Valvular disease Flashcards
Inlet valves
Mitral and tricuspid
Outlet valves
Aortic and pulmonary
Valves are defined by their
Downstream chamber or vessel
Primary function of cardiac valves
Provide minimal resistance to forward flow, while preventing backward regurgitant flow
Mitral valve apparatus is comprised of the
Valve leaflets (anterior and posterior), chordae tendinae and papillary muscles
The 2 mitral valve leaflets are each divided into how many scallops and clefts
3 scallops separated by 2 clefts
Largest scallop of mitral valve
Middle
Continuous fibrous ring that surrounds the mitral valve leaflets
Mitral annulus
Supplies the anterolateral papillary muscles
Left anterior descending coronary artery or the left circumflex coronary artery
Posteromedial papillary muscle is generally supplied by the
Right coronary artery
3 leaflets of tricuspid valve:
Anterior, posterior and septal leaflets
3 papillary muscles of tricuspid valve
Anterior, posterior and septal
The anterior papillary muscle of tricuspid valve can attach to
Anterior leaflet alone or to both anterior and septal leaflets
Posterior papillary muscle of tricuspid valve can attach to the
Posterior and septal leaflets
Septal papillary muscle of tricuspid valve cqn attach to
Septal and anterior leaflets
aortic and pulmonary valves are named according to
sinus of Valsalva from which coronary arteries typically arise
the noncoronary cusp is typically located where
posterior
left and right cusps of aortic and pulmonary valves usually abut or face the
pulmonary valve, referred to as the “facing” sinuses of Valsalva
aortic and pulmonary valves opens during
ventricular systole
aortic and pulmonary valves closes at the
end of ventricular systole, as the pressure in the RV drops
can be seen as “O” or “C”-shaped dense structure at the expected location of the mitral annulus
mitral annular calcification
chronic degeneration of the fibrous ring of the mitral valve and may be seen in younger patients with renal disease or abnormal calcium metabolism
mitral annular calcification
these valves are not well evaluated in echocardiography due to their position
pulmonary and tricuspid valves
clinical gold strandard for noninvasive measurement of blood flow and is routinely used to quantify the severity of valvular stenosis or regurgitation
phase contrast MRI
measurements of blood flow in phase contrast MRI are typically performed where
perpendicular to the direction of blood flow, centered in the vessel or valve of interest
for valuvular stenosis, peak velocities are measured where
near or just distal to the location of severe stenosis
for valvular regurgiation, two approaches are commonly used in phase contrast MRI
measuring the amount of regurgital flow below a zero baseline near the valve or vessel of interest, directly measuring the regurgitant jet during the systolic portions of the cardiac cycle where regurgitation is observed
two primary metrics in valvular regurgitation
RVol and RF
defined as the amount of blood flow backward through the valve and is typically defined in units of either liters per minute or milliliters per beat
RVol
defined as RVol divided by the forward flow volume
RF
Most common CHD, in which two of the leaflets of the aortic valve may be partly or completely fused, resulting in a two-cusped valve rather than the normal three cusped valve
Bicuspid aortic valve
Bicuspid aprtic valve is associated with
Aortopathy, aneurysm, aortic dissection and rupture, aortic coarctation; with approximately half demonstrates dilatation of the aortic root and proximal ascending aorta
most common type of subaortic stenosis, typically resulting in murmur
subaortic membrane
acquired aortic valve disease is often caused by
degenerative calcification and chronic leaflet deterioration
most common valve disease, generally occurring among older patients
aortic stenosis
aortic valve area is determined by ______, which states that the blood flow passing through a tube must be equal, measured at any location along that tube, in order to satisfy conservation of mass
continuity equation
AVAs below ____ cm2 are considered moderate
1.5 cm2
AVAs below __ cm2 are considered severe
1 cm2
AVAs less than ___ cm2 are considered critical
0.5 cm
severe aortic valve stenosis typically correlates with peak aortic velocities over __ m/s mean gradients exceeding ___ mmHg
4 m/s; 40 mmHg
management for severe aortic stenosis
surgical aortic valve replacement or transcatheter aortic valve replacement (TAVR)
preprocedure planning for TAVR is now routinely performed with cardiac ct, for measurement of
size of the aortic annulus, evaluation of vascular access, and prediction of projection angles for prosthesis deployment
aortic annulus is typically measured in
systole in a double oblique plane immediately below the hinge points of the aortic valve cusps
presents as initially increased total left ventricular stroke volume through compensatory mechanisms, resulting in dilation and concentric left ventricular hypertrophy
aortic regurgitation
aortic regurgitation is measured qualitatively by _____, but when needed for clinical management, RVol and RF can be quantified through ______
quali- echocardiography, quanti- MRI
defined as bowing or prolapse of the mitral leaflet of 2 mm or beyond the annular plane into the LA in ventricular systole
mitral valve prolapse
most common cause of sever nonischemic mitral regurgitation
MVP
MVP is caused by
rupture or elongation of the chordae tendinae
most commonly involved mitral leaflet in MVP
middle scallop of the posterior leaflet (P2 segment)
prolapsed mitral valve scallop is classified as a _____ (with bowing of the leaflet body) or _____ (with free leaflet edge prolapse)
billowing leaflet and flail leaflet
conditions that are associated with secondary MVP include
connective tissue disorders (such as Marfan) and CHD (ostium secundum ASD and aortic coarctation)
characterized by division of one of the mitral leaflets
mitral cleft
typically involved leaflet in mitral cleft
anterior
cleft mitral valve is associated with
progressive mitral regurgitation
in this condition, the mitral cleft is oriented toward the LVOT rather than the inlet septum, as is the case of patients with endocardial cushion defect (AVSD)
isolated mitral cleft
this condition can occur congenitally with hypoplasia of the mitral valve annulus, fusion of the mitral valve commissure and shortened or thickened chordae tendineae
mitral stenosis
mitral stenosis can be seen in association with
multiple left-sided cardiac anomalies in what is known as Shone complex, including parachute mitral valve or supramitral ring
mitral stenosis is often congenital or acquired
acquired (most commonly due to RHD)
MS characteristically results in ______ as a compensatory mechanism in order to maintain normal cardiac output
increased LA pressure
increased LA pressure in this condition presents with LA enlargement and increased pulmonary venous pressure, eventually leading to pulmonary hypertension
MS
noninvasive clinical standard for assessing severity of MS
transmitral gradient, measured by Doppler echocardiography, combined with mitral valve planimetry and pressure half-time
MR caused by changes of left ventricular structure and function related to ischemia
ischemic MR
caused by rupture of a mitral papillary muscle occurring during the acute phase of myocardial infarction, and is associated with high mortality
acute ischemic MR
occurs more than 2 weeks after infarction with absence of structural mitral valve disease, and is caused by modifications of geometry and kinetics of the subvalvular apparatus, resulting from abnormalities of regional myocardial contraction
chronic ischemic MR
can also occur secondarily as a result of LV failure
MR
management of primary MR
surgical repair
most common cause of congenital TR
Ebstein anomaly
characterized by variable and abnormal developmental anomaly of tricuspid valve including apical displacement of the septal and posterior tricuspid valve leaflets, redundancy and fenestration of the anterior tricuspid leaflet and dilation of the true tricuspid annulus
Ebstein anomaly
chambers that dilate in ebstein anomaly
RA and RV, with TR
pulmonary vascularity in ebstein anomaly
either normal or decreased
cut off of apical displacement of the septal leaflet for Ebstein anomaly
> 8mm/m2
cyanotic type of CHD characterized by agenesis of the tricuspid valve
tricuspid atresia
necessary for survival in TA
obligatory intra-atrial connection through an ASD or patent foramen ovale
in TA, RV is typically ___, while RA is
RV is small and hypoplastic, RA is dilated and hypertrophied
TA is associated with
right-sided aortic arch and TGA
patients with TA without TGA typically have
some degree of PS
pulmonary vascularity in TA
decreased pulmonary vascularity and flat or concave MPA
depicts fatty or muscular separation of the RA from RV in cardiac CT and MRI
TA
rare and is most often congenital or acquired due to RHD. it presents with increased pressure gradient between the RA and RV (?5 mmHg), resulting in venous congestion.
TS
RA in TS appears
enlarged
refers to dynamic or fixed anatomic obstruction to blood flow from the RV to the pulmonary arterial vasculature
congenital PS
levels of obstruction in PS
valvular, subvalvular or supravalvular
the pulmonic valve commissures may be partially fused resulting in a narrow central orifice, often leading to postenotic dilation of the MPA
PS
In PS, valve leaflets may also be irregular and thickened without commissural fusion, as is the case in the majority of patients with what syndrome
Noonan syndrome
occurs due to narrowing of the infundibular or subinfundibular right ventricular outflow tract and is present in individuals with TOF
subvalvular PS
rare condition resulting from fibromuscular narrowing of the RVOT with subvalvular RVOT obstruction
Double-chambered RV
can result from pulmonic valve obstruction at the level of MPA, at its bifurcation, or more distal branches
supravalvular PS
approximately 20% of patients with TOF have associated what type of PS
supravalvular PS
PR can develop from
congenital PS or TOF that underwent pulmonary valvuloplasty or surgical repair during infancy of early childhood
patients with severe PR may eventually dilate what chamber
RV, develop RV failure
MRI is commonly used to measure both severity of PR and measure the severity of dilation of the RV to determine the need for surgical or interventional valve replacement rather than 2d echo due to
pulmonary valve is not readily visualized in 2d echo due to its position behind the sternum
refers to an infection of the valve leaflets as well as prosthetic valves
infective endocarditis
often appears as an irregular mobile or fixed mass attached to the low-pressure side of a valve due to infection
vegetation formation from infective endocarditis
useful in diagnosing IE, assessing severity of disease and following patients undergoing treatment
Echocardiography
useful in identifying and characterizing vegetations, valve destruction and perivalvular extension
cardiac CT and MRI
often superior in detecting small vegetations and valve perforations
TEE
common heart-related manifestation in patients with SLE. Unlike IE, these lesions rarely result in hemodynamically significant valve dysfunction and rarely embolize
Libman-Sacks nonbacterial endocarditis
in Libman-Sacks nonbacterial endocarditis, small valve vegetations typically affect the ventricular and atrial sides of m
the ventricular and atrial sides of mitral valve
refers to valve fibrosis and scarring caused by an autoimmune reaction to infection with group A streptococci, resulting in valve stenosis and/or regurgitation
rheumatic valve disease
most common involved valve in RHD is
mitral valve, followed by aortic, tricuspid and pulmonic valves
true or false: in most cases of RHD, mitral valve is involved along with one or more other valves
true
in RHD, chronic elevation of LA pressure needed to move blood across the stenotic mitral valve results in
atrial dilation and elevated pulmonary pressure
approximately 30 to 40% of symptomatic patients with MS develop
atrial fibrillation
frequent occurrence in patients with carcinoid syndrome. approximately 30 to 40% of patients with neuroendocrine tumors (most commonly midgut carcinoids) present with carcinoid syndrome, including episodes of flushing, hypotensionm diarrhea and bronchospasm
carcinoid heart disease
important contributing factor in the development of carcinoid heart disease
chronic exposure to excessive circulating serotonin
characterized by development of plaque-like, fibrous endocardial thickening involving the heart valves
carcinoid heart disease
commonly involved valves in carcinoid heart disease
tricuspid and pulmonic
first imaging modality in carcinoid heart disease
TTE
imaging features include thickening of valve leaflets/cusps and subvalvular apparatus, retraction and altered motion of the leaflets/cusps and valve regurgitation (ranging from mild to severe)
carcinoid heart disease
postoperative complications following valve surgery include
infection, dehiscence and perivalvular leak
late complications of valve surgery include
valve regurgitation, IE anastomotic dehiscence, pseudoaneurysm and thromboembolic events
