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Echo 2 > Module 6 : Mitral Stenosis > Flashcards

Module 6 : Mitral Stenosis Flashcards

1
Q

definiton of mitral stenosis

A
  • incomplete opening of the MV during diastole with thickened mitral leaflets
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2
Q

MV anatomy

A
  • annulus
  • leaflets
    + anterior
    + posterior
  • chord tendinae
  • papillary muscles
    + ant-lat
    + post-med
  • LV walls
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3
Q

three layers of the MV

A
  • fibrosa
  • spongiosa
  • atrialis
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4
Q

fibrosa layer

A
  • provides structural support and stiffness when the valve is closed
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5
Q

spongiosa layer

A
  • provides flexibility to the valve with less dense tissue
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6
Q

atrialis layer

A
  • composed mostly of endocardium cells which line the entire atria
  • smooth
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7
Q

MV leaflet anatomy

A
  • anterior leaflet = more complex than the posterior leaflet
  • one layer extends medially toward the AV to form the aorta-mitral curtain
  • both the AML and PML cover roughly the same area of the valve orifice
  • PML is connected to annulus along 2/3 of its circumference whereas the AML is connected to 1/3
  • PML is about half of the length of the AML
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8
Q

MV scallops

A
  • MV scallops are well demarcated on the PML only
  • the apposing regions on the AML are assumed to have the regions as the PML
  • scallops are labelled from LATERAL TO MEDIAL A1, A2, A3 and P1, P2, P3
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9
Q

which leaflet is more susceptible to calcification from MAC

A
  • PML
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10
Q

what are the chordae tendinae responsible for

A
  • anchoring the valve
  • maintaining ventricular geometry
  • preventing prolapse during systole of the leaflets
  • over 120 little chord
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11
Q

two pap muscles

A
  • posteromedial
    + more susceptible to complications from ischemia or infarction
  • anterolateral
    + less susceptible (has 2 vessels)
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12
Q

position of posteromedial pap

A

-lies along the inferior wall as seen in the PSAX view adjacent to the septum

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13
Q

structure of posteromedial pap

A
  • has 2 bodies which triturates into three heads
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14
Q

blood supply posteromedial pap

A
  • posterior descending artery
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15
Q

position of anterolateral pap

A
  • located along the anterolateral wall as seen in the PSAX view
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16
Q

structure of anterolateral pap

A
  • has 1 body which bifurcated into 2 heads
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17
Q

blood supply of anterolateral pap

A
  • left anterior descending artery and the circumflex
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18
Q

4 etiologies of MV stenosis

A
  • rheumatic
  • degenerative MAC
  • congential
  • masses
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19
Q

rheumatic - MV stenosis

A
  • starts at leaflet tips
  • result of inflammation followed by scarring
  • MV commisures become thickened and fibrosed
  • matting shortening of the chordae
  • fish mouth appearance
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20
Q

degenerative MAC - stenosis

A
  • start at BASAL ANNULUS usually posterior
  • progresses inward on to the leaflets
  • leaflet tips usually spared
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21
Q

congenital - MV stenosis

A
  • usually involves SUBVALVULAR apparatus
  • single pap muscles parachute valve
  • atrioventricle septal defects
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22
Q

masses - MV stenosis

A
  • mass impeded blood flow
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23
Q

what is MAC (mitral annular calcification) associated with

A
  • systemic hypertension
  • diabetes
  • hyperglycemia
  • renal dialysis
  • elderly
  • marfans syndrome
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24
Q

pathophysiology of mitral stenosis

A
  • MS reduces size of opening between LV and LA
  • LA driving pressure must rise in order to maintain adequate blood flow
  • BACK UP OF PRESSURE INTO INCREASE TR
  • ends up being similar to backward heart failure
  • afib common
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25
Q

patient history - MS

A
  • dyspnea (SOB)
    + absent at rest in mild MS
    + progressively develops with exertion as LA pressure rises
  • reduced exercise capacity , fatigue
  • exacerbating factors (increasing HR and CO)
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26
Q

what are exacerbating factors

A
  • fever
  • anemia
  • pregnancy
  • hyperthyroidism
  • rapid arhhythmia
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27
Q

manifestations of MS

A
  • depend on the severity of MS / degree of reduction in valve area
  • causes murmur
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28
Q

MS complications

A
  • afib
  • thromboembolism
  • infective endocarditis fever
  • CHF signs
  • hemoptysis - frothy bloody sputum in the lungs
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29
Q

three things to asses for 2D assessment on MS

A
  • common on valve - anatomy, mobility, calcification
  • image - MV area
  • measure thickness of leaflet tips
  • LA size
  • LV size
  • RV size
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30
Q

5 things for doppler assessment of MV

A
  • mean trans-mitral pressure gradient
  • calculate MV are by measuring pressure half time
  • pulmonary artery pressures
  • coexisting mitral regurge
  • continuity equation
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31
Q

rheumatic MS 2D characteristics = commissural fusion

A
  • results in doming of anterior leaflet
  • restricted mobility of PML
  • HOCKEY STICK APPEARANCE
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32
Q

rheumatic MS 2D characteristic = restricted motion

A
  • due to fusion at medial and lateral commisures
  • thickening/calcifiactios starts at leaflet tips and moves outward towards annular ring
  • thickening and calcifications shortening of chordae tendonae
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33
Q

how to measure MV leaflet thickness

A
  • zoom on the MV
  • scroll until valve is at maximal opening and the leaflets are well seen
  • valve will no longer have the classic double bump movement during diastole
  • optimize gain to reduce over or under estimation
  • measure thickness of both leaflet
  • ## note any focal calcifications
34
Q

normal MV leaflet thickness

A

1-2mm

35
Q

extensive mitral annular calcification

A
  • MAC starts at the PML annulus and works its way around toward the anterior annulus
  • calcification progresses to include the base of the leaflets and sometimes even the chordae
  • calcification causes distal shadowing in the LA and posterior to the heart
36
Q

cor triatriatum sinister

A
  • left atrial membrane
  • MV is usually normal
  • gradient between LA and LV is caused by perforate membrane in the LA
  • membrane impedes the flow from LA to LV symptoms are identical to other forms of MS
  • use doppler to assess gradient through the hole in the membrane
37
Q

left atrial myxoma tumor

A
  • most common primary tumors in the heart and are often benign
  • often attach to fossa ovals with pedunculation or foot
  • if large can prolapse into the mitral valve during diastole impeding flow through the valve
38
Q

parachute MV

A
  • MV stenosis due to one pap muscle instead of two
  • pap muscle to far superior in LV
  • associated with shones syndrome
  • which includes
    + supravalvular ring
    + parachute MV
    + subaortic stenosis
    + bicuspid AV
    + aortic coarctation
39
Q

what is mitral valve planimetry

A
  • most accurate method to quantify MS with direct measurement of the orifice
  • traced zoom PSAX and Mv level
  • trace around blood tissue interface
40
Q

what does accuracy of an MV planimetry depend on

A
  • ability to clearly delineate the orifice
  • tracing orifice exactly at tehleaflet tips
  • gain settings
  • operator skill
41
Q

what does MV planimetry measure

A
  • measures MV area
42
Q

tips for MV planimetry

A
  • must transect exactly perpendicular to the orifice
43
Q

color doppler assessment of MV

A
  • place color over the valve in every view when seen
  • look for aliasing during diastole
  • note the direction of the aliasing jet
44
Q

3 parts of the functional doppler assessment

A
  • mean trans-mitral pressure gradient
  • calculate MV area by measuring pressure half time
  • continuity equation
    + pulmonary artery pressures
    + coexisting mitral regurgitation
45
Q

MV inflow mean pressure gradient

A
  • use CW to trace the capture the highest velocity throughout diastole through the MV
  • technique uses the modified Bernoulli equation but instead of the peak instantaneous pressure gradient we use mean
  • the mean PG is obtained by tracing MV inflow profile
46
Q

what is the mean PG

A
  • average pressure gradient over the diastolic cycle
47
Q

why is mean PG done

A
  • because waveform is not parabolic with a single peak like the AV and PV the PG varies throughout the diastolic cycle
48
Q

mild MV by mean PG

A

< 5 mmHg

49
Q

moderate MV by mean PG

A

5-10mmHG

50
Q

severe MV by mean PG

A

> 10 mmHg

51
Q

MVA via pressure half time

A
  • assess the severity of the mitral stenosis using the pressure half time
  • diastolic blood flow is from the LV to the LA is impeded in MS
  • normally the majority of flow through the MV occurs in early diastole
  • in MS the rate of atrial emptying is slowed due to the narrow orifice
    + prolongs the decline of the early diastole PG between LV and LA
52
Q

what is the relationship between MVA and P1/2

A
  • inversely proportional
53
Q

how is the MVA derived with pressure half time

A
  • the MVA can be derivived by dividing 220 by the pressure half time
  • always use 220
54
Q

does pressure fall slower or faster with a more stenotic valve

A
  • slower
55
Q

normal pressure gradients with MV doppler

A
  • rapid pressure decline leads to a steep downslope on the MV inflow profile
56
Q

MS pressure gradient with MV doppler

A
  • the pressure decline is slowed leading to a prolonged deceleration time and therefore pressure half time
57
Q

MVA via the continuity method

A
  • absence of regurgitation, the stroke volume through all four valves should be the same
  • be calculating the SV through the AV using the LVOT and VTI of the LVOT we can measure the VTI of the MV inflow and extrapolate a mitral valve area from it
58
Q

MVA equation continuity method

A

MVA = VTIlvot x CSAlvot / VTI MV

59
Q

two sources of error for continuity equation

A
  • diameter
    + LVOt diameter = any error will be multiplied by factor of 4
  • angle
    + must be precisely aligned to the LV inflow and LVOT outflow to accurately calculate MVA
    + a misalignment fo 20 degrees equal a 6-7% reduction in velocity
60
Q

continuity equation and regurgitation

A
  • if LVOT diameter and VTI and used to calculate the MVA but the AV has a significant leak then the SV through the 2 valves are no longer equal
61
Q

continuity for MVA less accurate for 3 reasons

A
  • significant MR = MVA underestimated
  • significant AR = MVA overestimated
  • ASD or other intracardiac shunt
62
Q

pros of P1/2 of MVA

A
  • quickest method
  • uses CW
    _ PW is AR present
63
Q

cons of p 1/2 of MVA

A
  • arrhythmias
  • noisy signal
  • must acquire peak velocity
64
Q

tips of P 1/2

A
  • use color to align to flow

- use mid diastolic flow if there is an early peak

65
Q

pros to mean gradient of MVA

A
  • also quick

- used to calculate continuity

66
Q

cons to mean gradient of MVA

A
  • no MVA given
  • OVER/UNDERESTIMATION IF PRELOAD ALTERED
  • less useful with significant MR
67
Q

tips for mean gradient

A
  • align to flow use CW or PW
68
Q

pros continuity equation for MVA

A
  • not as preload dependent
69
Q

cons to continuity equation for MVA

A
  • more time consuming

- all 3 measurements must be precise

70
Q

tips for continuity equation

A
  • DO NOT USE IF SHUNTS PRESENT

- LESS ACCURATE WITH SIGNIFICANT MR AI

71
Q

consequences of MS

A
  • left atrial enlargement and clots
72
Q

Left atrial enlargement - LAE

A
  • chronic pressure overload in the LA causes increased LA size
73
Q

potential clots

A
  • decrease flow velocity leads to potential clots in the LA appendage or along septal wall
  • more common with a fib
  • TTE has high specificity but low sensitivity to LA clots
  • TEE much better
74
Q

MS leading to pulmonary hypertension

A

MS causes pressure back up&raquo_space; increased pulmonary venous pressure&raquo_space; pulmonary arterial hypertension

75
Q

pulmonary hypertension from MV

A
  • reversible at first
  • longstanding PAH causes irreversible PVR increases that do not resolve after MV surgery
  • SURGERY TIMING ALSO DEPENDS ON LV/LA/RV function
76
Q

MV treatments - pharmacologic

A 
- beta blockers
  \+ slow HR and enhances filling time
- diuretics
  \+ decrease preload
  \+ unload the lungs
- anticoagulants - clot prevention
  \+ Coumadin 
- anti-arrhythmics
  \+ improve hemodynamics / CO
77
Q

MV treatments - surgical

A 
- valve repair
  \+ balloon valvuloplasty 
  \+ commissurotomy
- valve replacement 
  \+ bioprosthetic 
  \+ mechanical 
  \+ percutaneous
78
Q

normal MVA MS

A

4-6 cm ^2

79
Q

mild MS MVA value

A

> 1.5 cm^s

80
Q

moderate MS MVA value

A

1.0-1.5 cm ^2

81
Q

severe MS MVA value

A

< 1 cm^2

Echo 2 (18 decks)

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