8/14- Valvular Heart Disease 2 Flashcards Preview

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Flashcards in 8/14- Valvular Heart Disease 2 Deck (37):
1

How to calculate total mitral stroke volume in mitral insufficiency?

SV = Forward (aortic) + regurgitant (mitral)

(then % regurgitation = regurg/total)

2

Mitral insufficiency causes what type of murmur (diastolic or systolic)?

Systolic

- Pansystolic murmur that coincides with leak across MV 

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3

What causes acute mitral insufficiency?

Associated with what?

Caused by: injury to or dysfunction of any valvular component

Often associated with acute heart failure

4

Broad course in chronic mitral insufficiency?

When does heart failure occur?

- Pathology and insufficiency progress slowly over many years

- Allows for gradual enlargement of the atrium and ventricle

- Heart failure occurs very late

5

What are the components of the mitral valve?

- Leaflets

- Chordae tendinae (attach to:)

- Papillary muscles 

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6

What are the pathologic causes of mitral insufficiency?

Muscular (normal leaflets):

- Acute MI/infarction

- Trauma

Connective tissue:

- Chordal rupture (Marfan's, prolapse)

- Annular disruption or dilation due to LV dilation (CHF)

Leaflets

- Perforation, vegetations (endocarditis)

- Prolapse (myxomatous degeneration)

- Post inflammatory scarring (rheumatic)

7

Steps of mitral valve prolapse?

1. Valve tissue degenerates

2. Leaflets sag into atrium during systole (prolapse), separate from coaptation line: mild MR

3. Chordae elongate, fracture, leaflet fragment becomes flail: severe MR

8

What is myxomatous degeneration?

Aka prolapse aka Barlow's syndrome

9

Redundant leaflets cause what kind of murmur?

Mid-to-late systolic murmur

10

Mitral valve prolapse results in what heart sounds?

- Mid systolic click

- Mid-late systolic murmur

- If severe, holosystolic murmur, S2

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11

How is mitral valve prolapse affected by dynamic auscultation?

MVP results in a systolic murmur at apex

- Louder and longer murmur with maneuvers that decrease EDV or increase systolic function (standing, Valsalva)

- Later and softer murmurs when LVEDV is increased (squat and leg elevation)

12

Which condition responds like mitral valve prolapse in dynamic auscultation (increase in murmur with Valsalva/standing)?

Hypertrophic cardiomyopathy with dynamic LVOT obstruction

13

How can HCM and MVP be differentiated (since they return the same dynamic auscultation results)?

Hand grip exercise and the presence of click:

- HCM murmur will become softer

- MVP murmur will become louder

14

What is the pathophysiology of acute mitral insufficiency?

Sudden LV to LA leak -> acute LV volume overload

- LA and pulmonary venous pressures rise acutely

- Normal size LV

Early short systolic murmur and S3

- Soft S1

- LA pressures rise sharply, equaling LV systolic, terminating murmur 

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15

Pathophysiology of chronic mitral insufficiency?

Chronic LV to LA leak -> gradual LV volume overload

- Eccentric LVH with large LV, large LA

Holosystolic murmur and S3 gallop

- Holo (or pan)systolic murmur coincides with actual leak from LV to LA that starts with S1 and ends with S2

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16

What are these? 

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Left: acute mitral insufficiency murmur

Right: chronic mitral insufficiency murmur

17

What is the clinical course of chronic mitral insufficiency?

- Progressive leak with minimal symptoms

- Gradual LV volume overload

- Atrial fibrillation due to longstanding LAE

- Progressive CHF in late stages

18

Compare acute and chronic mitral insufficiency in terms of:

- Onset of symptoms

- Overload and chamber sizes

- Consequences

- Clinical outcomes

Onset of symptoms:

- Acute: acute onset

- Chronic: gradual onset

Overload and chamber sizes

- Acute: LV, LA volume overload but no LV dilation

- Chronic: LV, LA volume overload with dilated LA/LV

Consequences:

- Acute: acute increase in LA pressure

- Chronic: atrial fibrillation

Clinical outcomes

- Acute: acute pulmonary edema

- Chronic: long asymptomatic phase; progressive CHF is a terminal event

19

What is shown here? 

Q image thumb

Cardiomegaly and left ventricular enlargement as well as mild pulmonary venous redistribution

- All features of mitral regurgitation

20

Treatment for mitral insufficiency?

Drugs that reduce CHF symptoms:

- Diuretics

- Vasodilators

Surgery: definitive treatment

- Annuloplasty to reduce annular size

- Leaflet and chordal repair

- Valve replacement if repair not feasible

Earlier surgery leads to better survival!

21

What is mitral stenosis?

Obstruction to flow from LA to LV due to narrow mitral valve orifice

22

What causes mitral stenosis?

True valvular stenosis:

- Post-inflammatory "rheumatic"

Pseudo-stenosis*

- Tumors

- Thrombi

- Vegetations

*An obstruction to MV blood flow not caused by intrinsic valvular disease

23

What is shown here?

Q image thumb

Severe mitral stenosis

- Rheumatic fusion of mitral leaflets

24

Pathophysiology of mitral stenosis?

- Leaflets, chordae, papillary muscles scarred (due to rheumatic heart disease)

- LV preload reduced due to MV obstruction

- Elevated LA pressures causes pulmonary edema: dyspnea, orthopnea and PND

- Atrial fibrillation due to LA enlargement

- Diastolic “rumble” begins when mitral valve opens & coincides with flow through stenotic MV

25

What is the hemodynamic hallmark of mitral stenosis?

LAP > LVP throughout diastole

- Diastolic rumble with presystolic accentuation

26

What is the clinical presentation of mitral stenosis?

Pulmonary congestion and edema

- Increased LA and pulmonary venous pressure

Pulmonary arterial hypertension

- Elevated pulmonary venous pressures

- Pulmonary arteriolar constriction

- Structural changes in interstitium, pulmonary capillaries, arterioles

RV hypertrophy and elevated rt heart pressures. RV failure.

Tricuspid insufficiency

Low cardiac output

27

Sequence of abnormalities in mitral stenosis?

General: LAE may -> Afib (variable in time)

1. MS raises LA pressure

2. High PCWP -> dyspnea

3. High PAP

4. RVH

5. RV failure, low CO 

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28

How can you breakdown the different parts of the abnormal heart sounds/murmur due to mitral stenosis?

- OS: opening snap

- Diastolic murmur

- Pre-systolic accentuation 

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29

What are some key clinical symptoms of mitral stenosis?

- Dyspnea

- Fatigue

- Systemic embolism

30

Physical Exam findings in mitral stenosis?

- Reduced S1 in calcific MS

- Loud P2 followed by opening snap (OS) due to forceful RV if pulmonary HTN (RVH)

- Apical diastolic murmur after OS with PSA

- Atrial fibrillation (PSA lost) 

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31

Treatment for mitral stenosis?

Treatment:

- Reduce heart rate to increase LV filling time

- Anticoagulation if afib or embolism

- Relieve obstruction (balloon valvulotomy or surgery)

Treat underlying cause of inflow obstruction:

- Prosthetic valve degeneration, thrombosis

- Atrial myxoma or thrombus

32

Key points of mitral regurgitation/insufficiency

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33

Key points of mitral stenosis

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34

A 90 yo man presents with L sided heart failure and has a crescendo-decrescendo systolic heart murmur best heard at the base radiating to the neck. What valvular heart disease does he most likely have?

Aortic stenosis

35

Standing and Valsalva increase the murmur intesnity. What is the most likely etiology of the mitral regurgitation?

Mitral valve prolapse

- MVP is only thing that causes mitral regurgitation that is affected this way dynamically

36

Concentric hypertrophy is classically seen in which valvular disorder? Due to what?

Aortic stenosis due to pressure overload

37

Early heart failure with an early decreascendo diastolic murmur best heartd at the left 3rd ICS is present in which disorder?

A. Chroinc aortic regurgitation

B. Acute mitral regurgitation

C. Acute aortic regurgitation

D. Aortic stenosis

Early heart failure with an early decreascendo diastolic murmur best heartd at the left 3rd ICS is present in which disorder?

A. Chroinc aortic regurgitation

B. Acute mitral regurgitation

C. Acute aortic regurgitation

D. Aortic stenosis