Ch 11 Mitral Valve, Regurgitation and Stenosis

Question 1

The right* trigone of the mitral valve is near what aortic valve coronary *cusp?

Answer 1

Right trigone = Near non-coronary cusp

Question 2

The left* trigone of the mitral valve is near what aortic valve coronary *cusp?

Answer 2

Left trigone = Near Left Coronary Cusp

Question 3

What is the shape of the Aortic Valve and Pulmonary Valve?

Answer 3

Crown shaped

Question 4

What is the shape of the mitral Valve and tricuspid Valve?

Answer 4

Incomplete ovals

Question 5

Why is the P2 scallop more prone to chordal rupture and pathological lesions?

Answer 5

Mitral annuli fibrosa = Incomplete and becomes thinner is the posterior region

1. More prone to dilatation
2. High tension on the area = More prone to chordal rupture

Question 6

What is the highest points of the mitral valve?

Answer 6

ME view LAX (120 degrees)

Measure SAX MV annulus end-diastole (<36mm) = Highest point

Question 7

What is the lowest points of the mitral valve?

Answer 7

Commissural View

Measure LAX MV annulus end-diastole (<46mm)

Nadirs are at the commisures

Question 8

What shape is the mitral valve annulus during:

Systole?
vs.

Diastole?

Answer 8

Systole = Circular shape

Diastole = An ellipse is a circle that has been stretched in one direction, to give it the shape of an oval

Question 9

How much does the orifice area change from systole to diastole due to the constantly changing shape of the mitral valve?

Answer 9

Up to 40%

Question 10

Normally, what is the leaftlet height ratio of the mitral valve (Anterior compared to posterior)?

Answer 10

AMVL (2x) > PMVL (1x)

Also, SAM is more likely when the A/P ratio is <1.3

Question 11

Normally, what is the leaftlet circumference ratio of the mitral valve (Anterior compared to posterior)?

Answer 11

PMVL (70%) > AMVL (30%)

Said another way, the circumference of the mitral valve is only 30% of the AMVL vs. 70% of the posterior leaflet

Question 12

Normally, what is the leaftlet height area of the mitral valve (Anterior compared to posterior)?

Answer 12

Area = For both anterior vs. posterior leaflets

Question 13

Normally, what is the leaftlet coaptation area of the mitral valve (Anterior compared to posterior)?

Answer 13

30% (1 cm length)

What this means = Combined surface area of the mitral valve leaftlets is 2x the mitral orifice.

This permits a large area of coaptation (30%, 1 cm length), thus minimizing chordal tension.

Reducing this contact area as occursr in mitral annular dilation increasing chordal tension and thus rupture

Question 14

What is the carpentier classification of mitral valve anatomy?

Answer 14

A1, A2, A3

P1, P2, P3

Anterior commissure near lateral aspect (A1 and P1)

Posterior commissure near medial aspect (A3 and P3)

Question 15

Mitral Valve Chordae:

What is first order?

What is second order?

What is third order?

Answer 15

1st = Marginal; = Leaflet free margin, prevents prolapse

2nd = leaflet LV aspect, relieves excessive tension

3rd = LV wall insert (only base of PMVL)

Question 16

What is the blood supply of the anterolateral papillary muscle?

Answer 16

1. LCX (OM1 branch)
2. LAD (Diagonal arteries)

Question 17

What is the blood supply of the posteriomedial papillary muscle?

Answer 17

RCA

or

OM3 (LCX) if left dominant

Question 18

When are mitral valve leaflets determined to be thickened?

Answer 18

>5 mm

Question 19

When is the mitral valve annulus to be measured?

What is normal short axis of the mitral valve measurement?

Answer 19

Mid-Diastole (Start of the P-wave)

Normal measurement = 30-35 mm (SAX of MV seen in the ME LAX)

Question 20

What leaflets are seen in the MV commissural view?

Answer 20

Left of screen = P3

Middle = A2

Right of screen = P1

Question 21

What MV leaflets are seen in the 2 chamber views?

Answer 21

Left = P2

Right = A2/A1

Question 22

What is normal doppler velocities of the mitral valve?

Answer 22

< 1 m/s (<100 cm/sec)

Question 23

What is a normal Emax velocities during dopplers of the MV inflow?

Answer 23

60 - 80 cm/sec

Question 24

What is a normal Amax velocities during dopplers of the MV inflow?

Answer 24

20 - 40 cm/sec

Question 25

What is a normal MV area?

Answer 25

4-6 cm²

Question 26

What are normal MV annulus measurements? (Short axis vs. Long axis)

Answer 26

SAX = 30 - 35 mm (\>36 mm = Dilated) LAX = 40-45 (\>46 mm = Dilated)

Question 27

What is normal anterior leaflet mitral valve length?

Answer 27

1.9 cm

Question 28

What is normal posterior leaflet mitral valve length?

Answer 28

1.0 cm

Question 29

What is functional MR?

Answer 29

*_Structurally normal MV leaflets_* causing central or eccentric MR

Question 30

What is diastolic MR?

Answer 30

**LV pressure \> LAP during diastole** - Pressure gradient often is the regurgitant volume

Question 31

What happens during MVP (Mitral valve prolapse)?

Answer 31

Systolic displacement of one or more MV segments beyond the annular plane of the MV.

Question 32

What is the best view to correctly diagnose MVP?

Answer 32

**ME LAX** - only diagnosed when mitral leaflets move beyond the annular high points - Both leaflets, LA, LVOT, and AV are seen

Question 33

What is *_Type I_* Carpentier Classification for MR?

Answer 33

Normal Leaflet motion

Question 34

What is *_Type II_* Carpentier Classification for MR?

Answer 34

Excessive Leaflet Motion

Question 35

What is Type IIIa Carpentier Classification for MR?

Answer 35

Restricted Leaflet Motion (Systole and Diastole)

Question 36

What is Type IIIb Carpentier Classification for MR?

Answer 36

Restricted Motion (Systole only)

Question 37

When could you see an *_anterior_* MV regurgitant jet?

Answer 37

1. Posterior Prolapse 2. Anterior Restriction

Question 38

When could you see a *_posterior_* MV regurgitant jet?

Answer 38

1. Anterior Prolapse 2. Posterior restriction 3. SAM

Question 39

Left off on page 102

Answer 39

Left off on page 102

Question 40

What is the normal Mitral Valve area?

Answer 40

4 - 6 cm²

Question 41

What is the normal peak velocity across the mitral valve?

Answer 41

0.6 - 1.0 meters/sec (60 - 100 cm/sec)

Question 42

What MV area would be **mild** mitral stenosis?

Answer 42

1.5 - 2.5 cm

Question 43

What MV area would be ***_moderate_*** mitral stenosis?

Answer 43

1.0 - 1.5 cm²

Question 44

What MV area would be **Severe** mitral stenosis?

Answer 44

\< 1.0 cm²

Question 45

What is the most common cause of mitral stenosis in adults?

Answer 45

Rheumatic heart disease

Question 46

What happens to the **leaflets** in Mitral Stenosis?

Answer 46

Thickens

Question 47

What happens to the **commissures** in Mitral Stenosis?

Answer 47

**Fusion**

Question 48

What happens to the chordae in mitral stenosis?

Answer 48

Chordae shorten

Question 49

What is the 2nd most common cause of Mitral stenosis in adults?

Answer 49

MAC (Mitral annular calcification)

Question 50

What are the less common causes of MAC?

Answer 50

Congenital SLE Rheumatoid Arthritis Carcinoid Syndrome

Question 51

What is the most important 2d echo feature of MS?

Answer 51

Restricted MV leaflet opening

Question 52

What degree of thickness of the leaflets occur in Rheumatoid Mitral stenosis?

Answer 52

Leaftlet thickness \<3 mm

Question 53

Why does the "hockey stick" appearance occur?

Answer 53

Diastolic Doming Diastole = (AMVL) bows from elevated LAP (Left atrial pressure) Leaflets tips remains tethered = Hockey stick apperance)