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Valvular Heart Disease Flashcards

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1
Q

What are combined valve disorders?

A

Valve lesions that occur together, either in a single valve (e.g., MS/MR) or across multiple valves (e.g., AS/MR)

If therapy is problematic for multiple valve lesions, consider the patient as having a predominantly single lesion.

-correct the primary valve dysfunction!!

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2
Q

What is the anatomy of the mitral valve?

A

The mitral valve (MV) is a bicuspid valve with an anteromedial A leaflet and a posterolateral P leaflet, each divided into sections: A1, A2, A3 and P1, P2, P3

The MV is attached to a fibrous ring called the MV annulus.

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3
Q

What defines the commissures of the mitral valve?

A

The areas where the anterior and posterior leaflets come together

These are critical for the valve’s function and integrity.

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4
Q

What are scallops in relation to the mitral valve?

A

Multiple bumps and indentations on the posterior leaflet of the mitral valve that do NOT correlate with leaflet segments

The anterior leaflet is smooth.

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5
Q

What happens to the coaptation depth with annular dilation?

A

Line of coaptation-where the leaflets meet (U shaped and overlapping)

The coaptation depth decreases, but initially, there is still adequate overlap to prevent regurgitation.

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6
Q

What are chordae tendinae?

A

Inelastic tendons that anchor the mitral valve leaflets to the papillary muscles in the left ventricle

They play a crucial role in maintaining valve function.

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7
Q

What causes mitral stenosis?

A

Etiologies include rheumatic fever, mitral valve repair or replacement, calcification, vegetations, and prosthetic valve dysfunction.

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8
Q

What is the normal mitral valve area (MVA)?

A

Normal MVA is 4-6 cm².

<2cm^2 is MS

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9
Q

Describe MS murmur

A

characteristic decrescendo diastolic rumble after S2 and an opening snap (OS).

Louder immediately prior to S1 corresponding to atrial contraction if in SR

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10
Q

What are the consequences of elevated left atrial pressure (LAP) in mitral stenosis?

A

Pulmonary hypertension, right heart failure, left atrial enlargement (LAE), and thromboembolic disease.

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11
Q

What is the first symptom of mitral stenosis?

A

Dyspnea on exertion (DOE) due to pulmonary venous hypertension.

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12
Q

What is the role of echocardiography in mitral stenosis?

A

● Valve morphology and motion
● LA size and MVA
● LA clot and stasis
● Concurrent VHD (associated MR, other VHD)

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13
Q

What is the treatment for mitral stenosis?

A

Medical therapy (diuretics, anticoagulation),

percutaneous balloon mitral valvuloplasty,

surgical options like commissurotomy or mitral valve replacement.

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14
Q

What defines acute mitral regurgitation?

A

Most causes are primary, such as leaflet injury, chordae rupture, or papillary muscle rupture.

Primary-structural
Secondary-secondary to LV enlargement (dilation of annulus)

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15
Q

What is the pathophysiology of chronic mitral regurgitation?

A

Volume overload of the left ventricle, leading to LV remodeling and eccentric hypertrophy.

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16
Q

What is the regurgitant fraction in mitral regurgitation?

A

Volume of MR divided by stroke volume, used to measure MR severity.

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17
Q

What are the determinants of mitral regurgitation severity?

A
  • Mitral valve orifice size during regurgitation
  • Systemic vascular resistance (SVR)
  • Left atrial compliance
  • Duration of systole
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18
Q

What happens to pulmonary artery (PA) pressures in mitral regurgitation?

A

Active rise in PA pressures due to the regurgitant pressure jet

Passive rise due to high left atrial pressures.

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19
Q

What are the echocardiographic findings in mitral stenosis?

A

Thickened leaflets, commissural fusion, restricted separation during diastole, and assessment of mitral valve area.

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20
Q

What is the regurgitant fraction in the context of mitral regurgitation?

A

The regurgitant fraction refers to the volume of blood returning from the left atrium (LA) in a nonfailing heart.

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21
Q

What happens to left ventricular end-systolic volume (LVESV) in mitral regurgitation?

A

LVESV decreases due to greater systolic emptying from both the aortic (Ao) and left atrial (LA) circuits.

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22
Q

What is the hemodynamic profile of acute mitral regurgitation?

A

In acute mitral regurgitation, contractility does not change.

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23
Q

What does the ESPV line represent in the context of mitral regurgitation?

A

The ESPV line connects end-systolic pressures (ESPs) generated at end systole for different preloads; its slope represents contractility.

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24
Q

What are the characteristics of chronic mitral regurgitation?

A

Chronic mitral regurgitation is characterized by remodeling of the left atrium (LA) and left ventricle (LV), leading to dilation and eccentric hypertrophy.

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25
What are the consequences of chronic decompensated mitral regurgitation?
It results in both systolic and diastolic dysfunction, lower cardiac output (CO), higher left ventricular end-systolic volume (LVESV), and higher left ventricular end-diastolic volume (LVEDV).
26
What symptoms are associated with acute and chronic mitral regurgitation?
* Acute MR: pulmonary edema * Chronic MR: fatigue, decreased exercise tolerance
27
What is the natural history of acute mitral regurgitation?
Acute mitral regurgitation has a 25% 30-day mortality rate, and therapy is typically surgical.
28
What are the indications for mitral valve surgery?
* Symptoms * Fall in ejection fraction < 60% * Development of atrial fibrillation (AF) or pulmonary hypertension * Increasing left ventricular end-systolic volume (LVESV)
29
What is mitral valve prolapse (MVP)?
MVP is usually due to a connective tissue disorder causing elongation of the chordae tendineae, leading to prolapse of the valve leaflets into the LA during ventricular systole.
30
What is the role of color Doppler imaging in assessing mitral regurgitation?
Color Doppler imaging quantifies the severity of mitral regurgitation by assessing the: regurgitant jet area, vena contracta width, and effective regurgitant orifice area (EROA).
31
What are the anatomical components of the aortic root?
* Sinotubular junction * Sinuses of Valsalva * Annulus * Subaortic segment * Semilunar valve leaflets (cusps)
32
What is the most common cause of aortic stenosis in patients under 70 years old?
Calcification of a congenital bicuspid aortic valve.
33
What are the symptoms and survival timeline for aortic stenosis?
* Angina: 5 years * Syncope: 3-4 years * Congestive heart failure (CHF): 1-2 years
34
What characterizes the arterial waveform in aortic stenosis?
Parvus et tardus: low amplitude with a delayed peak and a prominent anacrotic notch.
35
How is the severity of aortic stenosis assessed?
* Aortic valve area (AVA) * Peak transvalvular velocity * Mean or peak transvalvular pressure gradient
36
What is the Gorlin formula used for?
The Gorlin formula is used to estimate aortic valve area based on the mean systolic pressure gradient.
37
What are the etiologies of aortic regurgitation?
* Leaflet issues (calcification, endocarditis, RHD) * Root dilation (degenerative dilation, aneurysm, dissection)
38
What is the pathophysiology of aortic regurgitation?
Aortic regurgitation causes diastolic volume overload of the left ventricle (LV).
39
What are the hemodynamic characteristics of aortic regurgitation?
* Widened pulse pressure * Increased stroke volume (SV) * Decreased diastolic blood pressure (DBP)
40
What are the differences between acute and chronic aortic regurgitation?
* Acute: LV size normal and noncompliant, causing acute pulmonary edema * Chronic: LV dilated and compliant, leading to fatigue Both with increased LVEDV, more markedly in chronic
41
What is the significance of the vena contracta in assessing aortic regurgitation severity? TEE
The width of the vena contracta helps categorize severity: mild (<3.0 cm), moderate (3.0-5.9 cm), severe (>6.0 cm).
42
What is a major presentation of chronic aortic insufficiency (AI)?
Fatigue ## Footnote Chronic aortic insufficiency often presents with fatigue as a significant symptom.
43
What factors determine the severity of aortic insufficiency?
Area of regurgitant orifice, DBP, duration of diastole ## Footnote These factors are critical in assessing how severe the aortic insufficiency is.
44
What are the hemodynamic characteristics of aortic insufficiency?
Widened pulse pressure, decreased CPP, increased MVO2 ## Footnote Widened pulse pressure is due to elevated SBP from increased stroke volume and lower DBP from regurgitant flow.
45
What does a widened pulse pressure indicate in aortic insufficiency?
Elevated SBP due to increased SV and lower DBP from regurgitant flow ## Footnote This phenomenon occurs as a result of the hemodynamic changes in AI.
46
What is characterized by decreased DBP and increased LVEDP in AI?
Decreased CPP ## Footnote Coronary perfusion pressure (CPP) is affected by the changes in diastolic blood pressure (DBP) and left ventricular end-diastolic pressure (LVEDP).
47
What is increased in the left ventricle due to aortic insufficiency?
MVO2 from dilated LV ## Footnote Increased myocardial oxygen consumption (MVO2) is a result of increased wall tension in the dilated left ventricle.
48
In the PV loop of acute aortic insufficiency, what happens to LVEDV?
Increased LVEDV leads to increased SV ## Footnote This reflects the acute changes in left ventricular dynamics.
49
What is absent in the PV loop during acute aortic insufficiency?
Isovolumetric relaxation or contraction ## Footnote This absence indicates significant changes in the normal cardiac cycle due to AI.
50
What are the characteristics of the PV loop in chronic aortic insufficiency?
Marked increase in LVEDV and increased LVESV ## Footnote This reflects the chronic changes and adaptations of the left ventricle.
51
What imaging techniques are useful to determine the etiology of aortic insufficiency?
TTE and TEE ## Footnote Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are essential for evaluating AI and associated valvular heart disease.
52
What parameters are assessed in TTE/TEE for aortic insufficiency severity?
Width and cross-sectional area of vena contracta ## Footnote These measurements help determine the severity of the aortic insufficiency.
53
Trigones
Fibrous structural support for the valves
54
Chordae tendinae attachment (subvalvular apparatus)
-Primary chords attach to free edges ● Secondary (“strut”) chords attach to body of leaflets ● Tertiary chords attach to ventricular wall
55
Describe closure of the mitral valve
Closure – V Systole ● Passive due to LV contraction pressure ● Active due to papillary muscle contraction [prevent prolapse]
56
Describe opening of the mitral valve
Opening – V Diastole ● Passive due to rise in LA pressure > LV pressure ● Active: end-diastole (LA contraction) – MV pushed open again
57
Passive Vs reactive pulmonary HTN in MS
● Passive Pulmonary Hypertension (100%): backward transmission of LAP necessitates rise in PAP to preserve forward flow ● Reactive Pulmonary Hypertension (40%) due to medial hypertrophy and intimal fibrosis of pulmonary arterioles
58
Consequences of LAE
AF- stretching of cardiac conduction system Thromboembolic disease
59
Severity parameters in MS
● MVA < 1.5 cm2 = severe ● MVA < 1.0 cm2 = very severe
60
Most common cause of chronic MR
CM with LV enlargement (enlargement of annulus)
61
Hemodynamic profile changes in MR- pressure volume loop
No isovolumetric contraction No isovolumetric relaxation Decreased LVESV
62
Clinical presentation of acute vs chronic MR
Acute- pulmonary edema Chronic- fatigue, decreased exercise tolerance
63
Concentric hypertrophy vs eccentric
Concentric- thickening Eccentric- dilation
64
Differentiating between Aortic murmur and carotids
Carotid would be unilateral (most likely) Aortic would radiate to both
65
Normal/mild and moderate AS by AVA measurement
2.5-3.5 Mild: 1.5-2.5 Moderate: 1-1.5 Severe: 0.7-1
66
What is AS?
condition resulting from systolic pressure overload of the LV with elevated LV pressures and development of concentric LVH with associated diastolic dysfunction. Symptoms are often precipitated by AF that results in decreased LV filling.
67
How does AI promote myocardial ischemia?
● Results in decreased LV CPP = DBP – LVEDP ● Lower DBP and elevated LVEDP ● LV dilation (increasing wall stress and myocardial oxygen consumption)
68
Heart rate control in Regurgitant vs stenosis lesions
Regurgitation- increase HR Stenosis- decrease HR
69
Coaptation
Leaflets coming together
70
Closest artery to the mitral valve
Left circumflex
71
Why is rheumatic heart disease bad?
Caused by strep- antibody reaction attacks valves
72
Mitral stenosis is a disease of?
The left atria
73
Most common cause of acute MR
Endocarditis
74
Most common cause of chronic MR
Annular dilation

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