Mitral Valve Disease - Stenosis

Question 1

When we listen to the heart we should be able to hear 2 separate sounds, S1 and S2. What does S1 relate to?

1 - closing of the tricuspid and mitral valves
2 - closing of tricuspid and aortic valves
3 - closing of mitral and aortic valves
4 - closing of aortic and pulmonary valves

Answer 1

1 - closing of the tricuspid and mitral valves
- also called the atrioventricular valves, as these 2 valves relate to the atrium

Question 2

Does the S1 heart sound occur at the start of diastole or systole?

Answer 2

• systole
• mitral and tricuspid valves close to stop blood moving back into the atrium

Question 3

When we listen to the heart we should be able to hear 2 separate sounds, S1 and S2. What does S2 relate to?

1 - closing of the tricuspid and mitral valves
2 - closing of tricuspid and aortic valves
3 - closing of mitral and aortic valves
4 - closing of aortic and pulmonary valves

Answer 3

4 - closing of aortic and pulmonary valves

Question 4

Does the S2 heart sound occur at the start of diastole or systole?

Answer 4

• diastole
• aortic and pulmonary valves close to allow atria to pump blood into ventricles

Question 5

In some patients a 3rd heart sound can be heard, S3, which occurs just after S2. What causes this 3rd heart sound?

1 - mitral regurgitation
2 - ventricular septal defect
3 - chordae tendineae pulling
4 - aortic regurgitation

Answer 5

3 - chordae tendineae pulling
- papillary muscles contract and pull chordae tendineae which attach to mitral valves

• sound is because they pull so hard to fully expand the left ventricle
• can be heard in some younger patients, BUT can signify HR in older patients

Question 6

How many leaflets does the mitral valve have?

1 - 4
2 - 3
3 - 2
4 - 1

Answer 6

3 - 2
- however, some patients can have a bicuspid valve due to genetics

Question 7

Does the mitral valve open during systole or diastole?

Answer 7

• diastole
• allows left ventricle to be filled

Question 8

Does the mitral valve close during systole or diastole?

Answer 8

• systole
• allows LV to pump blood around the body

Question 9

When a patient has mitral stenosis a murmur can be heard. At what time point around other heart sounds can this murmur be heard?

1 - after S2
2 - after S1
3 - after S3
4 - throughout S1 to S2

Answer 9

1 - after S2
- sound will be low pitched as slow velocity of the blood flow through the valve
- there will also be a loud S1 as the valves are under pressure to force blood through

Question 10

All of the following are causing of mitral stenosis, but which is the leading cause?

1 -Infective Endocarditis
2 - Degenerative
3 - Congenital
4 - Rheumatic

Answer 10

4 - Rheumatic

Question 11

The leading cause of mitral stenosis is rheumatic fever. This can cause commissural fusion of the leaflets. How does rheumatic fever do this?

1 - increases inflammation that can damage valves
2 - Group A Streptococcus release M protein that resembles self MHC-1 in cardiac and valve tissue
3 - Group A Streptococcus directly infect aortic valve
4 - all of the above

Answer 11

2 - Group A Streptococcus release M protein that resembles self MHC-1 in cardiac and valve tissue
- leads to thickening and fusion of leaflets
- called molecular mimicry, essentially antibodies target the mitral valve thinking it is Group A Streptococcus

Question 12

Which bacteria is associated with rheumatic fever that can lead to mitrali stenosis?

1 - Group A Streptococcus
2 - Corynebacterium diphtheriae
3 - Arcanobacterium haemolyticum
4 - Mycoplasma pneumoniae.

Answer 12

1 - Group A Streptococcus
- commonly referred to as strep throat

Question 13

What type of hypersensitivity is mitral stenosis caused by the release of M protein found in Group A Streptococcus?

1 - type 1 hypersensitivity
2 - type 2 hypersensitivity
3 - type 3 hypersensitivity
4 - type 4 hypersensitivity

Answer 13

2 - type 2 hypersensitivity

Question 14

Although mitral stenosis due to rheumatic fever is rare, it can happen. Which of the following patients is LEAST likely to develop this?

1 - <5 y/o
2 - >65 y/o
3 - low social economic background
4 - overcrowding home

Answer 14

2 - >65 y/o

Question 15

Mitral stenosis can cause all of the following, EXCEPT which one?

1 - increased pressure on LA
2 - VF
3 - increased pulmonary pressure
4 - pulmonary hypertension
5 - right heart failure

Answer 15

2 - VF
- typically mitral stenosis can lead to AF
- AF is caused by increased pressure of LA and disruption in electrical conduction

Question 16

Patients with mitral stenosis are likely to have all of the following symptoms, EXCEPT which one?

1 - dyspnoea (pulmonary oedema)
2 - haemoptysis
3 - hoarseness
4 - pericardial perfusion
5 - dysphagia
6 - fatigue
7 - palpitations

Answer 16

4 - pericardial perfusion

• haemoptysis = due to increased pressure causing rupture of pulmonary vessels
• hoarseness is due to enlarged LA pressing on recurrent laryngeal nerve
• dysphagia as enlarged LA presses on the oesophagus

Question 17

A clinical sign patients with MV stenosis can present with is malar flush, which is flushing of the cheeks. Why does this occur?

1 - haemoptysis
2 - dysphagia
3 - raised CO2 and vasodilation
4 - palpitations

Answer 17

3 - raised CO2 and vasodilation
- increased back pressure increasing CO2
- blood vessels in cheeks vasodilate

Question 18

All of the following are tests to diagnose a patient with suspected mitral regurgitation, but which generally provides a definitive diagnosis and is regularly used?

1 - echocardiogram
2 - ECG
3 - CXR
4 - transoesophageal echocardiogram
5 - cardiac catheterisation

Answer 18

1 - echocardiogram

Question 19

If the patient is presenting with suspected mitral stenosis and has symptoms, what treatment can be performed?

1 - mitral valve replacement
2 - balloon valvuloplasty
3 - mitral valve repair
4 - all of the above

Answer 19

4 - all of the above

Question 20

If a patient has mitral stenosis and is unable to have surgery, or is waiting for surgery, all of the following medications can be useful, EXCEPT which one?

1 - Furosemide
2 - Ramipril or Candesartan
3 - Bisoprolol or Digoxin
4 - Simvastatin
5 - Rivaroxaban or Warfarin

Answer 20

4 - Simvastatin
- IHD is not the cause here

• Furosemide = combat pulmonary oedema
• Ramipril or Candesartan = reduce afterload
• Bisoprolol or Digoxin = reduce HR and risk of AF
• Rivaroxaban or Warfarin = reduce risk of emboli forming

Question 21

In mitral stenosis AF can occur. Should DOACs such as Edoxaban, Apixaban and Rivaroxaban be used, or Warfarin?

Answer 21

• Warfarin
• high risk of AF and emboli formation so Warfarin should be given

Question 22

Complete the table below using the labels below using systole or diastole of when you would hear the murmurs:

Answer 22