Term
| What are 5 major causes of mitral stenosis? What is most common? |
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Definition
1) Congenital
2) Rheumatic**
3) Annular Calcification (degenerative)
4) Systemic Disease (Paget's, SLE, Marfans)
5) Pseudostenosis (external covering) |
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Term
What differentiates mitral valve disease in acute rheumatic fever, from chronic rheumatic disease?
How might this be reflected in auscultatory findings? |
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Definition
1) Acute disease involves inflammation of leaflets causing regurgitation
- Transient regurgitation murmors (Carey-Coombs)
2) Chronic thickening and fibrosis of commissures and leaflets leads to stenosis or stenosis with regurgitation
- Diastolic rumble (LV filling) and early systolic accentuation (atrial kick)
- Can become holosystolic as disease progresses |
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Term
| What are the major clinical symptoms associated with mitral stenosis? |
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Definition
1) Dyspnea/Cough
2) Hoarseness
3) Chest Pain
4) Thromboembolism
5) Edema
6) Fatigue |
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Term
| How does the Gorlin formula relate to determining disease severity and therapeutic intervention in mitral stenosis? |
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Definition
Explains that increasing atrial/ventricle pressure differential is related to increasing CO, increasing HR and decreasing valve area (MVA).
This means that to treat, you want to get CO and HR down, so as not to increase the pressure differential (reduce volume w/ diet and maybe diuretic, and HR with B-blockers). |
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Term
| What are the major medical treatments for mitral stenosis? |
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Definition
1) Regulate Volume (diet/salt intake), Rate (B-blockers) and other disease
2) Percutaneous balloon valvuloplasty (if candidates)
3) Mitral valve commisurotomy or valve replacement |
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Term
| What are 5 major causes of mitral regurgitation? |
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Definition
1) Rheumatic Disease
2) Mitral valve prolapse
3) Endocarditis
4) Dilated cardiomyopathy
5) Coronary ischemia |
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Term
| What pathophysiological changes take place in mitral regurgitation? |
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Definition
1) Total LV stroke volume increases, but in BOTH directions, with LA and aorta acting as parallel circuits (backwards dominates)
2) Backwards flow increases LA pressure (determined by regurgitant volume, LA compliance and IV volume), which can cause pulmonary HTN
3) Over time, chronic LV and LA volume overload leads to Eccentric hypertrophy (vs. concentric in aortic stenosis) |
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Term
| Why does mitral regurgitation cause more mitral regurgitation? |
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Definition
1) Chronic LV volume overload leads to eccentric hypertrophy and LV enlargement
2) LV enlargment maintains forward flow, but also increases diastolic wall stress, promoting further hypertrophy
3) Resulting annular dilatation and mitral regurgitation occurs with increasing LV size |
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Term
| What is the impact of Acute vs. Chronic mitral regurgitation on LVPVR? |
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Definition
1) Acute (giant V wave) shifts relationship along fixed PV curve (large increases in volume lead to marked increases in LV pressure)
- May lead to EDEMA
2) Chronic eccentric hypertrophy increases LV volume and compliance, shifting the relationship to new curve to the right (less pressure for increased volume)
- When chronic MR becomes decompensated, LV pressure rises and relationship shifts along fixed curve, often leading to CHF. |
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Term
| What auscultatory findings can you notice in mitral regurgitation? |
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Definition
1) Holosystolic murmor (S1-A2)
2) If severe, early diastolic rumble and S3 (rapid diastolic inflow through mitral valve)
** If caused by MV prolapse, look for mid-systolic click and mid-late diastolic regurgitant murmour** |
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Term
| When is surgical intervention most effective for mitral regurgitation? |
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Definition
BEFORE LV function decreases (before compensated becomes decompensated)
1) valve replacement
2) valve repair |
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Term
| What is the general medical management for mitral regurgitation? |
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Definition
1) Diuretics (get volume down)
2) Vasodilators (nitroprusside) to reduce systemic HTN
3) In cardiogenic shock, use intra-aortic balloon pump (IABP)
**DON'T USE FOR AORTIC REGURGITATION** |
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Term
| What are the major causes of aortic stenosis? |
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Definition
Similar to mitral stenosis
1) Congenital (unicupsid or bicupsid)
2) Rheumatic (tip to base and less common than mitral)
3) Calcification
4) Systemic disease |
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Term
| What pathophysiological changes take place in aortic stenosis? |
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Definition
1) Since outflow is restricted, LV pressure increases, creating a transvalvular pressure gradient (as does wall tension by Laplace's law)
2) LV hypertrophy develops and LV compliance decreases (up and left shift of P-V curve)
3) Since LVEDP increases, you see giant A-waves (atrial "kick") |
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Term
| What major changes on physical exam should you look for in aortic stenosis? |
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Definition
1) Inferolaterally displaced PMI
2) Pulsus parvus et tardus (small and late)
3) Rhomboid murmour (compared decrescendo in aortic regurgitation)
** may see early systolic click, if valves are pliable, but restricted** |
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Term
| What changes do you see in S2 splitting in aortic stenosis? |
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Definition
- Narrowing of split (A2-P2), which can become paradoxical
- if paradoxical, split will narrow upon inspiration and widen upon expiration. |
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Term
| What are the 3 cardinal symptoms of aortic stenosis? |
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Definition
1) Angina (5 years)- imbalance in oxygen delivery because increasing LVEDP reduces aorta-LV pressure gradient
2) Syncope (3 years)
3) Dyspnea and CHF (2 years)- passive transmission of pressure back to pulmonary system (HTN), which can cause interstitial pulmonary edema and congestive heart failure. |
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Term
| What is the major treatment options for aortic stenosis? |
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Definition
1) Diuretics (volume control)
2) Digoxin or IV inotropes
** AVOID vasodilators (heart can't compensate for dilation)
** AVOID percutaneous balloon valvuloplasty
3) Surgical (TAVI or valve replacement) |
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