Wk 2 Quiz 2 Valvular Disease Flag Questions Flashcards by Yoshiko Peterson

Murmur Intensity

Grade I

barely audible

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Murmur Intensity

Grade II

faintly heard

louder

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Murmur Intensity

Grade III

moderately loud but not accompanied by thrill

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Murmur Intensity

Grade IV

loud and can be heard on either side of the chest.

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Murmur Intensity

Grade V

very loud ( can be heard with a stethoscope)

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Murmur Intensity

Grade VI

loud with a thrill

like grade V murmurs, are very loud and can be felt through the chest wall, and are the most severe of the heart murmurs

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Crescendo-decrescendo murmur

murmur-begins softly, become louder,
and then decreases in intensity

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***Systolic murmur, heard best at apex, radiates to L axilla

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Diastolic murmur
usually heard at apex but faint
Decrescendo, low rumbling murmur

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Heard is 2nd to 4th left interspaces

Blowing decrescendo murmur may be mistaken for breath sounds

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R second intercostal
Harsh crescendo, decrescendo murmur
Radiates to the carotids, down the left sternal border, even to the apex

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Causes of Early systolic murmurs:

Small VSD
Large VSD with Pulmonary HTN
Severe acute or tricuspid regurgitation

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Causes of Systolic ejection murmurs:

AS/PS

Increased rate of ejection (heart block, fever, anemia, exercise, thyrotoxicosis, and sometimes heard in normal individuals)

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***Causes of Pansystolic (holosystolic) murmurs:

MR or TR
VSDs
Aortopulmonary shunts

*holosystolic/pansystolic: lasting throughout the systole of a heartbeat

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Causes of Early diastolic murmurs:

AR/PR

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***produced by the forward flow of blood through the atrioventricular valves (mid-diastolic and late-diastolic murmurs)

LA myxoma

large L to R shunt

MR (increased flow)

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***The most frequent complication of myxomatous valvular disease is the ________

mitral valve prolapse (MVP)

*note:

Common risk factors in the development of Myxomatous degeneration are Connective tissue disorders like Marfan’s Syndrome, Ehlers-Danlos syndrome, and other conditions with collagen abnormalities

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Which valve is affected in Marfan syndrome?

Cardiac manifestations of Marfan syndrome include aortic root dilation and mitral valve prolapse (MVP)

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What heart condition is associated with Turner’s syndrome?

The risk of congenital heart defects such as bicuspid aortic valves, aortic coarctation, other valve abnormalities, and septal defect is increased.

Turner syndrome, a condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing. Turner syndrome can cause a variety of medical and developmental problems, including short height, failure of the ovaries to develop and heart defects.

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Causes of continuous murmurs: result from blood flow constantly moving from a high-
pressure area to a low-pressure area.

PDA
Systemic arteriovenous fistula
Coronary artery from the pulmonary artery
Communications between the sinus of Valsalva and the right side of the heart

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Valsalva Maneuvers: Most murmurs _____ during the strain
phase of the Valsalva maneuver except _________ and _____

decrease

hypertrophic obstructive cardiomyopathy

mitral valve prolapse

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Isometric Handgrip: Sustained isometric handgrip increases
peripheral resistance, blood pressure, heart rate and cardiac
output.

The handgrip ______ the left heart murmurs of ___
___, ____.

The murmurs of ___ & ____ and
__________ will be reduced with sustained
isometric handgrip.

increases

MR/AR/VSD

AS/PS

hypertrophic cardiomyopathy

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Amyl Nitrite: Amyl nitrite is a fast acting vasodilator. The
inhalation of amyl nitrite will initially decrease venous return and blood pressure.

It increases: (4)

It decreases: (3)

Increase:

hypertrophic obstructive cardiomyopathy murmur
MVP
MS/TS (forward flow murmurs)

Decreases:

MR, AR, VSD

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Loud S1 with opening snap

Low pitch, rumbling, crescendo-decrescendo murmur

*with MR - holosystolic murmur

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High pitch Blowing Pansystolic (holosystolic) murmur (chronic)

severe AS AVA ?

\<1.0cm (\<0.75cm)

critical AS AVA ?

\<0.6 or 0.5cm

another name for severe AR?

Austin-Flint murmur

severe AR murmur best heard at ?

apex in the 5th intercostal space at the midclavicular line

Diastolic mitral regurgitation is associated with: A. Flail mitral valve B. Mitral valve prolapse C. Severe aortic insufficiency D. Severe tricuspid regurgitation

C. Severe aortic insufficiency

A heart sound associated with significant chronic pure mitral regurgitation is: A. Loud S1 B. Fixed split S2 C. S3 D. S4

C. S3 Results from **increased atrial pressure leading to increased flow rates**

Fixed split S2 indictes

ASD

clinical signs of significant AS

* murmur * angina pectoris * Feeling faint or dizzy or fainting with activity * SOB, DOE * Fatigue, especially during times of increased activity * palpitations

Chronic mitral regurgitation results in all the following EXCEPT: A. Left atrial enlargement B. Left ventricular enlargement C. Left ventricular volume overload pattern D. Mitral annular calcification

D. Mitral annular calcification

Possible etiologies for mitral regurgitation include all the following EXCEPT: A. Mitral annulus calcification B. Mitral valve endocarditis C. Papillary muscle dysfunction D. Pulmonary hypertension

D. Pulmonary hypertension

In patients with significant mitral regurgitation, the isovolumic relaxation time may be: A. Increased B. Decreased C. Affected by respiration D. Unaffected

B. Decreased \*significant MR decrease preload - less blood to pump - decreased IVRT

M-mode of Septum in Severe Mitral Stenosis: Impaired Left Ventricle Filling due to **Mitral Stenosis** Leads to Exaggerated Septal Diastolic Posterior ‘Dip’ (Yellow Arrows), Highlighting Unimpeded Right Ventricle Filling vs. the Left.

The proximal isovelocity surface area of a mitral regurgitant jet is 7.6 cm2. The aliasing flow velocity is 24 cm/sec. The time velocity integral (TVI) of the mitral regurgitation jet is 150 cm. The maximum velocity of the mitral regurgitation jet is 580 cm/sec. The mitral regurgitant stroke volume is: A. 24 cc B. 47 cc C. 150 cc D. 580 cc

B. 47 cc ## Footnote Reg Flow = 7.6 cm2 (PISA surface area) x 24 cm/s (V _aliasing) = 182.4 EROA = 182. 4 (Reg Flow) / 580 cm/s (Peak V _regurgitant) = 0.3144… Vol _regurgitant = 0.3144 (EROA) x 150 cm/s (VTI _{regurgitant jet}) = 47.12 ![]()

\_\_\_\_\_\_\_\_\_ is an abnormal increase in left ventricular myocardial mass caused by chronically increased workload on the heart, most commonly resulting from pressure overload-induced by arteriolar vasoconstriction as occurs in, **chronic hypertension** or **aortic stenosis.**

Concentric left ventricular hypertrophy

Flail mitral valve can be differentiated from severe mitral valve prolapsed on two-dimensional echocardiography because flail mitral valve leaflet demonstrates: A. A thicker mitral valve B. Chronic mitral regurgitation C. Leaflet tips that point toward the left ventricle D. Leaflet tips that point toward the left atrium

D. Leaflet tips that point toward the left atrium

Signs and symptoms of mitral valve stenosis secondary to rheumatic heart disease include: A. Angina pectoris B. Cyanosis C. Pulmonary Hypertension D. Vertigo

C. Pulmonary Hypertension

Conditions that may lead to clinical symptoms that mimic those associated with rheumatic mitral valve stenosis include: A. Aortic insufficiency B. Left atrial myxoma C. Pericardial effusion D. Ventricular septal defect

B. Left atrial myxoma

M-mode findings for the mitral valve in patients with rheumatic mitral valve stenosis include all the following EXCEPT: A. Anterior motion of the posterior mitral valve leaflet B. B notch of the anterior mitral valve leaflet C. Decreased E-F slope of the anterior mitral valve leaflet D. Thickened mitral valve leaflets

B. B notch of the anterior mitral valve leaflet *Mitral B bump is essentially* ***a late diastolic phenomenon in which the leaflets keep a semi-open position without LV inflow effectiveness****.* \***_Indicates increased LV end-diastolic pressure (\> 20mmHg)_**

In the M-mode echocardiogram, features of mitral valve stenosis include all the following EXCEPT: A. Anterior motion of the posterior mitral valve leaflets B. Decreased aortic root dimension C. Systolic anterior motion of the mitral valve leaflets D. Left atrial dilatation

C. Systolic anterior motion of the mitral valve leaflets

\*\*\*\*Two-dimensional echocardiographic examination reveals thin mobile mitral valve leaflet tips and a Doppler E velocity of 1.8 m/sec with a pressure half-time of 180 msec. The most likely diagnosis is: A. Abnormal relaxation of the left ventricle B. Aortic insufficiency C. Moderate to severe mitral annular calcification D. Rheumatic mitral stenosis

C. Moderate to severe mitral annular calcification

A deceleration time of 800 msec was obtained by pulsed-wave Doppler in a patient with rheumatic mitral valve stenosis. The pressure half-time is: A. 220 msec B. 232 msec C. 400 msec D. 800 msec

B. 232 msec

MS severe mean PG ? VS AS severe mean PG ?

MS: 10 (12) mmHg \*(mild: 5 (6) mmHg) AS: 40 mmHg \*(mild: 20 mmHg)

Flail Mitral Valve

**Failure of leaflets coaptation** with rapid systolic movement of the involved leaflet into the left atrium, due to rupture chordae tendineae or papillary muscle. May result in acute, subacute or chronic MR.

classic MVP cause

degenerative myxomatous disease of leaflets

\_\_\_ can be related to pectus excavatum (sunken chaest) or pectus carinetum (pigeon chest)

MVP

valve leaflet is displaced \>2mm above the annular plane in systole indicates

MVP

IVRT _____ with moderate to severe MR due to increased atrial pressure causing early opening of the MV

decrease

IVRT _____ with moderate to severe MR due to increased atrial pressure causing early opening of the MV

decrease

E velocity 1.2 m/s a supportive sign of ____ MR

severe \***Severe mitral regurgitation** results in an **increase in the antegrade volume flow rate** across the mitral valve, _which is reflected in an increase in the antegrade flow velocity across the valve_. \*severe MR increase LA pressure causing higher pressure gradient thus increasing E velocity A peak velocity (E-wave) \>1.5 m/sec suggests severe mitral regurgitation, provided that coexisting mitral stenosis is not associated \*Note: normal E peak velocity - between 0.6 m/s and 0.8 m/s

chronic severe MR nearly always leads to dilated ___ & \_\_\_

LA and LV

MR clinical symptoms:

1. systolic murmur (at the apex) 2. asymptomatic (usually) 3. atypical chest pain: any chest pain that doesn’t meet criteria for a common or obvious diagnosis 4. palpitation 5. fatigue 6. DOE 7. pulmonary edema for severe edema

secondary or functional MR can occur with any condition that causes severe dilatation of the LV such as:

significant AI large VSD dilated CM Afib CAD

487. A possible pitfall in the pressure half-time (PHT) method of assessing the severity of mitral stenosis is concomitant: A. Aortic insufficiency B. MR C. Pulmonary insufficiency D. TR

A. Aortic insufficiency

488. All the following values increase in patients with mitral valve stenosis during exercise EXCEPT: A. Left ventricular end diastolic pressure B. Pressure half-time C. Systolic pulmonary artery pressure D. Transvalvular pressure gradient

B. Pressure half-time

491. With aortic valve stenosis and significant aortic insufficiency, the severity of the aortic valve stenosis by the Doppler pressure gradient may be: A. Overestimated B. Unaffected C. Underestimated D. Unpredictable

A. Overestimated

Paradoxical Septal Motion: ‘Septal Bounce’ and its associate findings:

constrictive pericarditis MS LBBB post cardiac surgery RV pacing ischemic septum cor pulmonale

AS M-mode \_\_\_\_ mm cusp separation indicated significant obstruction

\<12mm

Diastolic fluttering of the aortic valve: pathognomonic M-mode features of \_\_\_\_\_

flail cusp

Myxoma of the Left Atrium Simulating \_\_\_\_

Mitral Stenosis

average normal AVA

3-4 cm2

For AS assessment ____ approach is preferred for CW (Pedof) Doppler = most accurate AS evaluation

SSN

Differentiating Waveforms AS vs MR

AR/AI M mode appearance

fluttering of the anterior mitral leaflet or IVS

significant AI can cause premature opening of \_\_\_\_\_

AR assessment by jet width mild value

\<25%

AR assessment by jet width severe value?

\>65%

AR assessment: VC mild value?

0.3cm

AR assessment: VC severe value?

\>0.6 cm

AR assessment: PHT mild value

\>500msec

AR assessment: PHT severe value

\<200 msec

What is this? * Hole or “window-like” opening in the leaflet or between the leaflets * can be congenital or acquired * can occur in bioprosthetic valve leaflets * cause AR * increased risk of valverupture * m-mode can be used to diagnose; diastolic flutter of the aortic leaflets considered a definitive finding

aortic fenestration \*Aortic fenestration is **a method for decompressing the hypertensive false lumen by creating a hole in the distal part of the dissection flap**

What is Graham-Steel murmur?

**The Graham Steel murmur** is the early blowing _diastolic murmur_ heard along the _left border of the sternum_ due to functional **regurgitation through the pulmonic valve.**

People with severe MR and left ventricular enlargement may eventually develop signs and symptoms of:

* heart failure * weakness * fatigue * shortness of breath with exertion and/or at rest * edema (abnormal fluid collection in the lower legs or abdomen)

What is the common cause of AR ?

infective endocarditis

M mode image shows significant increase in PV “a” wave \>\_\_\_\_ mm amplitude indicate pulmonary stenosis

symptoms of AR

CP orthopnea cough

chronic severe AR murmur

Austin Flint murmur

\*\*\*The waveform of MS and AR can be difficult to distinguish on the Doppler tracing; if the flow pattern begins before the MV opens, the wave form is \_\_\_\_

\*\*\*Possible presenting symptoms of significant chronic mitral regurgitation include: A. Angina pectoris B. Ascites C. Fatigue D. Syncope

C. Fatigue

M-mode findings associated with significant chronic mitral regurgitation include all the following EXCEPT: ## Footnote A. Left atrial enlargement B. Left ventricular enlargement C. Fine diastolic flutter of the mitral valve D. Flying W of the pulmonic valve

C. Fine diastolic flutter of the mitral valve \*M-mode recording through the mitral valve from the parasternal long axis position demonstrating diastolic fluttering of the anterior mitral valve leaflet in a patient with **aortic regurgitation or AFib** **\***motion of the pulmonary valve (PV) has historically been used to assess for **pulmonary hypertension** (PH). Parameters include the characteristic **systolic fluttering or notching of the PV (Flying W)**, its diastolic slope and its a-wave height. Furthermore, the notching can be seen in the Doppler pattern of the PV. \*sever chronic MR - backing up blood causing PHTN

An accepted method for determining the severity of mitral regurgitation by continuous-wave Doppler is spectral: A. Length B. Strength C. Velocity D. Width

B. Strength

The radius of a mitral regurgitation flow convergence hemisphere is 1.1 cm. The proximal isovelocity surface area (PISA) is: A. 1.21 cm2 B. 3.8 cm2 C. 7.6 cm2 D. 15.2 cm2

C. 7.6 cm2 \*note: Area_pisa = 2 x 3.14 x r_pisa² Area_{pisa = 2 (3.14) (1.1cm)²} Area_{pisa =}7.5988 = 7.6 ![]()

In pure rheumatic mitral valve stenosis, the left atrium is _______ and the left ventricle is \_\_\_\_\_\_\_. A. Decreased, decreased B. Increased, decreased C. Increased, increased D. Unchanged, increased

C. Increased, increased

The formula used to determine mitral valve area in the cardiac catheterization laboratory is: A. CO ÷ BSA B. CO ÷ MPG C. CO ÷ DFP ÷ 38 x √MPG D. CO ÷SEP ÷44.3 x √MPG

C. CO ÷ DFP ÷ 38 x √MPG

Wk 2 Quiz 2 Valvular Disease Flag Questions Flashcards

(89 cards)