Valve - Mitral

Question 1

Symptoms of acute ischemic mitral regurgitation

Answer 1

Shock; pulm edema

Question 2

Etiology of acute ischemic mitral regurgitation

Answer 2

Involvement of papillary muscle during MI (40% of STEMI); posteromedial papillary muscle is affected in 3/4 of cases, as its blood supply is from a single source (either right or distal circumflex)

Question 3

Temporizing measures for acute ischemic mitral regurgitation

Answer 3

IABP or ECLS. Usually requires emergent mitral valve replacements (rare repair) +/- CABG

Question 4

What is the Wilkins score

Answer 4

Assessment of mitral valve anatomy for mitral valve stenosis

Question 5

What characteristics included in Wilkins score

Answer 5

Mobility
Subvalvular thickening
Leaflet thickening
Calcification

The Score is the sum of severity number (1-4) to 4 valve characteristics

Wilkins score <9 and less than moderate mitral regurgitation has the best outcomes.

Question 6

Contraindication to balloon valvuloplasty

Answer 6

Mild mitral stenosis
Moderate or severe regurgitation
Left atrial thrombus

Question 7

What is considered a successful Balloon Mitral Valvotomy (BMV)>

Answer 7

Post-procedure mitral valve area >1.5 cm2with no more than moderate mitral regurg

Approximately 65% percent of patients are free of restenosis after 10 years.

Question 8

Criteria for severe Mitral valve insufficiency (5)

Answer 8

Vena contracta > 0.7 cm
Regurgitant volume > 60 mL
Regurgitant fraction > 50 %
Left ventricular dilation > 4 cm
Effective regurg orifice > 0.4 cm

Question 9

Which trial studied the surgical management of ischemic mitral regurgitation?

What are the findings of the trial?

Answer 9

CTSnet trial

Studied repair vs replacement

No significant difference in 2 year survival (although not powered to study survival)

No difference in LVESV

Risk of recurrence significantly more for MV repair than replacement (58.8% vs 3.8%). More readmission for CV and heart failure symptoms.

Question 10

Operation for ischemic mitral regurg

Answer 10

The best operation for ischemic MR is controversial.

a) Mitral valve REPAIR with a somewhat downsized annuloplasty ring can be performed with low mortality.
b) Mitral valve REPLACEMENT: higher operative mortality but a stable resolution of regurgitation. Unfortunately, this operation also fails to yield a survival benefit over continued medical therapy.

Question 11

Diagnosis of hemolysis after MV repair/replace

Answer 11

1) Persistent anemia (hgb <10 g/dL, hct< 33%)
2) LDH > 440 U/L
3) Haptoglobin <37 mg/dL
4) Presence of schistocytes, fragmented cells, and polychromasia on peripheral blood smear.

Question 12

Which type of surgical mitral valve cause more hemolysis?

Answer 12

More common with mechanical

Question 13

What is AV groove separation?

Answer 13

Separation between LA and ventricle

Question 14

What causes AV groove separation?

Answer 14

This can occur when the LV is elevated following mitral valve replacement

Question 15

Risk factors for AV groove separation?

Answer 15

Mitral annular calcification
Women
Elderly

Question 16

What to do after an AV groove separation?

Answer 16

Reinstitute CPB, cardioplegic arrest, remove the valve, then internal repair using a patch, followed by low profile mechanical prosthesis implantation. Other approaches:

• Placement of adhesive patch material and glue externally
• Removal of the heart, “bench” repair, and autotransplantation

Question 17

Dressler’s

Answer 17

Pericarditis following injury to heart or pericardium. AKA post-pericardiotomy syndrome

Question 18

Incidence of dressler’s

Answer 18

15-20%; colchicine post-op day 3 can reduce the incidence by 58%

Question 19

Rx for Dressler’s syndrome

Answer 19

NSAIDS (ibuprofen or indomethacin) 90% effective for resolving fever, chest pain or friction rubs

Question 20

Constrictive pericarditis is distinctive from restrictive cardiomyopathy because of what cardiac cath finding?

Answer 20

Diastolic equalization of pressures, ventricular interdependence (discordance with resp cycle), and square root sign. RVEDP and LVEDP are almost equal in constrictive pericarditis. Subsequently causes diastolic heart failure. In contrast, LVEDP is higher than RVEDP in restrictive

Question 21

Square root sign

Answer 21

A hemodynamic sign of dip (the rapid ‘y’-descent in the jugular venous pressure) and plateau during right heart catheterization

Question 22

Classification for mitral valve regurgitation

Answer 22

Carpentier’s mitral classification

Question 23

Management of chronic ischemic mitral regurg in the setting of multivessel CAD?

Prognosis?

Goal of surgery?

Answer 23

Indication for CABG + Mitral Replacement (Repair is prone to more re-op)

Less CHF symptoms when MVR is combined with CABG

Goal is symptom control. No change in survival

Question 24

Management of isolated severe, chronic secondary MR ?

Answer 24

Not an indication for MVR, may consider TMVR

Question 25

Patient with pulm edema and shock, with new systolic murmur that developed 7 days after an MI. Diagnosis? Diagnostic test? What would you see on right heart cath (RHC)

Answer 25

Acute massive mitral regurgitation may occur 4-7 days after MI TEE > TTE RHC: V waves