Mitral stenosis and mitral regurgitation
What are some complications of mitral stenosis?
Coexistence mitral regurgitation, passive/reactive pulmonary hypertension, left atrial thrombus, systemic embolization, infective endocarditis( more common in mild MS), pulmonary edema, hemorrhage, decrease stroke volume and cardiac output, right heart failure
What are other causes of mitral stenosis?
Congenital, severe mitral calcification, lupus, left atrial mass or tumor, prosthetic valve dysfunction, autoimmune disease
Moderate to severe mitral regurgitation with pulmonary vein assessment
Decreases S wave and increased d wave indicated moderate to severe MR
What are the signs and symptoms of mitral stenosis?
Dyspnea on exertion 80%, hemoptysis second most common symptom, chest pain, palpitations, syncope, heart failure-orthopnea, paroxysmal nocturnal dyspnea, fatigue, cough weight gain, and right heart failure, murmur
What are the signs and symptoms of MR
Dyspnea, fatigue is the earliest symptom, irregular rhythms, angina pectoris, orthopnea SOB when laying flat, palpitations, heart failure
What are the causes of mitral valve prolapse MVP
Exact cause is unknown, it is hereditary and more seen in women under 40, could be related to connective tissue disorder marfans syndrome, always evaluate all valves for prolapse if mvp is found.
Treatment options for MVP
If no symptoms no treatment, usually monitor, with symptoms is usually monitor but sometimes valve replacement or repair
What are the complications of mitral regurgitation?
Increase in volume because the blood is going the wrong way, left atrial dilation is the first thing to be seen, in extreme cases left atrial thrombus formation and embolization, pulmonary edema because of the fluid back up
How do we find the MVA?
It can be found by using the P1/Pt method, the most common is the deceleration time DT method. The deceleration time is the the time from the mitral stenosis peak velocity down the slope all the way back t the baseline.
What does RHD do to the mitral valve?
It damages the mitral valve by fusing and or thickening the leaflets
What is valvular heart disease
It is a disease the affects the valves of the heart, it has decreased due to technology and antibiotics, it arises from RHD,
How do we determine the mitral stenosis severity?
It is determined by pressure half time P1/Pt and the mitral valve area MVA and mean pressure gradient PG.
What does mitral regurgitation on M mode look like
Left atrial dilation, left ventricular volume overload pattern, right ventricle dilation, left ventricle dilation, aortic valve notching
What is the 2D echo findings of mitral stenosis?
Left atrial enlargement, doming looks like a hockey stick of the anterior mitral valve leaflet, evidence of pulmonary hypertension because of right ventricular hypertrophy, mitral valve leaflet thickening >3mm, a fib,
What does mitral regurgitation look like on 2d echo
Left atrial enlargement, left ventricular dilatation or hypertrophy, thickening/calcification/prolapse/flail leaflets of chordae or other, right ventricular dilatation, increase left atrium and right atrium ratio its normally 1;1
Severe MR flow
MR Jet is mid to back of the wall of the left atrium
Moderate to severe MR flow
MR jet is 1/2 way into the left atrium
Moderate MR flow
MR jet is 1/3 way into the left atrium
Mild MR flow distribution
MR jet is just beyond the MV leaflets
CFD with MVP
MR usually coexists with MVP, in most cases if the AMVL prolapse the MR is posteriorly directed If the PMVL prolapses the MR is anteriorly directed
M Mode findings with MVP
Mid to late systolic prolapse of the AMVL and or PMVL >2mm below the C-D points, holosystolic prolopse,
What is the medical or surgical treatment of mitral stenosis?
Percutaneous mitral balloon valvotomy PMBV is a cardiac catheritization procedure. Mitral valve replacement, sodium restriction, diuretics, anticoagulation, calcium antagonist,
What is mitral valve prolapse
Posterior displacement of any portion of the mitral valve leaflets beyond the mitral valve annular plane during ventricular systole, AMVL and or PMVL prolapse or slip from their usual position into the left atrium during systole while the mitral valve is closed.
What are the causes of MR
RHD, mitral annular calcification MAC, flail leaflets, infective endocarditis, congenital anomalies
What is a normal pulmonic vein
Systolic component is larger than the diastolic component
Mild to moderate MR flow
The MR jet between mild and moderate
What is the mitral regurgitation murmur ?
The MR murmur is a holosystolic murmur that radiates to the axilla and is described as a blowed or high pitched murmur
What is mitral regurgitation?
The backward flow of blood into the left atrium during ventricular systole it is the result of an incompetent mitral valve that allows the backward systolic flow from the left ventricle through the mitral valve into the left atrium while the valve is closed it can be acute chronic or intermittent
What does MVP look like on a 2d echo
The best view to see this is PLAX could have a systolic dip in inferolateral wall
Mitral stenosis murmur
low pitched, diastolic "rumble" with an opening snap
What is the most common cause of mitral stenosis?
rheumatic fever which leads to rheumatic heart disease
Moderate MS severity scale
150-219 P1/Pt ms, MVA 1.0-1.5 cm^2, mean PG is 5-10 mmHg
Severe MS severity scale
> or =220 P1/Pt ms, MVA <1.0 cm^2, mean PG is >10 mmHg
What does color flow doppler look like with mitral stenosis ?
A mitral stenosis creates turbulent diastolic flow that travels from the left atrium through the narrowed mitral valve into the left ventricle, mitral regurgitation is probable due to valvular abnormalities stenosis prevents normal closure and left atrial enlargement.
What is mitral stenosis
A narrowing of the mitral valve orifice impeding the diastolic flow of blood from the left atrium to the left ventricle
What are some physical examination findings for mitral stenosis?
Atrial fibrillation, Malar flush, small/absent left ventricle impulse, Parasternal right ventricle heave- pulmonary hypertension, blood pressure low normal, ortners syndrome- hoarseness.
Mitral regurgitation and color flow doppler assesment
CFD is the most popular way to evaluate MR, MR creates turbulent systolic flow that travels backwards from the left ventricle through the closed mitral valve into the left atrium, use this to report the severity
What are the M Mode findings of mitral stenosis?
Mitral stenosis causes the left ventricle to fill slow this creates a persistent gradient that keeps the valve open and doesn't allow for the natural movement of the mitral valve leaflets which changes the look of m mode, decreased EF slope 0-30 mm/s, reduced amplitude of the E wave, decreased/absent A wave, decreased MV excursion, thickened MV leaflets appear bright with multiple echoes, left atrial enlargement
What is the treatment option for mitral regurgitation
Monitor is the number one thing, diuretics, anticoagulants, low salt diet, MV replacement, valve repair is preferred over replacing it, open heart surgery, catheter procedures
What are the complications and symptoms of MVP
Most patients are asymptomatic but some will have chest pain, dizziness, irregular rhythms, syncope, increased risk for endocarditis, ruptured chordae tendinae, sudden death rare
What is the mitral stenosis murmur and when is it open?
Open in diastole its a diastolic murmur
What are the cardiac auscultation of mitral stenosis
Opening snap, low pitched diastolic rumble at cardiac apex, crescendo pre systolic accentuation of the diastolic rumble, loud S1, accentuated P2 pulmonary hypertension, murmur of mitral, aortic, tricuspid and or, pulmonic regurgitation
Mitral stenosis severity scale normal mitral valve findings
P1/Pt(ms)- 30-60 MVA(cm^2)- 4-6 no mean PG
What is the equation for finding the pressure half time and MVA?
P1/Pt= deceleration time x 0.29 MVA= 759/ DT MVA=220/pressure half time
Mild MS severity scale findings
P1/pt 90-150 ms, MVA >1.5 cm^2, mean PG <5mmHg
Severe MR in regards to pulmonary vein assessment
Reversed S wave and increased d wave aka pulmonary venous systolic flow reversed is severe ms
What is RHD?
Rheumatic heart disease is a complication of strep throat that usually occurs between the age of 5-15 an it may not manifest till 20-30 years later.
What will happen in patients with chronic mitral stenosis that acquire pulmonary hypertension?
The increased pulmonary pressure forces the right ventricle to work harder which results in right ventricular hypertrophy
Mitral stenosis and its doppler wave form appearance
The mitral stenosis CWD waveform has an increased peak velocity E and a flattened EF slope and an absent A wave. The severity of the MS is determined by the pressure half time and the mitral valve area and the mean pressure gradient
What is the murmur associated with MVP
The mitral valve prolapse murmur is a mid systolic click with or without a systolic murmur
Mitral regurgitation pulmonary vein assessment is what
The pulmonary venous flow into the left atrium is dependent on the pressure difference between the pulmonary veins and the left atrium
Why would we use CWD with MR
To evaluate the spectral strength and shape