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MRCP PACES Cardiology > Mitral Stenosis and Rheumatic Fever > Flashcards

Mitral Stenosis and Rheumatic Fever Flashcards

1
Q

What are the causes of mitral stenosis? (R4C)

A
  1. Rheumatic fever
  2. Calcific degeneration
  3. Rare causes
    - congenital: congenital parachute valve
    - connective tissue disease: SLE, RA
    - carcinoid
    - Rarer: mucopolysaccharidoses, Fabry’s disease, Whipple’s disease
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2
Q

Differential diagnosis of mid-diastolic murmur? (6)

A
  1. Mitral stenosis
  2. Left atrial mass (atrial myxoma)
  3. Left atrial thrombus (ball-valve thrombosis)
  4. Severe mitral regurgitation (increased flow through mitral valve during diastole)
  5. Austin flint murmur (severe AR)
  6. Flow across tricuspid valve in ASD
  7. Cor triatriatum - congenital defect with 3 atria divided by fibromuscular band
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3
Q

How do you classify the severity of mitral stenosis?
A. Clinically
B. Echocardiogram

A

A. Clinically
- Mild: no pulmonary hypertension
- Moderate: pulmonary hypertension
- Severe: congestive heart failure

B. Echocardiogram
Mitral valve area (normal 4-6)
- Mild is >1.5cm
- Moderate is 1-1.5cm
- Severe is <1.0cm

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4
Q

What are the signs/examination findings of mitral stenosis? (7)
What are features suggesting severe mitral stenosis? (5)

A
  1. Early diastole opening snap
  2. Irregular irregular pulse (AF from LAH)
  3. Tapping undisplaced apex beat
  4. Loud S1
  5. Mid-diastolic rumbling murmur (MDM) over mitral region with presystolic accentuation
    - Accentuated with expiration in left lateral position, exercise
  6. PHT: +/- RVH and PR- loud P2, palpable P2, left parasternal heave, PR murmur (EDM)
  7. Look for previous mitral valvotomy scar over left lateral chest wall

Features of severe MS
1. Increasing length of murmur
2. Shortening interval between S2 and opening snap (high LA pressure)
3. Pulmonary hypertension - mitral facies rash
4. Heart failure: raised JVP, +/- a wave, cyanosis
5. Low pulse pressure (pulsus parvus)

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5
Q

What are the complications of mitral stenosis? (5)

A
  1. AF from left atrial enlargement
  2. LA thrombus formation and embolism
  3. Pulmonary hypertension
  4. Right heart failure and pulmonary oedema
  5. Risk of infective endocarditis
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6
Q

What is the differential diagnosis of a malar flush? (8)

A
  1. Mitral stenosis (low output state due to pulmonary hypertension)
  2. Hypothyroidism
  3. SLE
  4. Carcinoid
  5. Polycythaemia
  6. Systemic sclerosis
  7. Irradiation
  8. Cold weather
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7
Q

How would you investigate a patient with mitral stenosis?
- ECG (3)
- CXR (4)
- TTE
- Pre-surgical workup

A
  1. ECG:
    - AF
    - LAH or dilatation (p mitrale, large p wave with a notch)
    - RAD, RVH (p pulmonale)
  2. CXR:
    - Enlarged LA (double heart border, straightening of left heart border, horizontalisation of left bronchus/splaying of carina)
    - Pulmonary congestion (upper lobe diversion, Kerley B)
    - Prominent pulmonary arteries
    - Calcified mitral valves
  3. Echocardiogram
    - Assess mitral valve
    - Grade severity
    - Assess left atrium and right heart function
    - Look for complications (IE)
  4. Coronary angiography: check coronary artery disease for concomittant CABG + valve replacement
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8
Q

How would you manage a patient with mitral stenosis?

A

Asymptomatic
- Education
- Endocarditis prophylaxis
- Regular interval echocardiogram

Symptomatic
1. Involvement of multidisciplinary team and management of complications
2. Atrial fibrillation:
- Rate/rhythm control
- Anticoagulation
3. CCF:
- Diuretics
- Medication
4. Refer for surgery if clinically indicated

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9
Q

What are the indications for surgery in mitral stenosis?
- Symptomatic (4)
- Asymptomatic (2)

A

Symptomatic (NYHA II-IV) patients with severe lesions:
- Valve area <1cm and valve gradient > 10mmHg
- Pulmonary hypertension
- Haemoptysis
- Recurrent thromboembolism despite anticoagulation

Asymptomatic patients
- Changes in symptoms
- Pulmonary pressure >50mmHg
(No evidence that surgical procedure improves prognosis of patients with slight or no functional impairment)

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10
Q

What surgical procedures can be used to treat mitral stenosis?

A
  1. Closed mitral ballooon valvuloplasty (PMBC) *
    (Percutaneous mitral balloon commisurotomy)
  2. Open heart commisurotomy (midline sternotomy)
  3. Mitral valve replacement
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11
Q

What causes tapping apex beat?

A

Accentuated first heart sound

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12
Q

What causes an opening snap in mitral stenosis?

A

Opening of stenosed mitral valve, indicating leaflets are pliable
The earlier the opening snap, the higher the LA pressure
(If > 0.1s, LA pressure < 15mmHg ; If < 0.1s, LA pressure > 20mmHg)

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13
Q

Why is the first heart sound loud in MS?

A

Mitral valve suddenly slammed shut during ventricular contraction

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14
Q

What causes presystolic accentuation of MS murmur?

A

In sinus rhythm only, during atrial systole, increase flow from LA to LV through stenotic valve

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15
Q

How do patients with MS present?

A
  1. Asymptomatic
  2. Precipitationg of symptoms during pregnancy or development of AF
  3. Left sided heart failure: exertional dyspnoea, PND, orthopnoea
  4. Right sided heart failure: haemoptysis, hoarseness, limb swelling
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16
Q

What are the two differentials of hoarseness in MS?

A
  1. Ortner’s syndrome - enlarged left atrium compresses recurrent laryngeal nerve
  2. Hypothyroidism 2’ amiodarone for AF
17
Q

In which trimester does pregnancy results in symptomatic MS?

A

Second trimester - increased blood volume

18
Q

What is Lutembacher’s syndrome

A

MS with ASD

19
Q

What is rheumatic fever? What age has the highest incidence?

A

Multisystemic inflammatory disease following group A streptococcus infection

Incidence:
- Mostly childhood between 5 - 15 years old
- 20% cases are from adulthood

20
Q

How do you diagnose rheumatic fever?
- Major (JONES), Minor (6P)

A

Revised Jones Criteria:
- 2 major or 1 major + 2 minor
- Recent streptococcus infection

Major (JONES):
- Joint: migrating arthritis
- Pancarditis
- Nodules: subcutaneous nodules over bones, tendons
- Erythema marginatum: annular eruptions
- Syndenham’s chorea: abrupt purposeless movement

Minor (6P):
- Polymorphic Leukocytosis
- Pyrexia
- Phase acute reactants: ESR, CRP
- Previous rheumatic fever or RHD
- PR interval prolonged
- Polyarthralgia

Evidence of streptococcal infection
- Anti-streptolysin O titre
- Throat culture for Group A streptococcus
- Rapid GAS antigen test positive
- Recent scarlet fever

21
Q

What heart valves are commonly affected in rheumatic heart disease?

A
  1. Mitral only (50%)
  2. Mitral and aortic (40%)
  3. Mitral, aortic and tricuspic (5%)
  4. Aortic only (2%)
  5. Other combinations (3%)
22
Q

How to manage rheumatic fever?

A

Primary:
- IM benzathine Pen G x1 dose or
- Pen V for 10 days

Secondary prophylaxis:
- IM benzathine Pen G once a month
- Pen V daily BD

23
Q

Pathogenesis of Rheumatic Mitral Stenosis
1. Chronic inflammation leads to diffuse __ valve leaflets, with formation of __ with __ deposits.
2. Mitral commisures and chordae tendinaea __ and __, cusps become __ leading to narrowing at apex of funnel-shaped “__” valve.
3. Progressive inflammation, fibrosis and trauma to valve due to altered flow pattern eventually causes __ of valve, which immobilises leaflet and narrows orifice further
4. Thromboembolism may be due to __ or __ from LA appendage

A
  1. thickened, fibrous tissue, calcific
  2. fuse and shorten, rigid, “fish mouth”
  3. calcification
  4. calcific valve, atrial fibrillation
24
Q

Haemoptysis in severe MS is due to __ from pulmonary hypertension.
It occurs in elevated LA pressure without marked elevated pulmonary resistance

A

Rupture of pulmonary-bronchial venous connections

25
Q

How do you differentiate ASD from MS?

A

No LA enlargement
No pulmonary congestions (Kerley B lines)
Fixed splitting of S2 (delayed PV closure unchanged with inspiration)
Mid systolic murmur at upper left sternal border
Large left-to-right shunt may cause functional TS

26
Q

How do you differentiate left atrial myxoma?
- symptoms, sign, investigation

A

LA myxoma obstructs LA emptying causing dyspnoea
Diastolic murmur but changes markedly with position
Features of systemic disease: weight loss, fever, anaemia, embolism
Elevated IgG, IL-6
TTE: echo-producing mass in LA

27
Q

Pathophysiology of mitral stenosis

A
  1. Small orifice area impedes free flow of blood
    - High LA pressure needed to propel blood from LA to LV and to maintain normal cardiac output (hallmark of MS)
    - Critical stenosis (< 1cm2) requires LA pressure 25mmHg to maintain CO
  2. LA enlargement, increase in pulmonary venous and arterial wedge pressure
    - Reduces pulmonary compliance (pulmonary congestion) causing dyspnoea
    - Chronic LA pressure causes pulmonary hypertension, PR TR and secondary right heart failure
    - Pulmonary vascular bed changes, fibrous thickening of alveoli wall and pulmonary capillaries, causes reduced VC, TLC, breathing capacity, and reduced oxygen uptake
  3. Acute decompensation in acute illness
    - Exertion, fever, anaemia, pregnancy, thyrotoxicosis, AF, etc demand for higher cardiac output
    - Pathological tachycardia shortens diastole and diminishes time available for flow across mitral valve to “augment” transvalvular pressure and elevate LA pressure -> precipitates MS
CO = HR x SV, as stroke volume limited by stenosis, HR needs to be increased to improve cardiac output
28
Q

What are the criteria for valvuloplasty?

A
  1. Mobile valve (loud S1, has opening snap)
  2. Minimal calcification of valve and subvalvular apparatus
  3. No mitral regurgitation
  4. No LA thrombus on TEE

MRCP PACES Cardiology (19 decks)

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