week 4 MR Flashcards

(43 cards)

1
Q

MR etiology

primary cause vs secondary (functional) cause

A

primary cause - smt wrong with MV apparatus

secondary cause - dilated LV so MV doesn’t close properly (normal MV but smt wrong with heart)

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2
Q

What are some primary causes of MR?

A

MVP
flail leaflet
trauma
endocarditis
prosthetic valve malfunction
cleft MV

MAC (mild MR)
rheumatic fever (usually causes MS, sometimes causes MR)

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3
Q

What are some secondary causes of MR?

A

tethered leaflet
LV dilation
Ischemic causes
ruptured pap muscle
SAM

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4
Q

MV prolapse

A

MVP = bowing of >2 mm above the MV annulus

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5
Q

Myxomatous degeneration of MV

A

another name for MVP

called myxomatous degeneration of MV bc weakening of CT

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6
Q

Barlow syndrome

A

another name from MVP

Named after doctor who first described MVP

usually refers to most severe form of MVP

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7
Q

What causes MVP?

A

Don’t know!

Idiopathic
genetic
associated with CT disorders

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8
Q

MVP murmur

A

mid systolic click then late systolic murmor

click bc sudden tensing of leaflet as it is pushed into LA

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9
Q

If there is MVP of AMVL, what does the MR jet look like?

A

Eccentric jet, posteriorly directed

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10
Q

What does the m-mode look like if have MVP?

A

late systolic dip

use M-mode to determine timing of MVP: mid - late systolic dip? holosystolic?

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11
Q

Flail MV leaflet

A

caused by torn chordae tendineae = acute MR

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12
Q

MR: how to tell the difference btw MVP and flail leaflet in 2D

A

MVP - tip of the leaflet point towards LV

Flail - tip of the leaflet points towards LA

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13
Q

If there is a flail AMVL, what does the MR jet look like?

A

Eccentric jet, posteriorly directed

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14
Q

Can trauma cause MR?

A

yes, if MVA, look at

Right heart bc most anterior

MV - sudden severe MR bc ruptured chordae or pap?

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15
Q

Endocarditis

A

bacterial infection of heart valves - get vegetation or bacteria eats a hole in valve

More likely to cause MR than MS

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16
Q

Prosthetic valve malfunction

A

most prosthetic valves have trivial MR = washes out valve so no clots

Shouldn’t see significant MR
especially bad if leaking through sewing ring!

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17
Q

cleft MV

A

hole in leaflet, usually AMVL

rare, congenital

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18
Q

Tethered leaflet

A

post MI, the LV changes shape and pap muscle shifts more apically
= tightens chordae
= MV can’t close properly

19
Q

LV dilation

A

post MI, LV dilates
= MV leaflets too far apart to close properly

20
Q

Ischemic causes

A

We used to think that damaged paps bc MI caused MR…

new research shows that revascularization of paps does not improve MR

21
Q

ruptured pap muscle

A

causes sudden severe MR - pap muscle is attached to leaflet with chordae and swings between LA and LV

bc trauma (MVA) or post MI (rare)

22
Q

SAM

A

Systolic Anterior Motion of MV

Associated with hypertrophic cardiomyopathy (= thick IVS)
= narrowed LVOT sucks AMVL over

  • more suctioning effect in late systole = more MR
22
Q

Which MV pap muscle is more likely to rupture?

A

PM pap muscle bc its supplied by only one coronary

PM pap - PDA
AL pap - LAD and Cx

23
Q

If there is SAM, what does MR jet look like?

A

eccentric MR jet, posteriorly directed

24
Hemodynamic consequences of Acute MR? Symptoms?
sudden significant MR Incr LA press Incr Pulm press Sudden severe pulm congestion, edema, SOB, cardiogenic shock
25
Hemodynamic consequences of chronic compensated MR (stable)? Symptoms?
Chronic significant MR LA dilates = normal LA press and pulm press LV dilates to accommodate excess blood = incr SV = extra blood pushed out No symptoms, incr risk clot and may have A-fib (bc dilated LA)
26
Hemodynamic consequences of chronic decompensated MR? Symptoms?
severe LV dilation decr LV contractility = decr EF systolic failure incr end systolic vol = incr LV filling press = diastolic failure = incr pulm press SOB, poor exercise tolerance, fatigue, edema, A-fib
27
Murmur for MR
holosystolic or pansystolic - lasts all of systole and both isovolumetric periods
28
Role of echo in MR
1. determine etiology - if see MR, you must find the reason especially if it is an eccentric jet 2. Assess for severity of MR a) visual assessment b) specific signs of MR: - colour jet area - vena contracta width - flow convergence - pulm vein reversal c) supportive signs of MR: - Mitral inflow pattern - LA size - CW of MR d) quantitative params: - PISA - Regurg Vol - Regurg Fraction
29
Assess for severity of MR: Visual Assessment - how would you grade an eccentric jet?
Assess MR in every view (PLAX, Ap) - go off axis to get max vel PSAX is good for location and number of jets *Always grade eccentric jets one higher than they look visually bc get sucked against wall which makes them seem narrower than they are
30
Assess for severity of MR: Colour jet area
A specific sign of MR - not routine in BC store clip with largest MR trace around aliasing jet get jet area or divide jet area by LA size to get %
31
Assess for severity of MR: Vena contacta width
A specific sign of MR PLAX with colour zoom in on MR measure the width of narrowest spot of jet * incr vena contracta width = incr MR severity
32
Assess for severity of MR: Pulm vein reversal
A specific sign of MR in severe MR, get S wave reversal bc MR jet enters pulm vein in systole
33
Assess for severity of MR: Mitral Inflow pattern
A supportive sign of MR if severe MR, get an E wave dominant pattern, bc so much blood in LA E > 1.2 m/s big E? MR or grade 3?
34
Assess for severity of MR: LA size
A supportive sign of MR if MR, expect big LA big LA? MR or diastolic dysf?
35
Assess for severity of MR: CW trace through MR jet
A supportive sign of MR Looking at INTENSITY of waveform (not Vmax - vel is ~4-5 m/s for mild mod and severe MR) Severe MR - bright - triangle shaped and asymmetric (bc incr LA press = decr LV/LA gradient in mid-late sys) Mild MR - not bright - parabolic * compare brightness to mitral inflow intensity
36
Assess for severity of MR: PISA
Quantitative param * only do PISA if mod or worse MR Ap 4 ch zoom on MV with colour shift baseline down to ~30 cm/s find largest PISA shell measure PISA radius from MV leaflet to first aliasing vel CW through MR trace get Vmax and VTI EROA = 2πr^2 * Vn / Vmax
37
for PISA, which way do you shift the baseline?
Shift the baseline in the direction of the regurg *careful if TEE!
38
PISA formula
PISA = EROA EROA = 2πr^2 * Vn / Vmax r is PISA radius Vn is aliasing vel Vmax is peak vel of MR
39
Should a MR trace include the valve clicks?
Yes, bc MR includes the isovolumetric periods
40
Assess for severity of MR: Regurgitant volume
Quant param - not done in BC volume of blood leaking in each beat Regurg Vol = EROA * VTI already have EROA from PISA calculation and VTI from the CW of MR trace
41
Assess for severity of MR: Regurgitant fraction
Quant param - not done in BC volume of regurg as % of total SV RF = R Vol/SV R Vol = EROA * VTI (already calculated) SV = CSA MV * VTI MV CSA MV - measure size of MV opening in early diastole in Ap 4 ch = NOT ACCURATE VTI MV - PW at MV annulus and trace
42
Treatment for MR
Meds Percutaneous - Percutaneous ring = tightens annulus - MitraClip = pins leaflets together Surgical - prosthetic valve