S2 L5.2: Valvular Heart Disease Flashcards
What is the normal mitral valve orifice area?
4-6 cm2
What is the value of the valv’es orifice when there is a significant obstruction in mitral stenosis?
< ~2 cm2
The following are true about the hemodynamic hallmarks for mitral stenosis, except:
A. MV opens during diastole; Blood can flow from the Left Atrium (LA) to the LV only if propelled by an abnormally
elevated left atrioventricular pressure gradient
B. If MV is tight, ↑ volume & pressure in LA
C. If there’s too much damming of blood in LA and it cannot accommodate it anymore, it will just push blood back to pulmonary arteries, then to pulmonary bed and the pt gets orthpnic or nocturnal dyspnea or really symptomatic
D. None of the above
C. If there’s too much damming of blood in LA and it cannot accommodate it anymore, it will just push blood back to pulmonary VEINS, then to pulmonary bed and the pt gets orthpnic or nocturnal dyspnea or really symptomatic
Measurement of the Mitral Orifice when there is severe MS
<1 cm2
Modified T/F: LA pressure of ~25 mmHg is required to maintain a normal cardiac output. LA has to push very hard to move blood to LV
TT
T/F: Atria are chambers of low pressure
True
Is the leading casua of mitral stenosis but it has many other causes
Mitral Stenosis
It is a manifestation of RHD and sequelae of RF and if a female pt in her 20s has this, think of RHD or RF
Mitral Stenosis
The following are less common etiologies of Mitral Stenosis, except:
A. Congenital mitral valve stenosis
B. Cor triatriatum
C. Mitral annular calcification with extension onto the leaflets
D. Systemic lupus erythematosus, rheumatoid arthritis
E. None of the above
E
Select the items that are included in other less common etiologies of mitral valve:
A. Left atrial myxoma
B. Infective endocarditis with large vegetations
C. Pure or predominant MS occurs in approximately 40%
D. Occurs with other valvular problems like mitral regurgitation 60% (can also occur with mitral stenosis)
All are included
OTHER COMMON ETIOLOGIES OF MITRAL STENOSIS
Tumor trapped in mitral valve; No stenosis
Left atrial myxoma
Blood goes from LA → LV, tumor comes with the
blood and get stuck in the mitral valve =
obstruction
OTHER COMMON ETIOLOGIES OF MITRAL STENOSIS
What is being described?
Hearts gets infected coming from something else
Infective endocarditis with large vegetations
OTHER COMMON ETIOLOGIES OF MITRAL STENOSIS
What is being described?
Bacteria from the mouth, lungs, or bloodstream which leads to infections. Material growth from infections that
mechanically destroys the structures and
obstruct flow of blood.
Infective endocarditis with large vegetations
RHEUMATIC MITRAL STENOSIS
Valve leaflets are diffusely thickened by fibrous tissue and/or calcific deposits
Fish-mouth valve
RHEUMATIC MITRAL STENOSIS
Commissures fuse on the inner and outer side of the valve, causing more obstruction/narrowing of the
mitral valve
Fish-mouth valve
RHEUMATIC MITRAL STENOSIS
Chordae tendineae fuse and shorten, see growth, becoming fibrotic and stiff. They then become not pliable, contributing to the stiffening or stenosis of
the mitral valve
Fish-mouth valve
Select the items that are considered as true regarding immobilization of leaflets and narrowing of orifice in rheumatic mitral stenosis?
A.Because of deposition or growth, there’s calcification causing the leaflets to become immobile
B.As mitral stenosis becomes severe, so does the immobilization, until they no longer move
C.d/t stagnation of blood in the LA, platelets have more tendencies to bind to each other, causing thrombus/clot formation
D. Fragments of blood clots can still pass through the narrow orifice and travel to the brain causing stroke
A and B
C & D are related to thrombus formation and arterial embolization
In Rheumatic Mitral Stenosis, d/t stagnation of blood in the LA, platelets have more tendencies to bind to each other, causing what?
Thrombus formation and arterial embolization
This is from the calcific valve
Thrombus formation and arterial embolization
The following are true about thrombus formation and arterial emobilzation in rheumatic mitral stenosis, except:
A. Fragments of blood clots can still pass through the narrow orifice and travel to the brain causing stroke
B. Constricted LA, particularly the left atrial appendage (in
atrial fibrillation patients)
C. Pts with mitral stenosis c large LA and have formed thrombus, they’re also at a high risk of developing stroke (cardio embolic stroke)
D. If the LA becomes bigger, the conduction system becomes overstretched, resulting in arrhythmias or more commonly,
E. With pts c large
LA, atrial fibrillation (heart beats irregularly, higher tendency for the blood to clot inside heart chamber, particularly LA)
B. DILATED LA, particularly the left atrial appendage (in
atrial fibrillation patients)
STAGES OF MITRAL STENOSIS
> 2.5 MVA cm2
Minimal
STAGES OF MITRAL STENOSIS
<1.0
Reactive Pulmonary HTN and Severe
STAGES OF MITRAL STENOSIS
1.0-1.4
Moderate
STAGES OF MITRAL STENOSIS
1.4-2.5
Mild
STAGES OF MITRAL STENOSIS
Symptoms
None
Minimal
STAGES OF MITRAL STENOSIS
Symptoms
Minimal dyspnea c marked exertion
Mild
STAGES OF MITRAL STENOSIS
Symptoms
Dyspnea, orthopnea, PND,
pulmonary edema
Moderate
STAGES OF MITRAL STENOSIS
Symptoms
Resting dyspnea; NYHA IV,
disabled, bed chair (symple
movements causes
symptoms)
Severe
STAGES OF MITRAL STENOSIS
Symptoms
As in severe disease, plus fatigue, RV failure
Reactive Pulmonary HTN
Select the clinical manifestations of mitral stenosis:
A. The development of symptoms due to MS is generally about two decades
B. Most patients begin to experience disability in the fourth
decade of life
C. Death within 2–5 years after onset of symptoms
D. Dyspnea and cough
E. Atrial Fibrillation is generally associated with acceleration of the rate at which symptoms progress
F. Hemoptysis
G. Recurrent pulmonary emboli
Thrombus formation.
H. Pulmonary infections
I. Infective endocarditis
J. Expect cardiac output to be decreased
All are clinical manifestations
T/F: Metallic valves are longer lasting (10-20 yrs) while
bioprosthetic are less long acting
True
Result from an
abnormality or disease
process that affects any
one or more of the five
functional components of
the mitral valve apparatus
MITRAL REGURGITATION
Modified T/F: Mitral regurgitation is the going back of blood from the
LV into the LA. Not all regurgitation are bad
TT
Occur in the setting of:
○ AMI with papillary muscle rupture
○ Blunt chest wall trauma
○ During the course of infective endocarditis
Acute mitral regurgitation
T/F: With AMI, the posteromedial papillary muscle is involved
much more frequently
True
Rupture of chordae tendineae can result in ____ in patients with myxomatous degeneration
of the valve apparatus
“acute on
chronic MR”
Patients get adapted to this one. If severe, it is often progressive
Chronic Mitral Regurgitation
One of the valves goes or swings back to the LA,
thus allowing space or creating space allowing more
blood to regurgitate back from the LV to the LA
Mitral Valve Prolapse
T/F: Enlargement of the LA places tension on the anterior
mitral leaflet, pulling it away from the mitral orifice
False. It should be POSTERIOR mitral leaflet
T/F LV dilatation decreases the regurgitation, which in turn
enlarges the LA and LV further, causing chordal rupture
and resulting in a vicious cycle
False. LV dilation INCREASES the regurgitation
○ Ruptured chordae tendineae
○ Can cause flailing of the mitral valve leaflets into the
LA causing more space = more blood to go back to the LA
Ruptured Chord
You would stretch the valves away from each other creating a space in between the valves or the leaflets
Annulus Dilation
T/F: In acute mitral regurgitation, there would be an increased
left atrial volume and end diastolic volume will be the same
True
The following are acute causes of mitral regurgitation, EXCEPT:
a. Endocarditis
b. Myxomatous
c. Trauma
d. Chordal rupture/Leaflet flail
e. A and C
f. All of the above
B (chronic cause siya not acute)
Which of the following items are CHRONIC CAUSES OF MITRAL REGURGITATION:
A. Myxomatous (MVP)
B. Rheumatic fever
C. Endocarditis (healed)
D. Mitral annular calcification
E. Congenital (cleft, AV canal)
F. HOCM with SAM
G. Ischemic (LV remodeling)
H. DIlated cardiomyopathy
All
The following are related to clinical manifestations of mitral regurgitation, EXCEPT:
A. Patients with chronic mild to moderate isolated MR are
usually asymptomatic
B. Palpitations may signify the onset of AF (atrial fibrillations)
C. Right-sided heart failure (if flow of heart is not controlled)
D. Acute pulmonary edema or pulmonary congestion is
common in patients with chronic severe MR
E. None of the above
D. it should be ACUTE sever MR not chronic
What are the management for mitral regurgitation?
● Follow up and close monitoring
● Medical therapy
● Mitral valve repair
● Mitral valve replacement
Systolic Click-Murmur Syndrome, Barlow’s Syndrome,
Floppy-Valve Syndrome, Billowing Mitral Leaflet
Syndrome
MITRAL VALVE PROLAPSE
A relatively common but highly variable clinical syndrome
MITRAL VALVE PROLAPSE
Results from diverse pathogenic mechanisms of the
mitral valve apparatus
MITRAL VALVE PROLAPSE
T/F: In mitral valve proplapse, cause is unknown at most
True
The following are true about mitral valve prolapse, EXCEPT:
A. May be genetically determined collaged disorder
B. May be associated with thoracic skeletal deformities
C. May occur rarely as a sequel to ARF, IHD, cardiomyopathies, ASD
D. none of the above
D.
T/F regarding Clinical Features of Mitral valve prolpase:
1. More common in females
2. Between the ages of 15 & 30 years
3. Usually benign clinical course
4. Increased familial incidence for some patients
5. Most patients are asymptomatic
6. Arrhythmias: Palpitations, light-headedness & syncope
7. Sudden death is very rare
8. Chest pain
9. TIA secondary to emboli from the mitral valve
10. Infective endocarditis
All are true
● Occurs in about 1⁄4 of all patients with chronic valvular
heart disease
● Approaximately 80% of adult patients with symptomatic
valvular AS are male
AORTIC STENOSIS
What are the general causes of aortic stenosis?
○ Degenerative calcification (comes with aging)
○ Congenital (commonly Bicuspid AV)
○ Rheumatic inflammation
Defined echocardiographically as focal thickening or
calcification of the valve cusps with a peak Doppler
transaortic velocity of 2.5 m/s
AORTIC STENOSIS
The following are risk factors of aortic stenosis, except:
A. Age
B. Female Sex
C. Smoking
D. DM
E. None of the above
B
Risk factors include Age, male sex, smoking, DM HTN, CKD, ↑LDL, ↓HDL
cholesterol, & ↑CRP (inflammatory marker)
The following are pathophysiology of aortic stenosis, except:
A. Obstruction to LV outflow
B. LVH & dilation
C. ↓ DV & CO
D. Elevated LV end diastolic pressure
E. Heart failure
F. decreased MVO2
G. Ischemia
H. None of the above
F. should be increased MVO2
T/F: In aortic stenosis, Most patients do not become symptomatic until the sixth
to eighth decades
True
What are the three cardinal symptoms of aortic stenosis
○ Exertional dyspnea
■ Most benign
○ Angina pectoris
○ Syncope
■ Worst of 3
If any of the 3 cardinal symptoms appear, it is usually poor prognosis
Identifiy what kind of valve disease is being described
● Rheumatic in 2⁄3 patients
● Thickening, deformity, and shortening of the individual
aortic valve cusps
PRIMARY VALVE DISEASE
Identifiy what kind of aortic disease is being described
● Due entirely to marked aortic root dilatation without
primary involvement of the valve leaflets
● Widening of the aortic annulus and separation of the
aortic leaflets
PRIMARY AORTIC ROOT DISEASE
The following are included in the pathophysiology of primary aortic root disease, except:
A. ↑ total stroke volume
B. ↑ LV end-diastolic volume (↑ preload)
C. Dilatation and eccentric LVH
D. As LV function deteriorates, the end diastolic volume
rises further and the forward stroke volume and EF
decline
E. Can bring about heart failure like aortic stenosis
F. None of the above
F
Identify what kind of regurgitation is being described:
● May be due to the sudden changes in the aortic valve
anatomy
● may occur in infective endocarditis, aortic dissection, or
trauma
● LV cannot employ adaptive mechanisms since it is acute,
thus, patients will be symptomatic immediately, moreso if
the aortic regugitation is at least moderate or severe
ACUTE AORTIC REGURGITATION
Identify what kind of regurgitation is being described:
● A long latent period
● Asymptomatic for as long as 10–15 yrs
● uncomfortable palpitations, especially on lying down,
may be an early complaint
● exertional dyspnea is followed by orthopnea, PND, and
excessive diaphoresis
CHRONIC AORTIC REGURGITATION
ARTERIAL PULSE FINDINGS
collapses suddenly as arterial pressure falls rapidly
during late systole and diastole
CORRIGAN (WATER-HAMMER) PULSE
ARTERIAL PULSE FINDINGS
capillary pulsations, an alternate flushing and paling of
the skin at the root of the nail while pressure is applied to
the tip of the nail
QUINKE PULSE
a booming “pistol-shot” sound can be heard over the
femoral arteries
TRAUBE SIGN
a to-and-fro murmur is audible if the femoral artery is
lightly compressed with a stethoscope
DUROZIEZ SIGN
● Head bob with each pulse
MUSSET SIGN
● much less prevalent than MS
● generally rheumatic in origin
● more common in females than in males
Tricuspid stenosis
T/F regarding Tricuspid stenosis: It does not occur as an isolated lesion and is usually
associated with MS
True
T/F regarding pathophysiology of tricuspid stenosis:
1.A diastolic pressure gradient between the RA and RV
defines TS
2.Augmented when the transvalvular blood flow increases
during inspiration and declines during expiration.
3. Systemic venous congestion
4.CO during exercises is usually depressed, and it fails to rise during
rest
1 - 3: True
4: CO at rest is usually depressed, and it fails to rise during
exercise
What are the symptoms of tricuspid stenosis?
Pulmonary congestion (due to MS)
Relatively little dyspnea for the degree of hepatomegaly,
ascites, and edema that they have
● Fatigue secondary to a low CO → dec amount of blood
back to the heart
● TS may be suspected for the first time when symptoms
of right-sided failure persist after an adequate mitral
valvotomy
T/F about tricuspid regurgitation:
- Most commonly, TR is non functional
- Secondary to marked dilatation of the tricuspid
annulus - May complicate RV enlargement
- Commonly seen in the late stages of heart failure with severe pulmonary hypertension
- Reversible in part if pulmonary hypertension is
relieved
2 - 5: True
1: False, TR is funcitonal
Give me at least two (other causes of tricuspid regurgitaiton
● Infarction of RV papillary
muscles
● Tricuspid valve prolapse
● Carcinoid heart disease
(tumors embedded in
the tricuspid valves)
● Endomyocardial fibrosis
● Infective endocarditis
● Trauma
● Congenital
● Chronic RV apical pacing
(pacemaker - wire inserted via femoral artery to RA; wire
gets implanted in RV to stimulate both ventricles; can
also be implanted c wires going to RA)
The following are clinical manifestations of tricuspid regurgitaiton, EXCEPT:
A. Systemic venous congestion
B. Reduction of CO
C. Left-sided heart failure
D. Atrial fibrillation is usually present
E. None of the above
C. RIGHT SIDED not left
What kind of valve disease is being described
● Infrequently due to rheumatic fever compared to other
valves
● uncommonly the seat of infective endocarditis
● The carcinoid syndrome may cause pulmonic stenosis
and/or regurgitation
PULMONIC VALVE DISEASE
● usually of little hemodynamic significance
● Usually secondary to dilatation of the pulmonic valve ring
as a consequence of severe pulmonary hypertension
PULMONIC REGURGITATION
Congenital in 95%; usually does not present alone, usually
together with another condition
PULMONIC STENOSIS
is the most common cause of
acquired PS
Carcinoid heart disease
