Mitral Valve Disease

Question 1

mitral valve

• discuss its anatomical structure and location in the heart.
• under physiological conditions - when is it open and how wide does it open?

Answer 1

• structure: a bicuspid valve made of 2 leafelets
  
  • its opening is enclosed by a fibrous ring
  • its leafelets are anchored by chordae tendinae to papillary muscles on the left ventricular wall
• location: in beween the LA and LV
• open: during diastole
  
  • this allows for filling of the left ventricle
  • normally opens to a cross sectional area of 4-6 cm²

Question 2

• cross sectional area of mitral valve
  
  • what is normal?
  • when do we start to see blood flow impairment?
  • when does the valvular area become “critical”?
• how do we determine this area?

Answer 2

• normal cross sectional area: 4-6 cm²
• blood flow impairment seen at < 2 cm²
  
  • ^​symptoms start to present at this area
• valve area becomes critical < 1 cm²

cross sectional area determined with echocardiogram.

Question 3

what is mitral stenosis?

Answer 3

decreased pliability of the mitral valve leafelets that impedes blood flow from the LA to LV

Question 4

what are the major causes of mitral stenosis?

Answer 4

• rheumatic fever - #1 cause
• congenital
• aging with annular severe calcification
• SLE (lupus)
• RA (rheumatoid arthritis)

Question 5

discuss the etiology of rheumatic fever

• what sex/demographics does it effect most
• what valvular diseases can it lead to

Answer 5

• # 1 cause of mitral stenosis worldwide
  • 40% of valvuar manifestations of RF are mitral stenosis, and the remainder are mitral regurgitation or aortic valve disease.
    
    • theses valvular manifestations usually present a few years - 20 years after initial infection
• demographics: most prevalent developing countries
• sex: seen more in females > males

Question 6

• discuss the major gross morphological changes seen in rheumatic valvular disease?
• what changes are characteristic of early vs end stage rheumatic valve disease?

Answer 6

i believe these are referring to changes in the mitral valve*

• major changes:
  
  • thickening of valve leaflets
  • fusion of comissures
  • chorda tendinae shortening/thickening
• stage-specific features:
  
  • early
    
    • leafelets flap open in a “curved over” manner due to restriction of motion at their tips.
      
      • this causes an opening snap on ascultation
  • as diease progresses:
    
    • symmetric fusion of comissures results in a small, central oval orifice during diastole
  • end stage:
    
    • ​leafelets can be so fibrotic/stiff they cannot open/shut

Question 7

pathogenesis of rheumatic valve disease

Answer 7

it is an abrnomal immune response to group A streptococcal pharyngitis

Question 8

what criteria must be met to diagnose rheumatic valve disease

Answer 8

• must see 2 major criteria OR 1 major + 2 minor criteria
  
  • major criteria
    
    • carditis
    • polyarthritis
    • erythema migratorum
    • subcutaneous nodules
    • chorea (uncontrolled movement)
  • minor criteria
    
    • fever
    • arthralgia
    • previous rheumatic fever/known rheumatic heart disease

Question 9

what clinical presentations might indicate carditis?

Answer 9

• pleuritic chest pain
• friction rub
• heart failure

carditis is one of the major criteria for dx of rheumatic valve disease

Question 10

what valves are most/least likely to be effected by rhuematic valve disease

Answer 10

• most likely = mitral/aortic valve
• least likely = pulmonic valve

Question 11

what physiological changes are seen in mitral stenosis

Answer 11

• mitral stenosis = impaired flow from LA to LV during diastole. blood backs up in LA, doesn’t make it to LV. this leads to:
  
  • LA pressure increase
  • LA enlargement
  • LV filling dimished
    
    • this decreases end diastolic volume (preload) –> decreases stroke volume –> thus decreases cardiac output
      
      • (CO = HR x SV)

Question 12

clinical presentation of mitral stenosis

Answer 12

• mild vs moderate
  
  • mild stenosis = typically asymptomatic
  • moderate stenosis (valve area 1-2 cm²) = exertional dyspnea and fatigue
• other clinical manifestations:
  
  • chest pain
  • atrial fibrillation/palpatitations
  • stroke (18 x higher risk in these pts)
  • right sided heart failure
    
    • presents w/ edema, ascities, liver failure
  • hoarseness (ortner’s dynrome)
  • dysphagia
  • hemoptysis from ruptured bronchial veins

Question 13

what two cinical manifestations of mitral stenosis are due to LA enlargement?

Answer 13

• orntner’s syndrome: hoarseness due to the LA enlarging and putting pressure on the recurrent laryngeal nerve
• dysphagia: trouble swallowing due to LA enlarging and impinging on the esophagus

Question 14

what kind of heart failure is seen in mitral stenosis & why?

what other clinical manifestations typically present alongside this heart failure?

Answer 14

• right sided heart failure
  
  • blood back up into LA backs up into lung and then creates a huge afterload that the right heart must overcome.
  • right sided HF can present with:
    
    • edema*
    • JDV*
    • ascites
    • liver failure

Question 15

discuss key exam findings indicative of mitral stenosis

• what sounds will heard on ascultation?
• other findings

Answer 15

• ascultation
  
  • murmurs/sounds:
    
    • loud S1 (mitral valve closure)
    • opening snap (mitral valve opening) after S2 (aortic valve closure)
    • low-pitched diastolic flow murmur
      
      • caused by turbulent blood flow thru valve
  • i_rregular heart rhythm_
• other findings:
  
  • signs of right sided heart failure
    
    • periperal edema
    • JVD
  • stroke symptoms:
    
    • facial drooping
    • weakness on one side of the body

Question 16

define the clinical significance of the “opening snap” heard on ascultation of a pt with mitral stenosis

Answer 16

• opening snap
  
  • often heard in the early phase of rheumatic valve diease
  • this sound is caused by the restriced motion of the diseased valve leafelets during mitral valve opening, which occurs after S2 (aortic valve closure)
    
    • the shorter the interval between S2 and the “opening snap” the more severe the mitral stenosis

Question 17

label these components of a stethoscope. what is purpose/proper orientation of each component

Answer 17

Question 18

• when ausculating a patient with possible mitral stenosis
  
  • what part of the stethoscope should you listen with and where on the heart should you place it?
  • how should the patient be positioned?

Answer 18

• listen to apex of heart with the bell of the stethoscope
• place patient in left lateral decubitus

Question 19

what is the “standard” diagnostic test for mitral stenosis

Answer 19

echocardiogram

Question 20

echocardiogram for dx of mitral stenosis

• what types of echocardiograms can be done and in what circumstances?
• what can an echocardiogram tell you?

Answer 20

• echocardiogram = standard diagnostic test for mitral stenosis
  
  • two possible views:
    
    • transthoracic - usually preferred
    • transesophageal (TEE) - preferred when 1. it is difficult to view valves or 2. we’re assessing for vegetations/thrombus
  • echocardiogram is key to tell you:
    
    • degree of stenosis
      
      • ​mild: mitral valve area > 1.75 cm²
      • moderate: mitral valve 1.25 -1.75 cm²
      • severe: mitral valve < 1.0 cm²
    • pressures across valves/heart chambers

Question 21

other than an echocardiogram - what other diagnostics tests can be done to assess mitral stenosis and under what circumstances?

Answer 21

• EKG - useful if there is an irregular rhythm. could show
  
  • LA enlargement
  • right axis deviation
  • RBBB
• cardiac catheterization - used if echocardiogram is undiagnostic. can tell you pressure in LA/LV
• exercise test stress - to induce exertional symptoms

Question 22

when to do a cardiac catheterization in diagnosis of mitral stenosis/what can it tell you?

Answer 22

• do if echocardiogram is diagnostic
• can tell you pressure of LA/LV

Question 23

when do an EKG if the diagnosis of mitral stenosis/what it can tell you

Answer 23

• do if there is an i_rregular rhythm_
• can show:
  
  • LA enlargement
  • right axis deviation
  • RBBB

Question 24

how to treat asymptomatic mitral stenosis

Answer 24

• generally, no treatment.
• unless:
  
  • there is severe pulmonary artery HTN OR new onset atrial fibrillation, in which case:
    
    • control HR with beta blocker/CCB
    • and give warfarin (anti-coagulant) if their INR is 2-3
  • they need a percutaneous balloon mitral valveotomy

Question 25

how to treat heart failure secondary to mitral stenosis

Answer 25

give diuretics

Question 26

how to treat mitral stenosis in patients with _exertional symptoms_ (what methods are preferred vs not preferred)

Answer 26

* NOT preferred: percutaneous balloon mitral valcotomy * preferred: * **open/closed surgical mitral valvotomy** * **open heart mitral valve replacement** * mechanical mitral valve: * these patients are given lifelong warfarin (comoudin) anticoagulant * bioprosthetic mitral valve: * for patients older than 65 or who can't take anti-coagulants

Question 27

* when are valve replacements done to treat mitral stenosis? * what are the _two types of valves_ that can be used in an open heart mitral valve replacement? * what are the pros and cons of each?

Answer 27

* done in mitral stenosis patients with _exertional symptoms:_ * valve replacements: * **mechanical mitral valve:** * **​**this valve has a longer lifepan than bioprosthetic valves * these patients are given lifelong warfarin (comoudin) anticoagulant * **bioprosthetic mitral valve:** * **​**dont require anti-coagulants * for patients 65 or older OR who cannot take anticoagulants

Question 28

_complications_ of mitral stenosis

Answer 28

aka, the clinical manifestations of mitral stenosis. this list should be familiar. * LA enlargement * stroke/thrombus formation * pulmonary hypertension * right ventricular hypertrophy * right sided heart failure * peripheral edema * JVD * ascites * hepatic congestion/cirrhosis

Question 29

what is mitral regurgitation

Answer 29

the inability of the mitral valve to fully close, resulting in a backflow of blood int the left atrium

Question 30

primary vs secondary mitral regurgitation

Answer 30

* Primary: resulting from detect of valve & its components * Secondary: regurgitation resuling from _progressive enlargement of LV_ that ends up causingcausing mitral annular dilation

Question 31

what are the two types of non-infective endocarditis? what do they have in common?

Answer 31

* marantic endocarditis and libman sacks disease * both involve **sterile** vegetations

Question 33

* marantic endocarditis * describe its vegetations * effects what valves * is associated with what underlying diseases/populations

Answer 33

* marantic endocarditis = a non-infective endocardtitis * vegetations * sterile * small (1-5 mm) * typically occur along the lines of closure * are non-invasive: _do NOT cause inflammatory response._ * **mitral & aortic valve** * **associated w/ underlying systemic hypergoabulable state** * **​**cancers patients, pts with catheters, sepsis, anti-phopholipid disorder * can cause systemic emboli --\> stroke

Question 34

* libman sacks disease * describe its vegetations * what valves does it effects * what underlying diseases/populations is it associated with?

Answer 34

* libman-sacks = a non-infective endocarditis * vegetations * small (1-4 mm) * single or multiple **sterile, pink vegetations** * **warty appearance** * tend to extend into endocardium/chordae tendinae (not confined to closure lines like marantic\*) * tend to cause _intense inflammation!_ (unlike marantic\*) * **mitral & tricusupid valve** * associated with: * **SLE (systemic lupus erythematous):** see in young females, causes strokes * **anti - phospholipid syndrome:** seen mostly on aortic/mitral vavlve

Question 35

what valvular disease is shown here?

Answer 35

marantic endocarditis (non-infective) note the **vegetations confined to the closure lines**

Question 36

what valvular disease is shown here?

Answer 36

libman sacks disease (non-infective endocarditis) note the **pink, warty vegetations** extending onto chordae tendinae/other valve components

Question 37

physiological presentation of _acute_ mitral regurgitation * note the volume/pressure status of the heart chambers * note cardiac ouput status

Answer 37

* regurgitation of blood from LV to LA during _systole_ increases LA pressure and volume. since not all of LV blood is getting to the aorta, the _end diastolic volume_ in the _LV is decreased_ * **_increased_ LA volume and pressure** * **​**can cause pulmonary edema * **_decreased_ LV volume -**-\> **therefore _low_ cardiac ouput**

Question 38

discuss the physiological presentation of _chronic_ mitral regurgitation * note the volumes/pressures of the four heart chambers * note the status of the cardiac ouput

Answer 38

* regurgitation of LV blood into LA _during systole_ increases LA pressure/volume. *over time,* accumulated LA blood + new blood from venous return increases the point of also increasing end diastolic volume in LV. * **i**_ncreased_** LA volume and pressure** * **_increased_ LV volume and pressure** * **​cardiac output _maintained_**

Question 39

clinical presentation of acute mitral regurgitation

Answer 39

* **acutely ill and often in cardiogenic shock\*** * **​**due to _low cardiac ouput_ unique to acute MR. * this would be indicated by *dyspnea, hypotension, tachycardia, cool extremities, diaphoresis* * **chest pain** * **acute pulmonary edema**

Question 40

clinical presentation of chronic mitral regurgitation

Answer 40

* _very similar to that of mitral stenosis_ due to LA volume "back up" the lung & right heart * dyspnea * peripheral edema * JVD * ascites * palpitations/atrial fibrillation * stroke

Question 41

what are the key exam findings pertinent to mitral regurgitation? * describe sounds heard on ascultation * other clinical findings

Answer 41

* ascultation * _sounds/mumurs:_ * **S1 decreased** (soft mitral valve closure sound) * **S2 is split** (delay between seminlunar valve closure) * occasional S3 heard - *would sound like kentucky* * **_systolic murmur:_** created by blood flow thru mitral valve during sysole when it _should be shut._ * ​_holosystolic murmur_ in chronic MR * _early systolic murmur_ in acute M * _possible laterally displaced PMI_ * *seen chronic MR, due to enlarged LV* * other exam findings * may see signs of right heart failure - ascites, JVD * may see signs of _cardiogenic shock_ - hypotension, tachy, cold skin - if acute MR

Question 42

* .discuss the _systolic murmur_ heard in mitral regurgitation * how is it different beween acute vs chronic MR? * do we hear this in mitral stenosis?

Answer 42

* acute vs chronic MR: * acute MR --\> **early systolic murmur** * chronic MR **--\> holosystolic murmur** * heard throughout systole (the _whole time_ between S1-S2) * radiates to the axilla * do not hear a systolic murmur in mitral stenosis. * in MS, the mitral valve closes sufficiently during systole but _does not open sufficiently_ in diastole. thus, in MS we hear a **_diastolic murmur_ -** created by turbulent blood flow during diastole

Question 43

diagnostic testing for mitral regurgitation * what is the "standard"? what are other useful tests and in what circumstances? * compare/contrast this to dx of mitral stenosis

Answer 43

* like in mitral stenosis: * echocardiogram is the diagnostic standard * TTE - sufficient in most circumstances * TEE - for detailed valvular anatomy/presence of thrombi * EKG - if you suspect rhythm abnormality * cardiac catheriziation - done if echocardiogram does not give definitive diagnosis * unlike mitral stenosis: * **consider chest x-ray** to assess _fluid overload/overall heart size_ * _don't_ need to do an exertional test

Question 44

how to treat severe acute mitral regurgitation

Answer 44

* **most important: treat shock** * treat underlying cause of MR * consider surgery

Question 45

how to treat _chronic asymptomatic_ MR

Answer 45

* control HTN * medications: warfarin if a-fib present * monitor w/ echocardiogram every 6-12 months * consider surgical repair if: * a-fib present * of EF \< 60% or LV end-diastolic volume of 4- mm * pulmonary HTN present

Question 46

how to treat _chronic symptomatic_ mitral regurgitation?

Answer 46

* *just like with asymptomatic chronic MR*: * control HTN * give warfarin if they have a-fib * specific tx for primary vs secondary chronic symptomatic MR: * **primary MR:** * **tx = valve surgery:** * **_repair:_** **open vs mitral cip** * mitral clip: * not as effective as open * but minimally invasive * *is thus good for high risk patients who cannot undergo open heart surgery as it can reduce symptoms enough to improve quality of life* * open alfari stitch repair * **_replacement:_ mechanical vs bioprosthetic valve** (same as MS) * recall that mechanical valves have a longer lifespan but require lifelong anti-coagulants * **secondary MR:** * **​no surgery** * since secondary MR is due to _LV enlargement rather than a defect of the valve itself_, repair/replacement does not fix the underlying problem

Question 47

what is mitral valve prolapse?

Answer 47

myxomatous degermation of the mitral valve that causes leafelets to _bulge back into_ the _left atrium_

Question 48

symptoms of mitral valve prolapse

Answer 48

* symptoms * Palpitations * Syncope * Chest pain not associated with CAD

Question 49

exam findings of mitral valve prolapse * what will the ausculation show? * other exam findings? * what diagnostic test is _standard_ to dx for mitral valve prolapse?

Answer 49

* ascultation: * could show **mid-systoic click** followed by **late-peaking systolic murmur** * other exam findings: typically normal unless MR (mitral regurgitation) is also present * diagnostic standard: echocardiogram * (like with all valvular diseases)

Question 50

what is the treatment for mitral valve prolapse?

Answer 50

* typically no treatment _unless MR_ is also present * if there is treatment: * possible beta-blockers - *if palpitations* * baby aspirin - *to reduce stroke risk* * if surgery: * done when pt's have severe MR symptoms * men typically have surgery more (if someone)

Question 51

triscuspid valve * describe its anatomy * where in the heart is it found * when during the cardiac cycle is it typically open? * what is its normal valvular area?

Answer 51

* three valves * between RA and RV * open during systole * normal valvular area: 4-6 cm²

Question 52

* describe the disease incidence of the tricuspid valve relative to the other valves * what diseases most commonly effect the tricuspid valve and in what populations?

Answer 52

* lower incidence of disease than in aortic/mitral valves * triscupid valve disease is most commonly **seen IV drug users**, and is usually one of the two: * rheumatic heart disease * infective endocarditis (IE)

Question 53

tricuspid stenosis * incidence * causes

Answer 53

* incidence: rare * causes: * rheumatic heard disease - most common * other causes: * carcinoid heart disease * myxoma/metastasis * vegetations obstructing RV inflow * typically from pacemaker leads

Question 54

carcinoid heart disease * cause * pathogenesis * gross presentation * associated clinical presentaiton * what markers aid in diagnosis of this cardinoid heart disease?

Answer 54

* cause/pathogenesis/presentations: * cardinoid tumors (though, typically not GI carcinoid tumors) * _bioactive products_ released from these these cardinoid tumors - serotonin (5-HT), kallikrein, bradykinin, histamine, prostaglandins - cause **"carcinoid syndrome"**- which can lead to the following: * _clinical presentation:_ * nausea/vomitting/diarrhea * cramps * _episodic skin flushing_ * _gross cardiac presentation:_ * **​plaque-like thickening** of the endocardium & valves of the heart. specifiaclly, the **right heart valves- pulmonary & tricuspid** * markers: * plasma levels of _serotonin_ and _5-hydroindoleacetic acid_ (urinary serotonin) correlete to severity of the lesions

Question 55

_clinical presentation_ resulting from carcinoid heart disease

Answer 55

* symptomatology resulting from carcinoid heart disease is largely due to the **increased systemic venous pressure** resulting from increased **_right sided pressure_** * **​peripheral edema** * **abdominal distention** * **RUQ pain/fullness** * **neck pulsation**

Question 56

exam findings seen with carcinoid heart disease: * auscultation * other exam findings

Answer 56

* _right sided_ heart failure findings: * **JVD with cannon-a waves** * hepatomegaly * ascites * peripheral edema * auscultation: * murmurs: * **low pitched diastolic mumur** at the **_lower left sternal edge_** * _​_due of turbulent flow thru tricuspid valve during diastole (tricuspid located at left lower sternal border) - all physicians take money * **increase with inspiration** * often heard alongside _mitral stenosis_ murmurs

Question 57

what is mitral regurgitations and its primary causes?

Answer 57

* inability of the leafelets the fully close * caused by same causes as carcinoid heart disease: *

Question 58

* what are the diagnostic tests to order for carcinoid heart disease and what key things will they show?

Answer 58

* echocardiogram - standard * shows **tricuspid valve pathology:** thickened leafelets, decreased mobiliby, doming * EKG: * **possible** **peaked P-wave in lead II** * **​**due to RA enlargement * atrial fibrillation * Chest X-ray: * **RA enlargement - seen as** **prominence of right heart border**

Question 59

what is the treatment regimen for _carcinoid hear disease:_

Answer 59

* first: _relieve venous congestion_ * use **diruetics** or **nitrates** (vasodilators) * next: dubulk obstructive tumors/myoxomas in the heart * consider the following: * control a-fib * anti-coagulants if needed * surgical valve replacement: * do if * mean diastolic pressure gradient **\> 5mmHg** & **tricsupid orifice \< 2.0 cm²** * or if concurrent mitral valve repair is happening * do NOT do balloon valvoltomy

Question 60

what is tricuspid valve regurgitation and its common causes?

Answer 60

* inability of valve leafelets to close * causes: * most are same as tricuspid stenosis/carcinoid heart disease: * rheumatic heart disease * IE * myxomatous disease * carcinoid heart * could also be dilation due to --\> pulmonary HTN --\> putting pressure on RV --\> RV overload opens trisupid valve

Question 61

clinical presentation of tricuspid regurgitation

Answer 61

* Symptoms often associated with left sided heart disease or pulmonary disease * Dyspnea * Paroxysmal nocturnal dyspnea * Peripheral edema * Abdominal distension * Peripheral edema * Chest pain

Question 62

_exam findings_ for **tricsupid regurgitation** * what will be seen on ascultation * other findings

Answer 62

* ascultation: * murmurs * **_low intensity holocystolic murmur:_** * due to open tricsupid valve when it should be closed during systole * heard at _left sternal edge/subxiphoid area_ * may hear S3 * **prominent cv wave** * signs right sided heart failure * JVD * ascites * hepatomegaly * perpheral edema

Question 63

treatment for tricuspid valve?

Answer 63

* medications * treat HF with diuretics * treat underlying cause (COPD, pulmonary HTN, ect) * surgery: * **surgical tricsupid annuloplasty** is the go-to * a "semi-prosthetic" ring * valve replacement is rare * but it if is, use **bioprosthetic valve** * this is because a bioprosthetic valve doesnt require anti-coagulants, and the tricuspid valve is _fairly prone to thrombosis_