Mitral Valve Disease Lecture
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| Mitral Stenosis | show 🗑
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| Mitral regurgitation or insufficiency | show 🗑
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| Combined valvular disease | show 🗑
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| What are the 3 basic forms of mitral valve disease? | show 🗑
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| show | 2 leaflets (anterior and posterior), each divided into 3 segments. Each leaflet attached to papillary muscles by chordae tendinae; the junction between anterior and posterior leaflets with the valve annulus referred to as the commissures
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| show | congenital deformities, rheumatic valvular disease, dense mitral annular calcification, systemic disease (lupus, rheumatoid arthritis, carcinoid syndrome, etc), pseudo mitral stenosis
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| What is the most common cause of mitral stenosis? | show 🗑
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| show | Calcification extends from the annulus to the leaflets, restricts leaflet motion
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| What is pseudo mitral stenosis? | show 🗑
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| How does rheumatic mitral stenosis arise? | show 🗑
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| Rheumatic fever | show 🗑
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| What histological changes are seen rheyumatic fever? | show 🗑
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| How is rheumatic fever diagnosed? | show 🗑
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| What are the major criteria in the modified jones criteion for the diagnosis of acute rheumatic fever | show 🗑
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| What are the minor criteria in the modified jones criteion for the diagnosis of acute rheumatic fever | show 🗑
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| show | Can be myocarditis (inflammation of myocardium with ventricular dysfunction), pericarditis (inflammation of the pericardium with pericardial friction rub or effusion), or valvulitis (inflammation of the cardiac valves)
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| show | Asymmetrical, migratory, polyarticular arthritis
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| show | Syndeham's chorea (aka St. Vitus's dance): choreiform activity with rapid uncoordinated, jerky movement of cae, hands, feet; thought to be caused by destruction of basal ganglions; resolves after several months of onset but may persist indefinitely
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| show | Usually 0.5-2 cm movable, firm painless nodules which develop on extensor surfaces of joints, spinous processess and occiput
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| show | Evanescent (fading), erythematous (red), nonpruritic macular rash with serpinginous (creeping, wormlike) margins and clear center
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| Describe the changes in the heart + blood during the acute phase of rheumatic fever | show 🗑
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| Describe the changes in the heart + blood during the chronic phase of rheumatic fever | show 🗑
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| What would you expect to find on an echocardiograph of a patient with chronic rheumatic valvular disease? | show 🗑
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| show | Mitral valve rebounds upon systole and deflects into left atrium, causing a deflection in the left atrial pressure tracing
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| show | Mitral valve reamins closed during systole-->as it fills (due to pulmonary venous inflow), pressure progressively rises
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| show | Towards END of ventricular diastole, left atrial contraction occurs, creating a transient increase in lef-atrial pressure tracing
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| What hemodynamic changes do you see in patients with Mitral Stenosis? | show 🗑
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| What are the hemodynamic changes associated with chronic elevation in left aterial pressure on the rest of the cardiopulmonary system? | show 🗑
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| show | Dyspnea and cough, orthopnea, chest pain, hoarseness, peripheral edema, fatigue, systemic thromboembolism
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| What symptoms of mitral stenosis develop as a result of pre-capillary block? | show 🗑
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| What symptoms of mitral stenosis develop as a result of post-capillary block? | show 🗑
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| show | Mild: decresendo diastolic rumble (due to turbulence) with possible pre-systolic accentuation (due to atrial contraction); moderate: pan-diastolic rumble; progressive decrease in A2 to opening snap interval (OS not normally heard); soft S1, louder P2
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| What is the Gorlin formula? | show 🗑
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| What conditions can lead to increased mitral valve gradients? | show 🗑
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| How is mitral stenosis treated? | show 🗑
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| show | Regulate oral fluid intake, restrict Na consumption; oral diuretics (furosemid); important in pregant women (increase in intravascular volume + CO)
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| Rate control management of mitral stenosis | show 🗑
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| How does percutaneous baloon valvuloplasty work? | show 🗑
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| Who are ideal candidates for balloon mitral valvuloplasty? | show 🗑
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| show | surgically separating mitral valve leaflets in regions of commissural fusion; done either on or off bypass
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| show | With either mechanical (metallic) or bioprosthetic (porcine or bovine)valve
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| show | Mitral valve prolapse, rheumatic valvular disease, endocarditis, dilated cardiomyopathy, cornoary ischemia, trauma, systemic diseases
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| How can mitral valve prolapse lead to mitral regurgitation? | show 🗑
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| How can rheumatic valvular disease lead to mitral regurgitation? | show 🗑
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| show | leaflet inflammation, obstruction of leaflet coaptation by large vegetations, or leaflet destruction in the form of flail leaflets, leaflet perforation and/or perivalvular abcessess
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| show | dilation of the mitral valve annulus and/or apical displacement of the mitral leaflet coatpation poin due to enlargement of the ventricular cavity
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| How can coronary ischemia lead to mitral regurgitation? | show 🗑
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| show | rupture of the papillary muscles
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| show | Possible causes: carcinoid syndrome and collagen vascular diseases (cause fibrosis and deformity of the mitral valve)
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| show | Increased LV stroke Volume (with decrease forward flow and increased backward flow) --> increased LA pressure and increased pulmonary venous pressure (may cause pulmonary edema)
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| What changes do you expect to see in the left atrium with mitral regurgitation? | show 🗑
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| What changes are seen in pathophysiology of chronic MR? | show 🗑
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| show | insufficient time for remodeling --> compliance remains same --> left ventrcile responds to shift in loading conditions by shifting along FIXED pressure volume curve; if shift large enough --> pulmonary edema
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| show | Rises less dramatically --> ventricular remodeling through eccentric hypertrophy --> increase in LV volume and compliance --> shifts patient to new left ventricular pressure-volume relationship --> chornic compensated phase of mitral regurgitation
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| What is the change you expect to see in the left-ventricular pressure-volume relationship in chronic mitral regurgigration? | show 🗑
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| show | Prominent V-waves (simultaneous filling of LA from lung and contracting LV); rapid y-descent due to augmented antegrade flow (due to increased atrial preload)
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| What auscultatory findings would you find in patients with significant mitral regurgitation? | show 🗑
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| What is the cause of mitral valve prolapse? | show 🗑
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| What happens during mitral valve prolapse? | show 🗑
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| What auscultatory finding would you find in mitral valve prolapse? | show 🗑
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| show | Increasing left ventricular volume --> mitral valve click and murmur later in systole
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| How is mitral regurgitation treated? | show 🗑
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| How does an intra-aortic baloon pump work and why does it help patients in cardiogenic shock? | show 🗑
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| show | Surgical repair or replacement of mitral valve
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| show | Potent arteriolar vasodilator: metabolized into NO --> guanylate cyclase activation in vascular smooth muscle cells --> stimulates cGMP production, which promotes calcium reuptake from cytoplasm into endoplasmic reticulum --> smooth muscle relaxation
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| What are the advatages and disadvantages of using nitroprusside? | show 🗑
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| Medical management of chronic mitral regurgitation focuses on: | show 🗑
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| What are the surgical treatment options for patients with mitral valve prolapse? | show 🗑
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| How is post-operative survival affected by LV ejection fraction? | show 🗑
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| show | Rule of thumb: mitral valve surgery for patients with severe regurgitation PRIOR to patient developing significant symptoms or left ventricular dysfunction
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karkis77
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