The Basics Flashcards
What are the components of the MV complex?
- Annulus
- Leaflets
- Chords
- Papillary muscles
Definition of primary MR?
- Structural alteration of ≥1 component of the MV complex or apparatus
- Also known as valvular/organic/degenerative MR
Possible causes of primary MR?
- Degeneration
- Inflammation
- Infection
- Trauma
- Congenital
Definition of secondary/functional MR?
- Structurally normal MV with insufficient coaptation due to chamber remodeling
- Also known as atrial/ventricular MR
Possible causes of secondary/functional MR?
- CAD
- Dilated CM
- Restrictive CM
- HOCM
- AF
Carpentier Classification: Definition and example of Type I MR?
Normal leaflet motion
Eg. annular dilatation
Carpentier Classification: Definition and example of Type II MR?
Excessive leaflet motion
Eg. mitral valve prolapse
Carpentier Classification: Definition and example of Type IIIa MR?
Restricted leaflet motion in systole and diastole
Eg. Rheumatic
Carpentier Classification: Definition and example of Type IIIb MR?
Restricted leaflet motion in systole only
Eg. ischaemic
Carpentier Classification: Definition and example of Type IV MR?
Systolic anterior motion (SAM)
Eg. HOCM
Carpentier Classification: Definition and example of Type V MR?
Hybrid (> 1 pathology)
Eg. rheumatic MV + perforation
Perforated leaflet:
Carpentier Classification? Primary or secondary MR?
- Type I: normal leaflet motion
- Primary MR: MR due to valve problem - perforated due to IE
Cleft leaflet:
Carpentier Classification? Primary or secondary MR?
- Type I: normal leaflet motion
- Primary MR: MR due to valve
MVP (Barlow’s disease, FED, MAD)
Carpentier Classification? Primary or secondary MR?
- Type II: excessive leaflet motion
- Primary MR: MR due to valve
Rheumatic MVD:
Carpentier Classification? Primary or secondary MR?
- Type IIIa: restricted leaflet motion in systole and diastole
- Primary MR: MR due to valve
Annular calcification:
Carpentier Classification? Primary or secondary MR?
- Type IIIa: restricted leaflet motion in systole and diastole
- Primary MR: MR due to valve
Radiation heart disease:
Carpentier Classification? Primary or secondary MR?
- Type IIIa: restricted leaflet motion in systole and diastole
- Primary MR: MR due to valve
Dilated (non-ischaemic) CM:
Carpentier Classification? Primary or secondary MR?
- Type I: normal leaflet motion
- Secondary MR: MR due to annular dilatation
AF (isolated LA dilatation):
Carpentier Classification? Primary or secondary MR?
- Type I: normal leaflet motion
- Secondary MR: MR due to annular dilatation
Ischaemic Heart Disease:
Carpentier Classification? Primary or secondary MR?
- Type IIIb: restricted leaflet motion in systole only
- Secondary MR: abnormal leaflet motion - systolic restriction due to leaflet tethering
Ischaemic CM:
Carpentier Classification? Primary or secondary MR?
- Type IIIb: restricted leaflet motion in systole only
- Secondary MR: abnormal leaflet motion as a result of ischaemic CM
Normal MV closing forces?
- LV contraction
- Basal rotation
- Annular contraction
Normal tethering forces?
- Passive annular constraint
2. Tethering
Closing and Tethering Forces in Secondary MR: Global LV Dilatation
- Increased tethering/tenting
- Impaired closing
- Annular dilatation
- Reduced basal rotation
Note: symmetric tethering = central MR jet
Closing and Tethering Forces in Secondary MR: Inferior regional dysfunction
- Increased tethering/tenting
- Impaired closing
- Annular dilatation
Note: asymmetric tethering = eccentric MR jet
Pathophysiology of Primary MR: Phases?
- Acute Phase
- Chronic Compensated Phase
- Chronic Decompensated Phase
Pathophysiology of Acute Phase of Primary MR?
- LA and LV size is normal
- Acute MR occurs due to sudden rupture of chords or papillary muscle
- Sudden LA volume overload => ↑↑ in LAP => pulmonary venous congestion and acute pulmonary oedema (APO)
- LV volume overload => ↑ LVEDP and ↓ LVESP (due to reduced afterload) allows LV to eject more completely => ↑ LVEF and ↑ total SV
- However, significant portion of total SV regurgitates into LA therefore ↓ forward SV (and CO)
Pathophysiology of Chronic Compensated Phase of Primary MR?
- ↑ LA and LV size
- Severity of MR increases slowly
- LA more compliant so LAP only slightly ↑
- LV develops eccentric hypertrophy or remodeling to better manage larger SV => ↑↑ LVEDV and LVESV near normal => ↑ LVEF and ↑↑ in total SV
- ↑↑ in total SV means forward SV is now near normal
Pathophysiology of Chronic Decompensated Phase of Primary MR?
- ↑↑ LA and LV size
- LV systolic dysfunction due to prolonged LV volume overload (which causes muscle damage and therefore reduces contractile function)
- ↑↑ LVEDV still but weakened LV can no longer shorten adequately and LVESV ↑
- = ↓ LVEF and ↓ total and forward SVs
- ↑↑ LAP => pulmonary congestion, acute pulmonary oedema (APO) and PHTN
Indicators of LV dysfunction in severe MR?
- Increased LVESD ≥ 40mm
2. LVEF ≤ 60% = impaired
Management of MR?
- Stages
- Diagnosis
- Medical therapy
- Interventions
What are the MR management stages based on?
- Valve anatomy
- Valve haemodynamics
- Haemodynamic consequences (primary, organic MR)
- Associated cardiac findings (secondary, functional MR)
- Symptoms
