.
False
What is the significance of increased LA volume in MR?
It leads to increased LA pressure and potential atrial fibrillation
What imaging technique can be used when echocardiography assessment of MR is indeterminate?
Cardiac magnetic resonance (CMR) imaging
CMR can be utilized when there is discordance with clinical symptoms or difficulties in echocardiographic assessment.
What situations may complicate echocardiographic assessment of mitral regurgitation (MR)?
Presence of an eccentric MR jet or multiple jets of regurgitation
These factors can make it challenging to accurately assess the severity of MR using echocardiography.
What can CMR accurately quantify regarding mitral regurgitation?
Mitral regurgitant volume and fraction, LV volumes and systolic function, LA volume
CMR provides detailed measurements that help in evaluating the severity and impact of MR.
What additional information can be obtained from CMR in patients with MR?
LV damage or scar
CMR can reveal structural changes in the left ventricle that may result from chronic mitral regurgitation.
What role does exercise stress echocardiography play in assessing MR?
Shows changes in MR during exercise and unmasking symptoms in asymptomatic patients
This technique helps to evaluate the dynamic nature of MR under different hemodynamic conditions.
When should invasive hemodynamic testing be considered for assessing MR severity?
When noninvasive imaging is equivocal or discrepant from clinical findings
Invasive testing allows for direct measurement of cardiac pressures to better assess MR severity.
What is the angiographic grade for mild mitral regurgitation?
11
Mild mitral regurgitation is characterized by a small central jet, with a color Doppler jet area of less than 4 cm² or less than 20% of the left atrial area.
What is the Doppler vena contracta width indicating moderate mitral regurgitation?
0.3–0.69 cm
Moderate mitral regurgitation is also associated with a regurgitant volume of 30–59 mL and a regurgitant fraction of 30%–49%.
What is the regurgitant volume for severe mitral regurgitation?
> 60 mL
Severe mitral regurgitation is indicated by a vena contracta width greater than 0.7 cm and a large central MR jet.
What defines severe mitral regurgitation in terms of vena contracta width?
> 0.7 cm
Severe mitral regurgitation can also include any wall-impinging jet or swirling in the left atrium.
What is the color Doppler jet area indicating severe mitral regurgitation?
> 40% LA area
The left atrium (LA) becomes enlarged in severe cases of mitral regurgitation.
Fill in the blank: The regurgitant fraction for mild mitral regurgitation is _______.
<30%
The regurgitant fraction is a measure of the amount of blood that flows backward through the mitral valve.
What is the Doppler vena contracta width indicating mild mitral regurgitation?
<0.3 cm
This indicates a very small regurgitant flow through the mitral valve.
True or False: An enlarged left atrium is a criterion for severe mitral regurgitation.
True
An enlarged left atrium or left ventricle is often associated with severe cases.
What is the regurgitant orifice area for moderate mitral regurgitation?
0.20–0.39 cm²
This indicates a moderate degree of regurgitant flow through the mitral valve.
What are the criteria for assessing the severity of mitral regurgitation?
Angiographic grade, Color Doppler jet area, Doppler vena contracta width, Regurgitant volume, Regurgitant fraction
These criteria help in categorizing the severity of mitral regurgitation into mild, moderate, and severe.
What is the role of medical therapy in patients with severe primary MR?
There is no clear role for medical therapy in patients with severe (Stage C or D) primary MR.
What should be considered even before the onset of symptoms in severe primary MR?
Surgical or transcatheter intervention.
How does systemic hypertension affect MR?
It can increase MR by increasing afterload.
What should be treated in patients with significant MR?
Systemic hypertension.
What therapy should be initiated in patients with LV systolic dysfunction who do not undergo surgical intervention?
Guideline-directed heart failure therapy.
List the components of guideline-directed heart failure therapy.
- Beta-blockers
- Angiotensin-converting enzyme inhibitors
- Angiotensin receptor blockers
- Angiotensin receptor neprilysin inhibitors
- Aldosterone antagonists
Why is routine follow-up crucial in patients with primary MR?
To monitor the progression of the disease.
When should repeat TTE be performed for patients with Stage C MR?
When there is a change in symptoms or at least once or twice a year.
When should repeat TTE be performed for patients with Stage B MR?
Less frequently than for Stage C MR.
What is the definition of Stage A in Primary MR?
At risk of MR
MR stands for mitral regurgitation.
What characterizes Stage B in Primary MR?
Progressive MR
MR refers to the worsening of mitral regurgitation.
What is Stage C in Primary MR?
Asymptomatic severe MR
This stage indicates severe mitral regurgitation without symptoms.
What is Stage D in Primary MR?
Symptomatic severe MR
This stage indicates severe mitral regurgitation with symptoms present.
What are the valve anatomy characteristics in mild mitral valve prolapse?
Mild mitral valve prolapse with normal coaptation, mild valve thickening and leaflet restriction
Coaptation refers to the closure of the valve leaflets.
What valve changes are seen in moderate to severe mitral valve prolapse?
Normal coaptation, rheumatic valve changes with leaflet restriction and loss of central coaptation, prior IE
IE stands for infective endocarditis.
What characterizes severe mitral valve prolapse?
Loss of coaptation or flail leaflet
A flail leaflet indicates significant dysfunction of the valve.
What are the hemodynamic consequences of mild mitral regurgitation?
None
Mild mitral regurgitation typically does not lead to significant hemodynamic changes.
What is indicated by a small vena contracta of less than 0.3 cm?
No MR jet or small central jet area, 20% LA on Doppler
LA refers to left atrium.
What does a central jet MR of 20%-40% LA indicate?
Late systolic eccentric jet MR, vena contracta less than 0.7 cm, regurgitant volume less than 60 ml, fraction less than 50%, ERO less than 0.40 cm²
ERO stands for effective regurgitant orifice area.
What defines a central jet MR of greater than 40% LA?
Holosystolic eccentric jet MR, vena contracta greater than or equal to 0.7 cm, regurgitant volume greater than or equal to 60 ml, fraction greater than or equal to 50%, ERO greater than or equal to 0.40 cm²
Holosystolic indicates that the regurgitation occurs throughout the entire systolic phase.
What symptoms are associated with moderate or severe mitral regurgitation?
Decreased exercise tolerance, exertional dyspnea
Exertional dyspnea refers to shortness of breath during physical activity.
How does pulmonary hypertension relate to mitral regurgitation?
Pulmonary hypertension may be present at rest or with exercise in moderate or severe cases
This condition can complicate the management of mitral regurgitation.
What is the LVEF in the context of symptomatic severe MR?
C1: LVEF > 60% and LVESD < 40 mm; C2: LVEF ≤ 60% and/or LVESD ≥ 40 mm
LVEF refers to left ventricular ejection fraction, and LVESD refers to left ventricular end-systolic dimension.
What is the definition of Stage A in secondary mitral regurgitation (MR)?
At risk of MR
Stage A includes patients who are at risk but do not yet have mitral regurgitation.
What characterizes Stage B of secondary MR?
Progressive MR
Stage B indicates the progression of mitral regurgitation.
What defines Stage C in secondary MR?
Asymptomatic severe MR
Stage C involves patients with severe MR who do not exhibit symptoms.
What are the symptoms associated with severe secondary MR?
HF symptoms attributable to MR persist even after revascularization and optimization of medical therapy
HF refers to heart failure, which can manifest as decreased exercise tolerance and exertional dyspnea.
What anatomical features are observed in patients with normal valve leaflets in secondary MR?
Normal valve leaflets, chords, and annulus in a patient with CAD or cardiomyopathy
CAD refers to coronary artery disease.
What hemodynamic criteria indicate mild mitral regurgitation?
No MR jet or small central jet area <20% LA on Doppler
LA refers to left atrial size.
What is the regurgitant volume in mild mitral regurgitation?
Regurgitant volume <60 mL
This volume is a key criterion for assessing MR severity.
What are the hemodynamic indicators of severe mitral regurgitation?
- ERO ≥0.40 cm²
- Regurgitant volume ≥60 mL
- Regurgitant fraction ≥50%
ERO refers to effective regurgitant orifice.
What associated cardiac findings are typical for severe secondary MR?
- LV dilation
- Systolic dysfunction attributable to primary myocardial disease
- Regional wall motion abnormalities with reduced LV systolic function
LV refers to left ventricular size and function.
True or False: Symptoms attributable to coronary ischemia or heart failure may respond to revascularization and appropriate medical therapy.
True
This response is common in patients with coronary ischemia.
Fill in the blank: The measurement of the proximal isovelocity surface area by two-dimensional transthoracic echocardiography in patients with secondary MR _______.
underestimates the true ERO
This underestimation occurs due to the crescentic shape of the proximal.
What is the primary surgical therapy for primary MR?
Mitral valve repair
Mitral valve repair is preferred over replacement due to better clinical outcomes.
What is the main reason for choosing repair over replacement of the mitral valve?
Better clinical outcomes
Successful mitral valve repair results in better outcomes than valve replacement.
What is a critical factor that affects the success of mitral valve repair?
Valve anatomy and surgeon experience
Not all mitral valves can be repaired; success depends on these factors.
What surgical technique is often used in mitral valve repair?
Annuloplasty ring with leaflet resection or reconstruction
Repair techniques may include resection of redundant tissue or using artificial neochords.
What should be done if successful mitral valve repair is not feasible?
Mitral valve replacement
Replacement can be done with either a tissue bioprosthesis or a mechanical prosthesis.
What is a notable disadvantage of mechanical prostheses?
Requires chronic anticoagulation
While durable, mechanical prostheses necessitate ongoing blood thinners.
When should patients be referred for surgery in cases of primary MR?
When symptoms develop
Untreated symptoms indicate a much worse prognosis.
What is the recommended timing for mitral surgery related to LV ejection fraction?
Before it falls to 60% or less
Surgery should be performed before significant LV dysfunction manifests.
What are additional indications for mitral surgery apart from LV ejection fraction?
Onset of atrial fibrillation or pulmonary hypertension
These conditions also warrant surgical intervention.
Is early surgical repair reasonable for asymptomatic severe MR patients?
Yes, especially if performed by experienced surgeons
Early repair is considered reasonable even without LV dysfunction markers.
What happens to LV function postoperatively when the mitral valve is replaced?
Precipitous fall in LV function
This decline does not occur when the valve apparatus is conserved.
What is recommended for symptomatic patients with severe primary MR (Stage D)?
Mitral valve intervention is recommended irrespective of LV systolic function.
Stage D indicates severe primary mitral regurgitation with symptoms.
In symptomatic patients with severe primary MR and LV systolic dysfunction (LVEF ≤60%, LVESD ≥40 mm) (Stage C2), what is recommended?
Mitral valve surgery is recommended.
Stage C2 indicates severe primary MR with LV systolic dysfunction.
What is the preferred surgical intervention for patients with severe primary MR and degenerative disease when surgery is indicated?
Mitral valve repair is recommended in preference to mitral valve replacement.
A successful and durable repair is essential for this recommendation.
What is reasonable for asymptomatic patients with severe primary MR and normal LV systolic function (LVEF ≥60% and LVESD ≤40 mm) (Stage C1)?
Mitral valve repair is reasonable when the likelihood of a successful and durable repair is >95% with an expected mortality rate of <1%.
This should be performed at a Primary or Comprehensive Valve Center.
For asymptomatic patients with severe primary MR and normal LV systolic function (LVEF >60% and LVESD <40 mm) (Stage C1), when may mitral valve surgery be considered?
When there is a progressive increase in LV size or decrease in EF on ≥3 serial imaging studies.
This consideration is irrespective of the probability of a successful and durable repair.
What is reasonable for severely symptomatic patients (NYHA class III or IV) with severe primary MR and high surgical risk?
TEER (transcatheter edge-to-edge repair) is reasonable if mitral valve anatomy is favorable and patient life expectancy is at least 1 year.
NYHA class III or IV indicates severe functional limitations.
In symptomatic patients with severe primary MR attributable to rheumatic valve disease, what may be considered?
Mitral valve repair may be considered at a Comprehensive Valve Center by an experienced team.
This is applicable when surgical treatment is indicated and a durable repair is likely.
When should mitral valve replacement not be performed in patients with severe primary MR?
Unless mitral valve repair has been attempted at a primary or Comprehensive Valve Center and was unsuccessful.
This applies when leaflet pathology is limited to less than one half of the posterior leaflet.
What do the acronyms COR, LOE, and NR stand for in the context of the recommendations?
COR: Class of recommendation, LOE: Level of evidence, NR: Nonrandomized.
These acronyms relate to the guidelines for evaluating treatment recommendations.
What does NYHA stand for?
New York Heart Association.
NYHA is a classification system for heart failure severity based on symptoms.
What is the only FDA-approved transcatheter mitral valve repair device currently available?
MitraClip
The MitraClip is an edge-to-edge leaflet repair device targeting primary mitral regurgitation.
What is the primary goal of the MitraClip procedure?
To improve coaptation of the mitral valve leaflets
The MitraClip approximates the anterior and posterior leaflets to create a ‘double orifice’ valve.
What are the indications for TMVr with MitraClip?
Symptomatic, at least moderate-severe primary MR and prohibitive surgical risk
Patients must also have suitable anatomical characteristics assessed by TEE.
What anatomical characteristics are assessed by TEE for MitraClip feasibility?
- Centrally located MR jet
- Not a very large flail gap
- Minimal leaflet calcification
- Sufficient valve area
These factors help reduce the risk of complications during the procedure.
True or False: Surgical intervention for secondary MR has been shown to prolong survival.
False
Surgical intervention may improve symptoms and quality of life but does not prolong survival.
What is the main medical therapy indicated for secondary MR?
Optimization of guideline-directed medical therapy for heart failure
This includes improving left ventricular function and remodeling.
What does the COAPT trial demonstrate regarding MitraClip for secondary MR?
MitraClip TMVr could benefit certain patients with secondary MR who are medically optimized
This trial showed positive outcomes for patients with significant MR relative to LV remodeling.
What is the FDA approval criteria for MitraClip in secondary MR?
Symptomatic, severe secondary MR and not very severe LV dysfunction
LV ejection fraction must be greater than 20% and LV end-systolic dimension less than 70 mm.
What are the key features assessed for MitraClip TMVr in secondary MR?
- Central jet
- Minimal leaflet calcification
- Adequate leaflet coaptation and length
These features ensure proper insertion and functioning of the MitraClip.
What types of devices are under investigation for secondary MR?
- Edge-to-edge repair devices with a central spacer
- Direct and indirect annuloplasty devices
- Various TMVR valves
These devices utilize different anchoring mechanisms to treat secondary MR.
When should surgical or percutaneous intervention be considered for secondary MR?
When persistent symptoms and significant MR exist despite optimal medical therapy
This includes considerations for patients with ischemic cardiomyopathy.
Fill in the blank: MitraClip was initially approved for use only in _______.
primary MR
What is recommended for patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF < 50%) and persistent symptoms while on optimal GDMT for HF?
TEER is reasonable for patients with appropriate anatomy as defined on TEE and with LVEF between 20% and 50%, LVESD ≤ 70 mm, and pulmonary artery systolic pressure ≤ 70 mm Hg.
GDMT stands for guideline-directed medical therapy; TEE stands for transesophageal echocardiography; TEER stands for transcatheter edge-to-edge repair; LVESD stands for left ventricular end-systolic dimension.
In which scenario is mitral valve surgery considered reasonable?
When CABG is undertaken for the treatment of myocardial ischemia in patients with severe secondary MR (Stages C and D).
CABG stands for coronary artery bypass grafting.
What is the recommendation for patients with chronic severe secondary MR from atrial annular dilation and preserved LV systolic function (LVEF ≥ 50%)?
Mitral valve surgery may be considered for patients with severe persistent symptoms (NYHA class III or IV) despite therapy for HF and therapy for associated AF or other comorbidities (Stage D).
AF stands for atrial fibrillation; NYHA stands for New York Heart Association.
What is the recommendation for patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF < 50%) and persistent severe symptoms?
Mitral valve surgery may be considered for patients with persistent severe symptoms (NYHA class III or IV) while on optimal GDMT for HF (Stage D).
What may be a reasonable option for patients with CAD and chronic severe secondary MR related to LV systolic dysfunction undergoing mitral valve surgery?
Chordal-sparing mitral valve replacement may be reasonable to choose over downsized annuloplasty repair.
CAD stands for coronary artery disease.
True or False: TEER is recommended for all patients with chronic severe secondary MR.
False.
TEER is only recommended for patients with specific criteria including appropriate anatomy and certain measurements.
Fill in the blank: In patients with chronic severe secondary MR, mitral valve surgery is reasonable when _____ is undertaken for myocardial ischemia.
CABG
What does LVEF stand for in the context of heart function?
Left ventricular ejection fraction.
What is the significance of the NYHA classification in assessing patients with heart conditions?
It categorizes patients based on the severity of their heart failure symptoms.
List the key considerations for TEER eligibility in patients with chronic severe secondary MR.
- LVEF between 20% and 50%
- LVESD ≤ 70 mm
- Pulmonary artery systolic pressure ≤ 70 mm Hg.
What does GDMT stand for?
Guideline-directed medical therapy.
What is mitral valve prolapse (MVP)?
MVP is the condition in which there is systolic billowing of one or both mitral leaflets above the mitral annulus into the left atrium (LA)
MVP can cause primary mitral regurgitation (MR) and is diagnosed by echocardiography.
What causes myxomatous degeneration in mitral valve prolapse?
Myxomatous degeneration can cause diffuse thickening and multisegment redundancy of the mitral leaflets
A severe form of this is called Barlow disease.
What is fibroelastic deficiency in relation to MVP?
Fibroelastic deficiency, often attributed to aging, can result in more focal prolapse
This condition affects the structural integrity of the mitral valve.
How is mitral valve prolapse diagnosed?
MVP is usually diagnosed by echocardiography
The diagnosis is defined as leaflet excursion of .2 mm beyond the highest points of the saddle-shaped mitral annulus.
What is the estimated prevalence of mitral valve prolapse?
The estimated prevalence of MVP is around 1% to 2.5%
This indicates how common the condition is in the general population.
What is the classic auscultatory finding in mitral valve prolapse?
The classic finding is a mid-systolic click and late systolic murmur
The click may vary somewhat within systole depending on changes in left ventricular (LV) dimension.
What causes the clicks heard in mitral valve prolapse?
The clicks are believed to result from the sudden tensing of the mitral valve apparatus as the leaflets prolapse into the LA during systole
Multiple clicks may be heard during auscultation.
What is the natural history of asymptomatic mitral valve prolapse?
The course can range from benign with normal life expectancy to worsening MR and progressive LA dilation, LV dysfunction, and congestive heart failure
Patients may experience sudden increases in MR due to chordal rupture and leaflet flail.
What are potential complications of myxomatous mitral valve prolapse?
Patients can experience malignant ventricular arrhythmias leading to sudden cardiac death
The mechanisms of these arrhythmias are incompletely understood and may relate to myocardial fibrosis or mechanical forces.
Fill in the blank: The sudden increase in mitral regurgitation may occur if MVP progresses to _______.
chordal rupture and leaflet flail
True or False: Asymptomatic mitral valve prolapse always leads to severe complications.
False
Many patients have a benign course with a normal life expectancy.
What is mitral annular disjunction?
Mitral annular disjunction is a fibrous discontinuity between the mitral annulus and ventricular myocardium
It can be identified on imaging and may contribute to arrhythmias.
