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The Mitral Valve > Mitral Stenosis > Flashcards

Mitral Stenosis Flashcards

1
Q

What are the two most common aetiologies of mitral stenosis?

A

Rheumatic and calcific (degenerative).

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2
Q

Rheumatic fever results from what?

A

A streptococcus infection.

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3
Q

In rheumatic heart disease, which valve is most commonly affected. The mitral or aortic valve?

A

The mitral valve.

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4
Q

Are the majority of mitral stenosis patients male or female?

A

Female.

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5
Q

A parachute mitral valve is a cause of congenital mitral stenosis. What is a parachute mitral valve?

A

A valvular congenital abnormality whereby a single papillary muscle exists to which all chordae of an otherwise normal valve attach.

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6
Q

A classic echocardiographic finding in rheumatic mitral stenosis is a “hockey stick” appearance of the open anterior leaflet. What is the official term for this?

A

Diastolic doming motion of the aMVL.

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7
Q

Why does diastolic doming motion of the aMVL occur?

A

Because of commissural fusion; the base and midsections of the leaflets move toward the apex while the motion of the leaflet tips is restricted.

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8
Q

On m-mode Doppler, normal mitral leaflets move in opposite directions in diastole. What happens in mitral stenosis?

A

The posterior leaflet will either show immobility or anterior motion (and move upward with the aMVL).

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9
Q

In mitral stenosis, why is diastolic closure of the mitral valve later than normal?

A

Because of the persistent gradient between the LA and LV.

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10
Q

What is considered normal for mitral valve leaflet thickness?

A

2-4mm.

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11
Q

True or false; annular calcification is a common finding in elderly patients. It often appears as an isolated area of calcification on the left ventricular side of the posterior annulus. The area of fibrous continuity between the anterior MVL and the aortic root is rarely involved.

A

True.

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12
Q

How can calcific mitral stenosis be distinguished from rheumatic disease?

A

By demonstrating thin and mobile leaflet tips without commissural fusion.

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13
Q

Differential diagnosis in patients with suspected mitral stenosis include other causes of pulmonary congestion such as what?

A

LV diastolic dysfunction, the rare case of an atrial myxoma or thrombus, or cor triatriatum dexter.

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14
Q

What is cor triatriatum dexter?

A

A congenital heart defect where the left or right atrium is subdivided by a thin membrane, resulting in three atrial chambers.

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15
Q

What three values are used to assess mitral stenosis severity?

A

Mean PG, PHT and valve area.

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16
Q

What values of “mean PG” indicate mild, moderate and severe mitral stenosis?

A

Mild <5mmHg | Moderate 5-10mmHg | Severe >10mmHG

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17
Q

What values of “PHT” indicate mild, moderate and severe mitral stenosis?

A

Mild 71-139ms | Moderate 140-219ms | Severe ≥220ms

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18
Q

What values of “valve area” indicate mild, moderate and severe mitral stenosis?

A

Mild 1.6-2.0cm2 | Moderate 1.0-1.5cm2 | Severe <1cm*2

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19
Q

How is △P calculated from the long form of the Bernoulli equation?

A

△P = 4 X (V22 - V12)

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20
Q

How is △P calculated from the simplified Bernoulli equation?

A

△P = 4 X V*2

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21
Q

In the long form of the Bernoulli equation, what does V1 and V2 signify?

A

V1 is the velocity proximal to the stenosis and V2 is the velocity distal to the stenosis.

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22
Q

When can’t the simplified Bernoulli equation be used?

A

When V1 is significantly raised.

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23
Q

Why might the mean PG not be the best marker of severity of mitral stenosis?

A

Because it is not only related to mitral valve area but is also dependant on other factors that affect transmitral flow such as heart rate, cardiac output and associated mitral regurgitation.

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24
Q

True of false; the presence of a low-gradient severe mitral stenosis is possible.

A

True.

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25
Q

Why is Doppler dependant on heart rate?

A

Because at higher heart rates, LA filling per beat is reduced as the cardiac cycle is shorter and transmitral flow terminates earlier (as diastole is shorter).

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26
Q

With regards to planimetry, how can valve area be underestimated?

A

If gain settings are too high.

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27
Q

With regards to planimetry, how can valve area be overestimated?

A

If the smallest area at the leaflet tips is not recorded (as mitral inflow area is similar to a funnel).

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28
Q

True or false; planimetry compares well with valve areas calculated with cardiac catheter data.

A

True.

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29
Q

How is mitral valve area calculated using the continuity principle?

A

MVA = SV(mv)/VTI(mv)

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30
Q

How is SV(mv) calculated?

A

SV(mv) = CSA(lvot) X VTI(lvot) (these measurements can also be taken from the pulmonary artery).

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31
Q

Why is the continuity principle for MVA only accurate in the absence of significant mitral and, or aortic regurgitation?

A

Because it relies on equal stroke volumes.

32
Q

How is LVOT cross-sectional area calculated (two ways)?

A

CSA(lvot) = 0.785 X d*2 | CSA(lvot) = π X r2

33
Q

How can MVA be calculated using pressure half time?

A

MVA = 220/PHT

34
Q

Define pressure half time.

A

The time interval (in ms) between the maximum early diastolic transmitral PG and the time point where the PG is half the maximum value.

35
Q

How does the orifice area affect pressure half time?

A

The smaller the orifice area, the slower the rate of pressure decline (the longer the PHT measurement).

36
Q

True of false; when measuring PHT, ideally the deceleration slope should be linear.

A

True.

37
Q

True or false; PHT measurements are not affected by mitral regurgitation.

A

True.

38
Q

What five conditions can affect PHT measurements?

A

Conditions that alter compliance in the LA/LV such as; diastolic dysfunction, LVH, aortic regurgitation, in the presence of an ASD or immediately after percutaneous balloon mitral commissurotomy.

39
Q

The presence of diastolic dysfunction/LVH will overestimate or underestimate the severity of mitral stenosis?

A

Overestimate.

40
Q

True or false; aortic regurgitation can underestimate and overestimate mitral stenosis severity.

A

True.

41
Q

Explain how aortic regurgitation can underestimate mitral stenosis severity?

A

In the presence of aortic regurgitation LV filling will occur antegradely and retrogradely. This will result in a more rapid rise in LV diastolic pressure, resulting in a shorter PHT measurement which overestimates the orifice area (and underestimates MS severity).

42
Q

Explain how aortic regurgitation can overestimate mitral stenosis severity?

A

An eccentric jet of AR can restrict the opening of the aMVL causing functional MS. This would prolong the PHT measurement and overestimate the degree of MS.

43
Q

The presence of an ASD will likely underestimate or overestimate the degree of mitral stenosis?

A

Blood will shunt form left-to-right and underestimate the severity on mitral stenosis.

44
Q

PHT measurements are invalid immediately after PBMC. Chamber compliances between the LA and LV can take how long to reach equilibrium?

A

Up to 72hrs.

45
Q

How does the PBMC technique primarily work?

A

Through commissural splitting.

46
Q

What score is used to determine the suitability of the mitral valve structure for PBMC?

A

The Wilkins Score.

47
Q

The Wilkins score grades the mitral valves suitability for PBMC according to what four criteria?

A
  1. Leaflet mobility, 2. Valvular thickening, 3. Subvalvular thickening and 4. Valvular calcification.
48
Q

A total score of what indicates a low probability of successful PBMC?

A

> 8.

49
Q

Each of the four criteria in the Wilkins score is graded out of what?

A

Between 1 and 4.

50
Q

True or false; a score of 1 (in the Wilkins score) is essentially normal, whilst a score of 4 indicates immobility, severe thickening and extensive brightness.

A

True

51
Q

What can be used as an alternative to the Wilkins score?

A

The commissural calcification score.

52
Q

How does the commissural calcification score work?

A

Each mitral commissure is scored according to the degree of calcification seen in the pSAX view. A score of 0 is given for no calcification, 1 for calcification across half the commissure and 2 for calcification across the whole commissure.

53
Q

A commissural calcification score of what predicts higher valve areas post-PBMC?

A

A score of 0, 1 or 2.

54
Q

True or false; more than mild mitral regurgitation is a relative contraindication to PBMC.

A

True.

55
Q

Apart from mitral regurgitation what are the other contraindications to PBMC (absolute and relative)?

A

Absolute; In the presence of bilateral commissural calcification or a thrombus which is mobile or situated in a high risk position.
Relative; In the presence of thrombus which is localised to the left atrial appendage or unilateral commissural calcification.

56
Q

What is considered a “high risk” position for a thrombus (in terms of PBMC contraindications)?

A

On the atrial septum, protruding in the left atrial cavity, or obstructing the mitral valve orifice.

57
Q

Why is TOE mandatory prior to valvuloplasty?

A

Because it has a higher sensitivity and specificity for detecting thrombus in the left atrial appendage than TTE.

58
Q

Post PBMC, the mitral valve should be carefully assessed for what?

A

Any residual stenosis, the development of mitral regurgitation, or for any residual ASD.

59
Q

What are the six consequences of mitral stenosis?

A

Left atrial enlargement, atrial fibrillation, left atrial thrombus, mitral regurgitation, LV diastolic dysfunction and pulmonary HTN.

60
Q

Left atrial thrombi are more common when? And are usually located where?

A

In the presence of Atrial Fibrillation and in the left atrial appendage.

61
Q

Exercise echocardiography should be considered when, in terms of mitral stenosis?

A

When discordance exists between symptoms and the severity of MS at rest.

62
Q

Apart from when discordance exists between symptoms and the severity of MS at rest, when else might stress testing be useful?

A

In patients with a large BSA (as indexed values are not defined for MS).

63
Q

In exercise echocardiography, exercise is generally preferred (by using a supine bicycle or upright treadmill), however, what can be used as an alternative.

A

DSE (dobutamine stress echocardiography).

64
Q

How does dobutamine stimulate the effects of exercise?

A

It increases cardiac output and heart rate.

65
Q

What two pressures rise with exercise?

A

Mean transmitral pressure gradients and pulmonary artery systolic pressure (PASP).

66
Q

How is RVSP calculated?

A

RVSP = 4V*2 + RAP

67
Q

In the RVSP calculation, what should be used for “V”?

A

Max velocity of the TR jet.

68
Q

If there is an incomplete TR envelope, what can be done?

A

Saline or blood contrast can be used.

69
Q

RVSP = PSAP assumes what?

A

There is no significant pulmonary stenosis.

70
Q

If pulmonary stenosis is present, will RVSP of PASP be higher?

A

RVSP.

71
Q

In the presence of pulmonary stenosis, the difference between RVSP and PASP will be equal to what?

A

The pressure gradient across the stenosis.

72
Q

How can RAP be estimated)?

A

From the IVC.

73
Q

An IVC measuring ≤ 2.1cm that collapses by > 50% on inspiration indicates a RAP of what?

A

3mmHg.

74
Q

An IVC measuring >2.1cm that collapses by < 50% on inspiration indicates a RAP of what?

A

15mmHg.

75
Q

An IVC measuring >2.1cm that collapses by > 50% on inspiration indicates a RAP of what?

A

8mmHg.

76
Q

A PASP of greater than what (at rest) is an indication for intervention in moderate MS?

A

> 50mmHg.

77
Q

A PASP of greater than what (following stress) is an indication for intervention in moderate MS?

A

> 60mmHg.

The Mitral Valve (3 decks)

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