Flashcards in MS/MR/MVP Deck (41):
What is the most common cause of mitral stenosis?
What is the diagnostic criteria for Rheumatic fever (Jones Criteria)? **** EXAM
S. pyogenes + swab or inc antistreptolysin O titre
J - joints (polyarthritis)
O - onset murmur (carditis)
N - nodules (subQ)
E - erythema marginatum
S - Sinead chorea
P - PR interval
E - ESR or CRP
A - Arthralgia
C - CRP or ESR
E - elevated temp
What is the pathology of mitral stenosis?
thickening & calcification of leaflets
fusion of commissures
thickening & shortening of chordae tendinae
What is the normal MV area? When is there significant stenosis?
4-6 cm ^2
< 2 cm ^2
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
What are sx of mild MS?
dec exercise capacity
What are sx of severe MS?
pulmonary congestion at rest
orthopnea & PND
RSHF --> hepatomegaly, ascites, peripheral edema
AF --> palpitations
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)
- 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
- tachycardia - red CO compensation
- irregular rhythm - AF
severe MS =dec pulse volume (dec CO) and RV heave (RVH)
What might you see on EKG in a pt with MS?
LA enlargement +/- RVH, AF
What might you see on CXR in pts with MS?
LA enlargement, NO CARDIOMEGALY, pulmonary vascular distribution/edema, Kerley B lines
What are complications of MS?
pulmonary htn & hemoptysis
thrombus formation in LA, stroke
What is Rx for Rheumatic fever?
acute: anti-inflammatory, penicillin
low dose penicillin prophylaxis until early adulthood
What are medical Rx MS?
digoxin, BB, non-dihydropyridine CCB
anticoagulation with warfarin (if AF or Hx of thrombus formation in LA)
What are surgical options for MS?
percutaneous valvuloplasty (best if no MR/extensive calcifications/clots)
mitral valve replacement
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)
What is the most common cause of MR?
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
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
What factors make MR worse?
inc preload (more volume in heart), inc afterload
What factors make MR better?
dec preload (less volume), dec afterload
What are sx of acute MR?
pulmonary edema (dyspnea, orthopnea, PND)
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
What are sx of chronic MR?
sx of low CO
fatigue, weakness, SOBOE
once pts 'decompensate' - orthopnea, PND, sx of RSHF (eg edema)
What are physical exam findings in MR?
pansystolic murmur at the apex radiating to the axilla
S1 may be soft
displaced apex (chronic)
signs of RSHF if acute or decompensated chronic (elevated JVP,peripheral edema, hepatomegaly)
What is seen on CXR with acute MR? chronic MR?
acute: pulmonary edema
chronic: LA/LV enlargement
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
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
What is the prognosis of acute MR?
acute - can be deadly within hours - can decomp very quickly
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
Is endocarditis prophylaxis indicated for MS, MR or MVP?
What conditions are associated with mitral valve prolapse (MVP)?
Marfan's, Ehler's, Danlos (CT disorders)
What is the prevalence of MVP? More common in women or men?
women > men
What is the pathology of MVP?
excessive valve tissue makes the valve "floppy" and prone to chordal rupture and/or prolapse
What is the clinical presentation of MVP?
little or no MR
mid systolic click followed by murmur (if MR present)
What is the prognosis of MVP?
How can MVP be treated?
resect failed cord, sew edges, put a ring around it
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
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)
What would cause a left parasternal impulse in MR?
What are surgical options in MVP?
mitral valve repair
mitral valve replacement with or without chordal preservation