Mitral and Tricuspid Valve Disease Flashcards Preview

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Flashcards in Mitral and Tricuspid Valve Disease Deck (31):

Mitral valve anatomy

1. Annulus - ring:helps seat the valve
2. Leaflet
3. Chordae
4. Papillary muscle - Anchor into myocardium


Role of mitral valve

Opens in diastole, allow blood to flow from LA to LV

Closes in systole to prevent blood from flowing backwards from LV to LA


Main etiologies of mitral stenosis (MS)

MAINLY Rheumatic MS (80-99%), only 1/2 report rheumatic fever
Calcific MS (3%), advanced age & renal disease


Jones criteria (how many major and minor?)

2 major or 1 major + 2 minor -> high risk


Clinical presentation of mitral stenosis (6)

1. Dyspnea
2. Hemoptysis
3. Pulmonary hypertension/CHF
4. Right sided heart failure (edema, ascites)
5. Atrial fibrillation (because of LA dilation)
6. Thromboembolic event - stroke (because stagnant blood in LA leads to clot formation)


Physical exam findings of mitral stenosis

Loud S1: High AV pressure keeps MV open until ventricular systole forcefully closes valve

Snap: Follows S2, due to opening of stenotic leaflets (hearing it open!) Can assess severity by listening to timing of snap - inversely proportional. Higher LA pressure forces valve to open earlier

Diastolic rumble: Low frequency decrescendo murmur due to turbulent flow across stenotic valve during diastole.


Pulm hypertension physical exam (4)

1. Loud P2
2. RV thrill or lift
3. JVD
4. Tricuspid regurg


EKG findings for MS

1. Left Atrial Enlargment
2. RVH if pulm hypertension exists
3. Possible atrial fibrillation


ECHO findings for MS (4)

1. Left atrial enlargement
2. Restricted opening of MV in diastole
3. Thickened mitral valve leaflets, fusion of commissures
4. MS severity estimated by Doppler or direct visualization


Drug Tx for MS

1. MOST IMPORTANT: Beta blockers slow HR and allow more time for blood to cross the MV in diastole
2. Diuretics to treat CHF symptoms
3. Anticoagulants if aFib is present (MV can cause stasis)


Mechanical Tx for MS

1. Mitral valve replacement (biprosthetic or mechanical valves)
2. Percutaneous Ballon Miral Valvuloplasty


Indications for intervention of MS

1. Symptoms
2. Atrial Fib
3. Pulmonary hypertension


What is mitral regurgitation? What causes it?

Inadequate mitral valve closure such that blood flows backwards, from the LV to the LA during systole

Mitral valve prolapse is the most common cause of primary mitral regurg.
May be caused by abnormality of any of the components of the MV anatomy


Etiology of mitral regurgitation

1. Myxomatous degeneration: MV prolapse
2. Ischemic heart disease: papillary muscle dysfunction or rupture
3. Endocarditis: valve deformity, perforation
4. Rheumatic valve disease
5. LV enlargement: stretches mitral annulus and/or papillary muscles


What physical exam finding do you have for mitral regurgitation?

Holosystolic murmur best heard at apex with radiation to the axilla


What physical exam finding do you have for mitral valve prolapse?

Midsystolic click (between S1 and S2)- due to the sudden tensing of the chordae tendinae and mitral leaflet, followed by a late systolic murmur


What is the clinical course of mitral valve prolapse?

Usually benign with good prognosis.
Primary concern is development of mitral regurgitation


Primary mitral valve disease vs Functional mitral valve disease

1. Primary mitral valve disease - Issues with the MV itself

2. Functional disease - mitral valve iself doesn't have a problem, but LV puts extra stress on valve and causes issues.


Hemodynamics of mitral regurgitation

Part of LV stroke volume is ejected backwards into LA.

- Leads to LA elevated volume and pressure = pulmonary edema, pulmonary HTN

- Decreased forward CO

- Volume related stress on the LV which may lead to LV dysfunction over time


Clinical presentation of mitral regurgitation

1. Dyspnea on exertion
2. Orthopnea
3. PND
4. Edema


Tx of mitral regurg:

1. Medications
- diuretics for CHF
- Afterload reduction (ACE-I, and ARBs)

2. Surgery
- mitral valve repair or replacement

3. Mitraclip (transcatheter valve repair)


Indications for surgery for MR

1. Symptoms
2 LV dilation
3. Decreased LV systolic function
4. New onset atrial fibrillation
5. Pulmonary hypertension


Fxn of tricuspid valve

Opens in diastole to allow blood to flow from RA to RV

Closes in systole to prevent blood in RV from flowing backwards into the RA


Tricuspid regurgitation mechanism

During systole, tricuspid doesn't close adequately and blood flows backwards into RA

- elevated RA pressure leads to INCREASED venous pressure
- L extremity edema, ascites, hepatic congestion


Etiology of tricuspid regurgitation

1. 80% of cases are functional; secondary to annular dilation and leaflet tethering in the setting of RV dilation from volume and/or pressure overload
2. Other causes can be: rheumatic disease, congenital disease, endocarditis, radiation, carcinoid, trauma, pacemaker leads


Physical findings of tricuspid regurgitation

1. JVD with a visible systolic "v" wave
2. Hepatomegaly in 90% of patients, and less common systolic pulsation of liver
3. Classically the holosystolic murmur is heard along the sternal border and increases intensity with inspiration


Symptoms of TR

1. Fatigue from low CO
2. Abdominal fullness
3. Edema
4. Palpitations (if atrial arrhythmias pressent)
5. Hepatic congestion


Tx of TR

1. If functional TR, treat underlying cause of RV pressure/overload
2. Medications = diuretics
3. Surgery = Tricuspid repair or replacement


Indications for TR surgery

1. Severe TR undergoing Left-sided valve surgery
2. TV repair with less severe TR with annular dilation or R sided HF
3. Symptomatic severe TR unresponsive to medical therapy
4. Asymptomatic severe TR and progressive RV dilation or dysfunction



Triscupid stenosis

1. Rare!
2. Usually from rheumatic heart disease!
3. Murmur similar to MS but close to the sternum and intensifies with inspiration
4. Symptoms of dyspnea and edema. Usually occurs simultaneously with mitral stenosis
5. Tx: Diuretics or surgery (for isolated, symptomatic severe TR)


What type of murmur becomes louder with inspiration?

Tricuspid murmur from tricuspid regurgitation.