The Basics

Question 1

What are the components of the MV complex?

Answer 1

1. Annulus
2. Leaflets
3. Chords
4. Papillary muscles

Question 2

Definition of primary MR?

Answer 2

• Structural alteration of ≥1 component of the MV complex or apparatus
• Also known as valvular/organic/degenerative MR

Question 3

Possible causes of primary MR?

Answer 3

1. Degeneration
2. Inflammation
3. Infection
4. Trauma
5. Congenital

Question 4

Definition of secondary/functional MR?

Answer 4

• Structurally normal MV with insufficient coaptation due to chamber remodeling
• Also known as atrial/ventricular MR

Question 5

Possible causes of secondary/functional MR?

Answer 5

1. CAD
2. Dilated CM
3. Restrictive CM
4. HOCM
5. AF

Question 6

Carpentier Classification: Definition and example of Type I MR?

Answer 6

Normal leaflet motion

Eg. annular dilatation

Question 7

Carpentier Classification: Definition and example of Type II MR?

Answer 7

Excessive leaflet motion

Eg. mitral valve prolapse

Question 8

Carpentier Classification: Definition and example of Type IIIa MR?

Answer 8

Restricted leaflet motion in systole and diastole

Eg. Rheumatic

Question 9

Carpentier Classification: Definition and example of Type IIIb MR?

Answer 9

Restricted leaflet motion in systole only

Eg. ischaemic

Question 10

Carpentier Classification: Definition and example of Type IV MR?

Answer 10

Systolic anterior motion (SAM)

Eg. HOCM

Question 11

Carpentier Classification: Definition and example of Type V MR?

Answer 11

Hybrid (> 1 pathology)

Eg. rheumatic MV + perforation

Question 12

Perforated leaflet:

Carpentier Classification? Primary or secondary MR?

Answer 12

• Type I: normal leaflet motion

- Primary MR: MR due to valve problem - perforated due to IE

Question 13

Cleft leaflet:

Carpentier Classification? Primary or secondary MR?

Answer 13

• Type I: normal leaflet motion

- Primary MR: MR due to valve

Question 14

MVP (Barlow’s disease, FED, MAD)

Carpentier Classification? Primary or secondary MR?

Answer 14

• Type II: excessive leaflet motion

- Primary MR: MR due to valve

Question 15

Rheumatic MVD:

Carpentier Classification? Primary or secondary MR?

Answer 15

• Type IIIa: restricted leaflet motion in systole and diastole
• Primary MR: MR due to valve

Question 16

Annular calcification:

Carpentier Classification? Primary or secondary MR?

Answer 16

• Type IIIa: restricted leaflet motion in systole and diastole
• Primary MR: MR due to valve

Question 17

Radiation heart disease:

Carpentier Classification? Primary or secondary MR?

Answer 17

• Type IIIa: restricted leaflet motion in systole and diastole
• Primary MR: MR due to valve

Question 18

Dilated (non-ischaemic) CM:

Carpentier Classification? Primary or secondary MR?

Answer 18

• Type I: normal leaflet motion

- Secondary MR: MR due to annular dilatation

Question 19

AF (isolated LA dilatation):

Carpentier Classification? Primary or secondary MR?

Answer 19

• Type I: normal leaflet motion

- Secondary MR: MR due to annular dilatation

Question 20

Ischaemic Heart Disease:

Carpentier Classification? Primary or secondary MR?

Answer 20

• Type IIIb: restricted leaflet motion in systole only

- Secondary MR: abnormal leaflet motion - systolic restriction due to leaflet tethering

Question 21

Ischaemic CM:

Carpentier Classification? Primary or secondary MR?

Answer 21

• Type IIIb: restricted leaflet motion in systole only

- Secondary MR: abnormal leaflet motion as a result of ischaemic CM

Question 22

Normal MV closing forces?

Answer 22

1. LV contraction
2. Basal rotation
3. Annular contraction

Question 23

Normal tethering forces?

Answer 23

1. Passive annular constraint

2. Tethering

Question 24

Closing and Tethering Forces in Secondary MR: Global LV Dilatation

Answer 24

1. Increased tethering/tenting
2. Impaired closing
3. Annular dilatation
4. Reduced basal rotation
   Note: symmetric tethering = central MR jet

Question 25

Closing and Tethering Forces in Secondary MR: Inferior regional dysfunction

Answer 25

1. Increased tethering/tenting 2. Impaired closing 3. Annular dilatation Note: asymmetric tethering = eccentric MR jet

Question 26

Pathophysiology of Primary MR: Phases?

Answer 26

1. Acute Phase 2. Chronic Compensated Phase 3. Chronic Decompensated Phase

Question 27

Pathophysiology of Acute Phase of Primary MR?

Answer 27

1. LA and LV size is normal 2. Acute MR occurs due to sudden rupture of chords or papillary muscle 3. Sudden LA volume overload => ↑↑ in LAP => pulmonary venous congestion and acute pulmonary oedema (APO) 4. LV volume overload => ↑ LVEDP and ↓ LVESP (due to reduced afterload) allows LV to eject more completely => ↑ LVEF and ↑ total SV 5. However, significant portion of total SV regurgitates into LA therefore ↓ forward SV (and CO)

Question 28

Pathophysiology of Chronic Compensated Phase of Primary MR?

Answer 28

1. ↑ LA and LV size 2. Severity of MR increases slowly 3. LA more compliant so LAP only slightly ↑ 4. LV develops eccentric hypertrophy or remodeling to better manage larger SV => ↑↑ LVEDV and LVESV near normal => ↑ LVEF and ↑↑ in total SV 5. ↑↑ in total SV means forward SV is now near normal

Question 29

Pathophysiology of Chronic Decompensated Phase of Primary MR?

Answer 29

1. ↑↑ LA and LV size 2. LV systolic dysfunction due to prolonged LV volume overload (which causes muscle damage and therefore reduces contractile function) 3. ↑↑ LVEDV still but weakened LV can no longer shorten adequately and LVESV ↑ 4. = ↓ LVEF and ↓ total and forward SVs 5. ↑↑ LAP => pulmonary congestion, acute pulmonary oedema (APO) and PHTN

Question 30

Indicators of LV dysfunction in severe MR?

Answer 30

1. Increased LVESD ≥ 40mm | 2. LVEF ≤ 60% = impaired

Question 31

Management of MR?

Answer 31

- Stages - Diagnosis - Medical therapy - Interventions

Question 32

What are the MR management stages based on?

Answer 32

1. Valve anatomy 2. Valve haemodynamics 3. Haemodynamic consequences (primary, organic MR) 4. Associated cardiac findings (secondary, functional MR) 5. Symptoms