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MR/MS Flashcards

1
Q

Describe the key features of rheumatic MS?

A
  • Commisural Fusion
    • ​leaflet: thick at tips
    • Chordae: thick/retracted
    • Short posterior leaflet
    • Calcification: late
    • MS > MR
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2
Q

Describe the key features of degenerative MS?

A
  • Annular calcification
    • ​Leaflet: thick at base
    • Associated with atherosclerosis, HTN, AS
    • MR > MS
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3
Q

What are the methods for determining MVA in MS?

A
  • Planimetry
  • Continuity equation
  • PHT
  • PISA
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4
Q

What is the formula for calculating MVA using PHT?

A

MVA = 220 / PHT

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5
Q

Define PHT

A

time required for the gradient between the LA and the LV to fall to one half of its initial value

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6
Q

What PHT correlates with severe MS?

A
  • 150 ms
    • 220/150 = 1.46 cm2
    • < 1.5 cm2 –> severe MS
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7
Q

Under what conditions is PHT assessment of MS inaccurate?

A
  • AR (short PHT)
    • will rapidly increase the LV diastolic pressure and shorten PHT –> underestimation of MS (overestimation of MVA)
  • Sudden changes in LA-LV compliance
    • immediately following BMVP
  • Diastolic dysfunction
    • increased LV filling pressure
  • ASD

****less accurate in calcific MS

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8
Q

What group of patients should PHT assessment of MS be avoided?

A

Elderly patients with calcific, degnerative MS

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9
Q

How do you calculate MVA using the continuity equation?

A

MVA = LVOTVTI x LVOTarea / MVVTI

  • MVA = LVOT D2 x 0.785 x ( LVOTVTI / MVVTI )
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10
Q

What situations make use of the continuity equation unreliable in assessment of MS?

A
  • MR
  • AR
  • A-Fib
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11
Q

What is one change in the echo settings that is useful when calculating PISA?

A

shift baseline (aliasing velocity) in the direction of the flow

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12
Q

What is the formula for calculating MVA using PISA?

A

MVA = 6.28 x r2 x Vr / Peak Vmax x angle/180

  • r = radius of convergence hemisphere
  • Vr = aliasing velocity c/s
  • Vmax = peak CWD velocity of mitral inflow c/s
  • angle = opening angle of mitral leaflets relative to flow direction
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13
Q

What are the Class I ASE recommendations for MVA?

A
  • Planimetry
  • PHT
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14
Q

What are the Class 2 ASE recommendations for MVA?

A
  • PISA
  • Continuity equation
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15
Q

What is the best/most reproducible method for assessing MVA in rheumatic MS?

A

3D planimetry

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16
Q

What is the best/most reproducible method for assessing MVA in degenerative MS?

A

Continuity equation > 3D planimetry

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17
Q

What are the levels of severity for MS: MVA

A
  • Progressive > 1.5 cm2
  • Severe 1.0-1.5 cm2
  • Very severe < 1.0 cm2
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18
Q

What are the levels of severity for MS: MG

A
  • Progressive < 5 mmHg
  • Severe 5-10 mmHg
  • Very severe > 10 mmHg
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19
Q

What are the levels of severity for MS: PHT

A
  • Severe > 150
  • Very Severe > 220
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20
Q

What are the levels of severity for MS: PASP

A
  • Severe > 30 (50) mmHg
  • Very severe > 30 (70) mmHg
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21
Q

What factors should be considered in evaluation for balloon valvuloplasty of MS?

A
  • Valve pliable:
    • commissural calcification
    • Wilkins/Abascal Score < 8
      • Mobility (1-4)
      • Thickening (1-4)
      • Calcification (1-4)
      • Sub-valvular thickening (1-4)
  • MR < 2+
  • No thrombus in LAA
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22
Q

What are the indications for PMBV?

A
  • Symptoms
  • Severe MS
  • Feasibile valvuloplasty
  • Asymptomatic + Pulmonary hypertension
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23
Q

What are unusual (acquired) etiologies of MS?

A
  • Lupus
  • Carcinoid
  • Drugs
  • Radiation
  • Infiltrative (Maroteaux-Lamy)
    • Mucopolysaccharidosis Type IV
  • Iatrogenic
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24
Q

What are unusual (congenital) etiologies of MS?

A
  • Luttembacher (ASD + MS)
  • Shone (AS + MS + Coarctation)
  • Supravalvular membrane
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25
What is the formula to calculate PHT from deceleration time (DT)?
PHT = 0.29 x Deceleration Time (DT)
26
What is vena contracta?
* narrowest width of the regurgitant jet, measured using color doppler flow imaging * both proximal acceleration region and the distal jet expansion should be seen to ensure the narrowest segment of the jet is measured * \< 0.3 cm = mild MR * \> 0.7 cm = severe MR
27
What are the four components of the mitral valve?
1. mitral leaflets (anterior and posterior) 2. mitral annulus 3. subvalvular structure (including both chordae tendinae and papillary muscles) 4. LV wall
28
What are the categories of MR?
* Primary (predominantly degenerative) * lesions of the mitral leaflets and subvalvular apparatus * Secondary (functional) * annular or LV dilation
29
What are causes of primary MR?
* Myxomatous valve disease * prolapse * Barlow's syndrome * Elongated/Ruptured/Flail Chordae * Degenerative diseases: * Thickened/calcified MV apparatus with restricted mobility and poor coaptation * Ruptured chordae/flail valve * Infectious etiology/endocarditis * Vegetations * Perforation * Leaflet aneurysm * Abscess * Inflammatory * Rheumatic * Collagen vascular diseases * Radiation * Drugs * Congenital * Cleft valve * Parachute mitral valve * Blood cysts
30
What is the most common cause of MR? What is the pathophysiology that leads to MR?
* myxomatous degeneration * localized, fibroelastic deficiency due to abnormalities in connective tissue --\> results in chordal thinning and elongation and subsequent MV prolapse
31
What occurs in Barlows disease?
MR secondary to diffuse, myxoid degeneration of the MV --\> excess tissue in multiple valve segments, including leaflets, chordae, and annular dilation \*\*myoxoid degneration: degenerative process in which the connective tissues are replaced by a gelatinous or mucoid substance.
32
What is the mechanism of MR in secondary or functional MR?
LV dilatation and/or dysfunction --\> mitral annular dilation and impaired leaflet mobility or tethering
33
How does the Carepntier classificaiton system classify MR types?
* focus on differences in leaflet mobility as the cause of leaflet malcoaptation and MR * 3 types
34
Define the Carpentier classification - Type I
* **Dysfunction** --\> normal leaflet motion (poor leaflet coptation) * **Lesions** --\> isolated annular dilation + leaflet perforation / tear * **Etiology** * Dilated cardiomyopathy * Ischemic cardiomyopathy * Congenital * Endocarditis
35
Define the Carpentier classification - Type II
* **Dysfunction** --\> excessive leaflet mobility (leaflet prolapse) above the mitral annulus plane * **Lesions** --\> * elongation / rupture chordae * elongation / rupture of papillary muscle * **Etiology** * Degenerative valve disease * fibroelastic deficiency * Barlow's disease * Marfan's disease * Ischemic Cardiomyopathy * Endocarditis * Ehler-Danlos syndrome * Trauma
36
Define the Carpentier classification - Type IIIa
* **Dysfunction** --\> restricted leaflet motions (diastole and systole - opening) * **Lesions** --\> * leaflet calcification / thickening / retraction * chordal fusion / thickening / retraction * commisural fusion * **Etiology** --\> * Carcinoid heart disease * Hypereosinophilic syndrome * Radiation * Rheumatic heart disease * Mucopolysaccharidosis * SLE
37
What are the best views for evaluating vena contracta (in MR) on TTE and TEE?
* TTE: parasternal long-axis view * TEE: long-axis view at 120
38
In what other clinical situation is Sgarbossa criteria utilized for the diagnosis of MI?
RV pacing (also demonstrates LBBB on EKG)
39
What are the Doppler parameters used in the assessment of MR severity?
* Color flow jet area * Mitral inflow - PW * Jet density - CW * Jet contour - CW * Pulmonary vein flow
40
What does the image show? What is the treatment of choice?
* SAM of the mitral valve - consistent with LVOTO * Nondihydropyridine CCB's (Verapamil) or BB's * Afterload reducing agents (Lisinopril and Amlodipine) and diuretics are likely to exacerbate the obstruction
41
What is the pathophysiology of hemoptysis in MS cases?
elevated postcapillary pulmonary pressure
42
Describe MV leaflet scallops visualized in A2C view?
43
Describe MV leaflet scallops visualized in A4C view?
44
What are causes of mitral regurgitation secondary to systolic anterior motion?
* hypertrophic cardiomyopathy * hypertensive heart disease with prominent basal septum * acute anterior infarcts with hyperdynamic compensatory function * apical ballooning syndrome with a hyperdynamic base
45
What are the components of the Wilkins score for MS/PMBV?
* Leaflet/valvular * thickening * mobility * calcificaiton * Subvalvular thickening
46
What is the diagnosis?
* Flail P2 scallop *
47
What is the formula for PHT in MS, utilizing deceleration time?
PHT = 0.29 x DT MVA = 220/PHT
48
Describe MV leaflet scallops visualized in PLAX view?
49
What is the mechanism of successful mitral valuloplasty?
commisural separation
50
Describe scallop anatomy
51
Describe MV leaflet scallops visualized in parasternal SAX view?
52
What is one major contraindication to percutaneous MitraClip repair?
leaflet calcification at the device landing zone (in this case A2 and P2
53
Describe scallop anatomy
54
Describe MV leaflet scallops visualized in these views: * PLAX * PSAX * AP4 * AP2
55
What is the problem with heavy calcification in patients undergoing PMBV?
* Lower procedural success rate * Higher incidence of significant MR
56
What is the formula for RV (in MR evaluation)?
RV = EROA x regurgitant VTI
57
What is a possible diagnosis in Systolic anterior motion (SAM)-related MR with an anteriorly directed regurgitant jet?
Superimposed organic MV pathology - likely a flail posterior leaflet
58
What is the most common angle of mitral valve leaflets at the time of PISA (in MR evaluation)? What if the jet creates an angle other than 180?
* 180 degrees * Angle adjustment (angle/180) * frequently occurs when jet originates from commisures, which are in close proximity to the LV wall * not enough space for a full hemisphere to form
59
What is the TEE - 60 degree called (in MR evaluation)?
commisural view
60
What is the diagnosis? What is the findings that support the diagnosis? What will clinical examination (auscultation) reveal?
* Rheumatic MS (given history of multiple infections as a child * Supportive signs on imaging: * hockey-stick defomrity of the anterior MV leaflet * incomplete opening of the posterior MV leaflet * visible mitral inflow acceleration * CW doppler is consistent with severe MS (MG = 16 mmHg) * Opening snap occurring early after A2
61
Describe the ausculatory findings in MS in relation to A2
* Interval between the second heart sound (A2) and the opening snap reflects the isovolumic relaxation time * typically shorter with higher left atrial pressures * the shorter the A2-opening snap interval --\> more severe the MS *
62
* young patient with lightheadedness associated with physical activity * 2/6 systolic murmur at the left parasternal border * increases with Valsalva maneuver * orthostatic BP's normal
murmur suggestive of dynamic LV outflow obstruction
63
What is the best line for PHT tracing (in MS evaluation)?
* Number 2 * Number 1 is incorrect as this will be reflective of both left atrial and ventricular pressure, not only mitral stenosis
64
* young patient with worsening dyspnea on exertion * systolic murmur over precordial area * sustained apical impulse * normal splitting of 2nd heart sound * increases with squat to stand maneuver
hypertrophic cardiomyopathy with dynamic outflow obstruction
65
What is the optimal aliasing velocity for PISA in MR evaluation?
30-40 cm/s * values greater --\> small radii * lower values --\> identify isovelocity shells too far from the regurgitant orifice, where surface is no longer a hemisphere
66
What are the Quantitative parameters used in the assessment of MR severity?
* VC width (cm) * R Vol (ml/beat) * RF (%) * EROA (cm2)
67
What is the typical leaflet abnormality and doppler appearance of Systolic anterior motion (SAM)-related MR?
Posteriorly directed regurgitant jet * if anteriorly directed --\> consider superimposed organic MV pathology
68
Central jets are typically seen with this type of MR? Etiology?
* Secondary (functional) MR * LV dilation
69
What is the relation to mitral gradient and HR?
significantly increased with increasing HR's
70
When should your PISA radius be measured (in MR evaluation)?
* Should be selected to match the timing of the peak MR velocity * Usuually occurring close to the T wave on ECG
71
What view should be utilized in PISA (MR evaluation)?
Any view that allows optimal Doppler alignment (parallel with the flow) * eccentric jets may require parasternal and subcostal views for better window alignment
72
Ischemic MR typically results in what pattern of MR jet?
eccentric, posteriorly directed jet
73
Describe the type of MR jet caused by MVP?
eccentric jet, directed away from the affected leaflet
74
Within 24 hours of a STEMI, when should an ACE inhibitor be initiated?
* STEMI with an anterior location * Heart Failure * EF \< 40%
75
Define the Carpentier Classification - Type IIIb
* **Dysfunction** --\> restricted leaflet motion (systole, closure) * **Lesions** --\> * LV dilatation / aneurysm * papillary muscle displacement * chordae tethering * **Etiology** * Ischemic / Dilated Cardiomyopathy
76
What is the underlying mechanism for EKG changes with TCA overdose?
excess sodium channel blockade
77
What are the two major side effects of sodium-channel blocker poisoning?
* Seizures * Ventricular dysrhythmias \*\*\* due to blockade of sodium channels in the CNS and myocardium
78
What are the major EKG findings in TCA overdose?
* Sodium channel blockade * Interventricular conduction delay (QRS \> 100ms in lead II) * RAD * Terminal R wave \> 3 mm in aVR * R/S ratio \> 0.7 in aVR * Muscarinic (M1) receptor blockade * sinus tachycardia * Potassium channel inhibition * QTc prolongation
79
What additional vavlvular abnormality makes PMBV ineffective?
MR \> 2+
80
TCA overdose * sinus tachycardia with 1st degree AV block (p waves hidden in the T waves, best seen in V1-V2) * Widened QRS * Positive R' wave in aVR
81
What is the pathophysiologic mechanism of chronic MR?
Volume overload of the LV --\> ventricular and atrial remodeling via eccentric hypertrophy * dilation of the LV without increased wall thickness * increase in LV size is adaptive for increasing LV volume without an increase in diastolic filling pressure * increase in ventricular compliance and maintaining stroke volume and cardiac output
82
What is the pathophysiologic mechanism of chronic MR?
Volume overload of the LV --\> ventricular and atrial remodeling via eccentric hypertrophy * dilation of the LV without increased wall thickness * increase in LV size is adaptive for increasing LV volume without an increase in diastolic filling pressure * increase in ventricular compliance and maintaining stroke volume and cardiac output
83
This finding is the major influence on clinical manifestations of chronic MR?
elevation of LA pressure (leads to) * pulmonary congestion * pulmonary hypertension * A-fib
84
What are common causes of acute MR?
* chordal or papillary muscle rupture * Infective endocarditis
85
What is the pathophysiology of acute MR?
* sudden increase in LA and ventricular volume in the absence of LV or atrial dilation --\> * Pulmonary venous pressure rises rapidly --\> pulmonary edema --\> * LV stroke volume is reduced --\> * systemic hypotension despite compensatory increase in HR to maintain Stroke Volume
86
Describe the physical examination findings of MR?
* Holosystolic * best heard at the apical or left midclavicular region * Worsened: * left lateral decubitus position * increased afterload (handgrip) * Radiation is highly variable depending on jet direction * Mid-systolic click may be heard if MVP present * S3 may be present if associated with LV systolic dysfunction
87
What is the diagnosis in patients with a central MR jet origin with normal valve structure but restricted mobility and LV dilation?
functional (secondary) MR
88
What associated conditions should be documented in Echo evaluation of MR?
* Pulmonary Hypertension * TR * LA dilation * LV dilation * LV systolic dysfunction \*\*\*Class I recommendation
89
What is the most common technique for quantitating MR severity?
Doppler Echocardiography
90
What congenital anomaloy is associated with unicuspid aortic valve?
hypoplastic left heart syndrome
91
unicuspid aortic valve
92
Most common cause of AS in developed countries
Degenerative calcific aortic stenosis
93
What is the normal LA volume for men/women? Mildly abnormal? Moderately abnormal? Severely abnormal ?
* Normal: 22 mL/m2 +/- 6 * Mild: 29-33 mL/m2 * Moderate: 34-39 mL/m2 * Severe: \> 40 mL/m2
94
What are the Class I indications for MV surgery in Severe, Asymptomatic (stage C) MR?
LVEF 30% - ≤ 60% or LVESD ≥ 40 mm \*\*Stage C2
95
What are the next steps/paramters to evaluate in a patient with Primary, Severe, Asymptomatic (Stage C) MR?
* Stage C2 --\> MV surgery (class I) * LVEF 30% - ≤ 60% or LVESD ≥ 40 mm * Stage C1 (repair vs. surgery vs. monitoring) * LVEF \> 60% and LVESD \< 40 mm * Stage C1 (repair vs. monitoring) * New-onset AF or PASP \> 50 mmHg
96
What are the next steps/paramters to evaluate in a patient with Primary, Severe, Asymptomatic (Stage C1) MR with LVEF \> 60% and LVESD \< 40 mm?
* Progressive increase in LVESD or Decrease in EF * MV surgery (IIa) * Likelihood of successful repair \> 95% and expected mortality \< 1% * Yes --\> MV repair (IIa) * No --\> Periodic monitoring
97
What is the net effect of an IABP?
* increase in mean arterial pressure (MAP) * augmented ventricular stroke volume
98
* Prolapse of the posterior mitral valve leaflet on TEE * TEE 3D reconstruction of the MV; viewed through the left atrium (surgeon's view) * Barlow's disease with prolapsed segment along lateral scallop of the posterior leaflet * MV repair * BD-resection of redundant tissue and insertion of a mitral ring
99
Prolapse of posterior MV leaflet with severe MR
100
Perforated anterior mitral valve leaflet
101
Anterior mitral valve leaflet prolapse
102
What specific defect leads to MR in rheumatic mitral disease?
* shortening of the posterior mitral leaflet * restricted motion of the anterior mitral leaflet * usually producing a centrally or posteriorly directed jet
103
isolated cleft of anterior mitral valve leaflet on 3d TEE
104
Isolated cleft of anterior MV leaflet on TTE, parasternal short axis
105
What are causes of secondary/functional MR?
* Dilated LV * dilated MV annulus and poor coaptation * Segmental wall-motion abnormality with tethering of a leaflet and ecreased coaptation (usually ischemic in origin) * Ruptured papillary muscle * Systolic anterior motion (SAM) of valvular apparatus
106
Describe the mechanism for functiona/secondary MR
107
What quantitative measures are more accurate in secondary/functional MR?
* EROA * RF * RV - not as accurate, underestimates severity
108
Acute MR with rupture of posteromedial papillary muscle TEE - mid-esophageal 2-chamber view
109
What patients are at increased risk to develop post-MI acute MR?
* Single blood supply to a papillary muscle (more commonly the posteromedial papillary muscle) * Require urgent surgical intervention
110
Describe anatomy of mitral valve
111
What scallops are visible?
112
Describe scallop anatomy
113
What is the next step after identifying dynamic LVOT obstruction + severe MR intraoperatively?
Reassess intraoperatively after coming off of cardiac bypass
114
Describe ischemic MR
* associated with a posterior regurgitant jet * posterior leaflet tethering * anterior leaflet override
115
What EROA in ischemic MR is associated with a poor prognosis?
EROA \> 0.20 cm2
116
What is the current recommendation for mitral valve correction in IMR?
moderate or greater MR --\> should be corrected at time of surgery
117
What are medications that can be used to decrease the effects of LVOT obstruction with SAM and MR? What effects of these medications make them effective?
* BB * Verapamil * Disopyramide * negative chronotropic and inotropic agents
118
What is the surgical management for LVOT/SAM/MR?
septal reduction therapy
119
What medications and/or actions will make LVOTO/SAM/MR worse?
* Afterload reduction (Lisinopril) * Valsalva maneuver
120
What is the diagnosis?
flail P2 scallop with severe MR
121
What LVEF likley reflects LV dysfunction in patients with severe MR?
LVEF \< 60% * indication for surgical intervention
122
When is restriction from competitive sports recommended in patients with MVP?
* moderate LV enlargement * LV dysfunction * uncontrolled tachyarrhythmias * unexplained syncope * aortic root enlargement \*\*\*\*Regular exercise is recommended
123
Which leaflet has a higher success rate for repair in MVP?
posterior \>\> anterior
124
What is the likelihood of repair for posterior MVP? Expected mortality with surgical intervention?
* \> 90% * \< 1%
125
Describe the image
* Repaired mitral valve * Edge-to-edge (Alifieri) repair of the mitral valve * anterior and posterior leaflets are sutured together in the mid portion, giving the typical appearance of a double-orifice mitral valve
126
This is a common finding after septal myectomy for SAM/MR
* corrected by surgical intervention on the LVOT * residual MR * **color jet on septal wall represents flow from a coronary-LV fistula** * common benign finding after septal myectomy procedures
127
What is the success rate of mitral valve repair in experienced centers?
\> 90% at 10 years
128
What is one complication that may ocur following myectomy for SAM/MR?
residual MR --\> necessitating mitral valve procedure
129
What is one potential complication of an edge-to-edge MV repair (Alifieri stitch) postmyectomy?
double orifice mitral valve --\> relative mitral stenosis
130
Describe an MR murmur
* laterally displaced * apical impulse * 4/6 holosystolic * increases during inspiration
131
What is the severity scale for EROA in MR?
* Mild \< 0.2 cm2 * Moderate * Grade II - 0.2-0.29 cm2 * Grade III - 0.30-0.39 cm2 * Severe \> 0.40 cm2
132
What is the severity scale for Regurgitant Volume (RVol) in MR?
* Mild \< 30 mL * Moderate * Grade II - 30-44 mL * Grade III - 45-59 mL * Severe \> 60 mL * \*\*\*\*for severe MR may be lower in low flow conditions
133
What is the severity scale for Regurgitant Fraction (RF) in MR?
* Mild \< 30% * Moderate * Grade II - 30-39% * Grade III - 40-49% * Severe \> 50%
134
What are the specific criteria for mild MR diagnosis?
* Small, narrow central jet * VC \< 0.30 cm * PISA radius absent or \< 0.30 cm (at Nyquist 30-40 cm/s) * Mitral A wave dominant inflow * Soft or incomplete jet by CW doppler * Normal LV and LA size \*\*\*\*2-3 criteria --\> perform quantitative methods (EROA, RV, RF)
135
What are the specific criteria for severe MR diagnosis?
* Flail leaflet * VC \< 0.70 cm or VCA \> 0.50 cm2 * PISA radius absent or \> 1.0 cm (at Nyquist 30-40 cm/s) * Central large jet \> 50% of LA area * Pulmonary vein systolic flow reversal * Enlarged LV with normal function \*\*\*\*2-3 criteria --\> perform quantitative methods (EROA, RV, RF)

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