Valvular disorders (Mitral and aortic valve disorders) Flashcards
Draw and describe the 5 structures of the mitral valve
The mitral valve consists of the mitral annulus,
anterior and posterior leaflets, chordae tendineae, the papillary muscles
and the LV wall.
What is the structure below?
Mitral valve
___ is the most common cause of mitral stenosis and manifests as fusion of the cusps from fibrosis + calcification of the valve leaflets
Rheumatic heart disease is the most common cause of mitral stenosis and manifests as fusion of the cusps from fibrosis + calcification of the valve leaflets
A characteristic appearance of the mitral valve in a case of mitral valve stenosis is that of a ___
A characteristic appearance of the mitral valve in a case of mitral valve stenosis is that of a fish mouth
Compare the normal mitral valve and the one that is stenosed. What is the characteristic appearance of the mitral valve indicated in the echo below?
Here the mitral valve would normally open and the leaflets would spread apart but since there is stenosis, part of the anterior leaflet and posterior leaflet are stuck to each other >> “hockey stick” appearance
Name (5) expected symptoms of mitral valve stenosis
**basically the same ones as those of congestive heart failure, which makes sense because you’re increasing pressure in the left atrium, which means increased pressure in pulm veins >> pulmonary congestion
*see below*
Review the Wigger’s diagram below
___ (atrial arryhtmia type) is often associated with mitral stenosis (why?)
Atrial fibrillation is often associated with mitral stenosis (because the increased pressure in the left atrium can cause dilation)
How can mitral stenosis lead to right ventricular failure?
Increased pulmonary arteriolar pressure >> increased pulmonary artery pressure >> right ventricular failure
What are the clinical manifestations of right ventricular failure related to mitral stenosis?
A-fib >> palpitations
Pulmonary HTN:
edema
gi symptoms
liver congestion/ascites
hoarseness
What are the physical findings if mitral stenosis? (what 3 pulses/impulses will be normal)
What is a classical finding?
**what abnormal findings would you hear in this pt?* (3)
Normal arterial pulse
Normal apical impulse
Normal jugular venous pulse
**’
- Opening snap + diastolic rumble
- Pulm HTN: loud P2, RV heave, large “a” wave in jugular venous pattern
Upon auscultation, what 3 things would you expect to hear from a pt who has mitral valve stenosis?
Opening snap
Diastolic low-pitched murmur
Loud S1
**
- Opening snap
- Mid-diastolic rumble
- Pre-systolic crescendo
To be able to hear the murmur in MVS, what maneuver do you have to do?
Left lateral decubitus (apparently that’s when you tell the pt to turn to their side and then you listen for the murmur)
**done to hear S3, S4 and mitral stenosis**
2 chest X ray findings for mitral valve disease are __ and __
2 chest X ray findings for mitral valve disease are left atrial enlargement and RV hypertrophy
**can see left atrium pushing against the esophagus and the border of the left heart straightens out because the enlarged atrial appendage also becomes prominent**
Note that there will also be pressure differences between the left ventricle and left atrium in diastole
What are the goals of medical management of mitral stenosis? (3)
Left atrial pressure is high so you want to limit elevations of that pressure - control heart rate (BB? CCB?), control congestion - diuresis
Manage a-fib
Prevent systemic emboli b/c blood can clot here: use anticoagulant
If a clot forms in the left atrium, where is it most likely to form?
Blood in the atrium tends to clot in the left atrial appendage
**visualize via TEE**
What is the treatment of mitral stenosis? (2 - hint: one of these you’ve seen before)
Mitral commissurotomy
Mitral valve replacement
(can also do balloon valvuloplasty)
What are the etiologies of mitral regurgitation?
Many. As in, very many.
Describe the difference between primary and secondary mitral regurgitation
What actually is mitral rgeurgitation? What is the end result of mitral regurg that affects both the LA and LV?
Primary mitral regurgitation - regurg from valve pathology
Secondary mitral regurgitation - secondary to something other than valve pathology (e.g. dilatation of the LV and annulus)
Mitral regurgitation is when blood is moving back into the left atrium from the left ventricle; both the LA and LV dilate
***
Mitral regurgitation: reflux of blood from the left ventricle back to the left atrium during systole;
- Usually complex of mitral valve prolapse; can also be left ventricular dilatation, acute rheumatic heart disease, infective endocarditis, papillary ms rupture after MI
- Holosystolic blowing murmur
Below is a dilated LV.
How do you know if it’s secondary to dilated cardiomyopathy or to volume overload?
Check the LV ejection fraction:
If there’s a low EF: its a pump problem; secondary to cardiomyopathy/end stage disease
If there’s a high EF: pump is fine, problem is volume overload
What is the difference between mitral regurg in an acute vs chronic setting?
The main difference between chronic and acute mitral regurgitation is that in the acute setting, your LA and LV are normal size so you end up with increased LA pressure, whereas in the chronic situation, both chambers are dilated so the pressure in the LA is not as high
**you can end up with pulmonary edema in the acute setting**
Describe the clinical presentation of mitral regurg
Literally the same as those of CHF (+ palpitations)
A characteristic ___ murmur, __ sound and __ apex are all found in mitral regurgitation
A characteristic holosystolic murmur, S3 sound and hyperdynamic apex with palpable thrill are all found in mitral regurgitation
What results can you expect to see on an EKG/Chest xray?echo when a pt has mitral regurg?
EKG - enlarged LA, dilated LV
Chest X ray - dilated LV and LA
Echo - can actually see the blood shooting back into the right atrium (and measure other things)
*see below*
(will also see V wave in capillary wedge position - see slide 74)
What are the treatment options for the following:
Acute MR
Chronic MR
Acute MR: nitroprusside, baloon counterpulsation
Chronic MR: oral vasodilators
Also treat pulmonary edema, heart failure
How can you surgically treal mitral valve regurg? (2)
Mitral valve repair
Mitral valve replacement
Describe mitral valve prolapse
Part of one of the leaflets of the mitral valve prolapse into the atrium (the valve is loose/floppy – it literally balloons backwards into the atrium)
What is the condition below?
Mitral valve prolapse
What is the condition below?
Mitral valve prolapse
Describe the pathology of MVP
Enlarged leaflets, esp the posterior ones
Normal dense collagen + elastin matrix replaced w/ loose, myxomatous tissue
**know that it can be an AD disease or ass’d with connective tissue disease like Marfan’s syndrome or Ehlers - Danlos
What is the presentation of mitral valve prolapse?
Typically asymptomatic but some folks have symptoms of congestive heart failure
+/- MR; symptoms would be related to degree of MR
What would you expect to find on auscultation with MVP? (2)
Mid to late systolic click; late systolic murmer
(note that the timing changes w/ maneuvers)
What changes happen to the timing of the click and murmur when you change positions to standing and squatting in a pt with MVP?
Can change the click and murmur timing with standing (will happen earlier) and squatting (will happen later)
How dp you treat MVP?
Usually nothing apparently
Only rx is surgery/depends on whether they have MR as well (then you Rx based on severity of the pts symptoms)
What is one complication of MVP? (see below) hint: it leads to severe MR
You can have a ruptured chordae tendineae
How do you treat mitral valve prolapse w/ a ruptured chordae?
Surgery
Name two primary diseases of the aortic valve
Aortic valve stenosis
Aortic valve regurgitation
Aortic disease can be split into ___ and ___
Aortic disease can be split into stenosis and insufficiency
The most common etiology for aortic stenosis (in the elderly, at least) is___ aortic stenosis
Tme most common causes of aortic insufficiency are ___ (3)
The most common etiology for aortic stenosis (in the elderly, at least) is degenerative/calcific/senile aortic stenosis
Tme most common causes of aortic insufficiency are infective endocarditis, acute aortic dissection, iatrogenic causes
Below are different aortic valve pathologies
Describe the ones circled in black/what their etiologies are
Severe aortic stenosis is below __ cm2
Aortic stenosis of calcific/senile disease: Studs of calcium on the aortic leaflets
Rheumatic heart disease can also cause aortic stenosis (the one without calcifications around the valve leaflets)
Bicuspid aortic valve – congenital abnormality with fused aortic valve
Severe aortic stenosis is below 1 cm2
Explain the ECG below
What is the hemodynamic hallmark and what is its relationship to aortic valve area?
The white shaded area represents the extra work that the heart is doing to pump blood thru the stenosed aortic valve (and you can see that the pressure in the LV is mad high meanwhile that in the aorta is low)
The slope of the aortic valve is delayed relative to the pressure in the left ventricle (so all the pressure that is generated in the ventricle isn’t being translated to the aorta)
***
The hemodynamic hallmark is a pressure gradient between the LV systolic pressure and aortic systolic pressure
The aortic valve gradient and the aortic valve area are inversely related: when one is really low (e.g. the area is low), the other will be high (so the pressure gradient will be high)
Describe the murmur and heart sounds you would expect to hear with aortic stenosis
**see below**
The murmur is high pitched because of all that pressure coming from the ventricle trying to push all of that blood through (high velocity of flow of blood across the stenotic valve)
S2 sound is diminished because the valve doesn’t give a crisp closure because the leaflets are pretty rigid
What are 4 things to look out for in physical diagnosis of aortic stenosis? (hint: what carotid pulse characteristics would you expect? Is there a gallop and if so where would it be coming from?)
T/F: The loudness of the murmur is directly correlated to the severity of aortic stenosis
So you will find weak and delayed carotid pulses, an S4 gallop because the walll of the ventricle is now stiff and thickened from all that pushing thru a stenosed valve
Falsehood. The severity of the murmur does not correlate with the severity of aortic stenosis
Describe the changes in the pressure gradient between the LV and the aorta that happens when AS gets worse
What effects does AS have on the left ventricle? (hint: concentric vs eccentric hypertrophy)
As aortic stenosis worsens, the pressure gradient increases
The left ventricle undergoes concentric hypertrophy in response to the increased difficulty of pushing thru a stenosed valve
Severe symptoms of aortic stenosis can predict mortality once they develop in a pt. What are these symptoms? (3)
Symptoms of aortic stenosis: chest tightness, syncope, breathlessness
When symptoms develop severe symptoms, mortality is predictable
There are 3 categories of aortic stenosis, namely ___
How do you Dx aortic stenosis (what’s the test of choice) and what are the mean pressure gradients ass’d which each AS category?
There are 3 categories of aortic stenosis, namely mild, moderate and severe
The test of choice for diagnosing AS is to do a standard surface 2D echo
Mean pressure gradients: mild - <20mmHg; moderate - 20-40mmHg; severe - 40mmHg
How do you treat aortic stenosis? (3)
Surgically replace the aortic valve - gold standard
Transcatheter aortic valve replacement - for those too high risk for surgey
Aortic balloon valvuloplasty - palliative
The heart responds differently to aortic stenosis vs aortic regurgitation. Describe how the heart responds these two conditions
In aortic stenosis, the heart undergoes left ventricular hypertrophy to deal with the increased pressure of pumping through the stenotic aortic valve, but with aortic regurgitation, the heart has a volume overload problem, so it responds by dilating (aka stretching)
Define aortic regurgitation
What are the most common causes of aortic regurgitation (acute vs chronic, 4 conditions each)
Aortic reurgitation is when you have blood returning from the aorta back into the left ventricle
Acute causes: aortic dissection, infective endocarditis, trauma, iatrogenic injury
Chronic causes: bicuspid aortic valve, rheumatic heart disease, chronic calcific disease, rare things like chronic healed endocarditis
A characteristic physical exam finding of aortic regurgitation is a ___ murmur
A characteristic physical exam finding of aortic regurgitation is a diastolic blowing murmur
Would you be able to hear an S2 sound in aortic regurg? Why or why not?
You won’t hear an S2 sound because the aortic valve doesn’t close completely
On physical exam, you can hear a low-pitched diastolic rumble in severe AI. Where is this rumble coming from?
From the rapid flow of blood hitting the endocardium (see image for the alternative explanation)
The mainstay of treatment for aortic insufficiency (especially if the ventricle can no longer tolerate the insufficiency) is ___
Surgery - aortic valve replacement (transcatheter aortic valve replacement isn’t indicated except for valve disease with calcific leaflets)
