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Flashcards in MS/MR/MVP Deck (41):
1

What is the most common cause of mitral stenosis?

Rheumatic fever

2

What is the diagnostic criteria for Rheumatic fever (Jones Criteria)? **** EXAM

JONES PEACE
S. pyogenes + swab or inc antistreptolysin O titre

major:
J - joints (polyarthritis)
O - onset murmur (carditis)
N - nodules (subQ)
E - erythema marginatum
S - Sinead chorea

minor:
P - PR interval
E - ESR or CRP
A - Arthralgia
C - CRP or ESR
E - elevated temp

3

What is the pathology of mitral stenosis?

thickening & calcification of leaflets
fusion of commissures
thickening & shortening of chordae tendinae

4

What is the normal MV area? When is there significant stenosis?

4-6 cm ^2
< 2 cm ^2

5

What is the pathophysiology of Mitral stenosis?

abnormal pressure gradient between LA and LV
LA pressure is higher than normal - required for blood to be propelled across obstructed valve
dec SV & dec CO
LA enlargement --> AF (dec CO)
inc pulmonary venous pressure --> right sided heart failure

6

What are sx of mild MS?

SOBOE
dec exercise capacity

7

What are sx of severe MS?

pulmonary congestion at rest
orthopnea & PND
voice hoarseness
RSHF --> hepatomegaly, ascites, peripheral edema
AF --> palpitations

8

What are the physical exam findings of mild and severe MS and the physiology behind each?

mild MS = loud S1
severe MS = quiet S1 (leaflets less mobile)

mild MS = opening snap - when MV opens - after S2 - as stenosis worsens in severity, left atrial pressure increase so pLA > pLV (MV opening) occurs sooner, OS occurs closer to S2
very severe MS = no OS (valve barely opens)

murmur:
- diastolic rumble - turbulent flow across stenotic mitral valve in diastole
- decrescendo - loudest when flood first pushes against stenotic valve & opens it
- pre-systolic accentuation - atrial contract right before S1, inc pressure gradient
- severe MS = longer murmur - pressure in LA is higher - takes longer for LA to empty and for pressure gradient to dissipate

other:
- tachycardia - red CO compensation
- irregular rhythm - AF
severe MS =dec pulse volume (dec CO) and RV heave (RVH)

9

What might you see on EKG in a pt with MS?

LA enlargement +/- RVH, AF

10

What might you see on CXR in pts with MS?

LA enlargement, NO CARDIOMEGALY, pulmonary vascular distribution/edema, Kerley B lines

11

What are complications of MS?

AF
pulmonary htn & hemoptysis
thrombus formation in LA, stroke
endocarditis

12

What is Rx for Rheumatic fever?

acute: anti-inflammatory, penicillin
low dose penicillin prophylaxis until early adulthood

13

What are medical Rx MS?

diuretics
digoxin, BB, non-dihydropyridine CCB
anticoagulation with warfarin (if AF or Hx of thrombus formation in LA)

14

What are surgical options for MS?

percutaneous valvuloplasty (best if no MR/extensive calcifications/clots)
mitral valve replacement
mitral commisurotomy

15

What are the possible causes of mitral regurgitation?

annulus - MAC, dilation
leaflets - prolapse, Rheumatic, endocarditis, SAM
chordae - rupture
papillary muscle - rupture, dysfunction
LV - cavitary dilation (ischemic CM, functional DCM)

16

What is the most common cause of MR?

mitral prolapse

17

What is the pathophysiology of MR?

Co reduced bc part of it is going back into LA
volume related stress on LV - SV inc through Frank-Starling mechanism
LV becomes increasingly dilated and less functional

18

What factors affect the severity of MR and the ratio of forward to backward flow?

size of the regurgitant hole
pressure difference between LA and LV (as LA pressure starts to increase, regurg. decreases)
systemic vascular resistance (afterload) - more afterload = more likely regurg.
compliance of the LA
duration of regurgitation with each systole

19

What factors make MR worse?

inc preload (more volume in heart), inc afterload

20

What factors make MR better?

dec preload (less volume), dec afterload

21

What are sx of acute MR?

pulmonary edema (dyspnea, orthopnea, PND)

22

WHat is the physiology of chronic MR?

LA dilates slowly over time and becomes more compliant - LV dilates and high SV maintained - eventual LV failure
dilated LA with normal pressure

23

What are sx of chronic MR?

sx of low CO
fatigue, weakness, SOBOE
once pts 'decompensate' - orthopnea, PND, sx of RSHF (eg edema)

24

What are physical exam findings in MR?

pansystolic murmur at the apex radiating to the axilla
S1 may be soft
S3
displaced apex (chronic)
signs of RSHF if acute or decompensated chronic (elevated JVP,peripheral edema, hepatomegaly)

25

What is seen on CXR with acute MR? chronic MR?

acute: pulmonary edema
chronic: LA/LV enlargement

26

What is seen on EKG with acute MR? chronic MR?

acute: ischemic changes if MR secondary to ischemic papillary muscle rupture
chronic: LA enlargement, LVH

27

What are the differences seen on Echo in MS vs MR?

MS - in diastole, a lot of turbulence
MR - in systole, see some blood go in reverse; dont see turbulence in diastole

28

What is the prognosis of acute MR?

acute - can be deadly within hours - can decomp very quickly

29

What is criteria for surgery in chronic MR?

sx, LV dilatation (LV function starts to drop), reduction in EF, new-onset AF/pulmonary Htn, whether or not valve is repairable, red exercise capacity

30

Is endocarditis prophylaxis indicated for MS, MR or MVP?

No

31

What conditions are associated with mitral valve prolapse (MVP)?

Marfan's, Ehler's, Danlos (CT disorders)

32

What is the prevalence of MVP? More common in women or men?

2%
women > men

33

What is the pathology of MVP?

excessive valve tissue makes the valve "floppy" and prone to chordal rupture and/or prolapse

34

What is the clinical presentation of MVP?

asx
little or no MR
mid systolic click followed by murmur (if MR present)

35

What is the prognosis of MVP?

usually benign

36

How can MVP be treated?

resect failed cord, sew edges, put a ring around it
surgical

37

What is the physiology behind a persistently split wide S2 in severe MR?

A2 closes when pAo > pLV
pLV decreases faster b/c blod enters LA as well as Ao so pAo > pLV occurs earlier and causes persistently split wide S2

38

What is the physiology behind S3 in MR?

large volume flow from LA to LV in early diastole causes S3 (in this cause it is not an indication of LV failure)

39

What would cause a left parasternal impulse in MR?

LA expansion

40

What are surgical options in MVP?

mitral valve repair
mitral valve replacement with or without chordal preservation

41

What kind of arterial pulse would you expect in chronic MR?

In chronic mitral regurgitation (MR), the arterial pulse may be reduced in volume, but is usually brisk in upstroke, reflecting the increased left ventricular ejection rate and normal ejection fraction. Since there is a rapid reduction in the volume of forward flow late in systole and therefore a decrease in ejection time, the arterial pulse falls off rapidly, giving the impression of a bounding pulse, similar to that seen with aortic regurgitation.