4. Mitral Stenosis & Mitral Regurgitation

Mitral Regurgitation effects which sex more?

Female

Mitral Stenosis predominately occurs in what sex?

Female

What is the management of congestive heart failure associated with Mitral Regurgitation?

In *acute setting*: - Decrease preload (diuretics, vasodilators) In *Chronic setting*: - No benefit shown from medications - Goal is to get them *surgical repair* before deterioration occurs

What produces the pathological findings of rheumatic Mitral Stenosis?

Inflammation (acute/chronic) - Calcification/thick fibrous valve leaflets, thick/shortened chord tendinae

What is the pathophysiology of pulmonary hypertension?

Leads to *RVH* and enlargement -> tricuspid regurgitation -> ↑ RA pressure then *right HF*

What is a Chronic Mitral Regurgitation specific sign?

Low Cardiac Output

What is the pathophysiology of Mitral Stenosis?

MS -> Fixed Cardiac Output -> *↑ Left Atrial Pressure* -> ↑ pulmonary venous/capillary pressures -> *↑ hydrostatic pressure* leads to transudation of plasma into the lungs ->> *CHF*

Which leaflets are most commonly affected by Mitral Regurgitation?

Posterior

What is the prognosis associated with Mitral Stenosis?

Progressive disease in the absence of correction of the stenotic valve

What is an Acute Mitral Regurgitation specific sign?

Pulmonary Edema

How does an Exercise Doppler Echocardiography help evaluate Mitral Regurgitation?

Reasonable in asymptomatic Pts w/ severe MR to assess exercise tolerance & effects of exercise on pulmonary artery pressure & MR severity If asymptomatic and want to be more active => exercise doppler

What are echocardiogram findings associated with Mitral Valve Prolapse?

Systolic displacement of thickened MV leaflets into left atria

Pathophysiology of MR varies in relation to ________________

left atrial size and compliance, as well as, eventually left ventricular adaptation

What are ECG findings associated with Mitral Valve Prolapse?

usually *normal* unless co-existing chronic MR

What are echocardiogram findings associated with Mitral Regurgitation?

**TTE in most** - Left atrial enlargement - Left ventricular hypertrophy - Potential identification of etiology - May quantify severity

How often should you perform serial echocardiograms to assess progression of valve disease?

- Every 3-5 years (MVA >1.5 cm2) - Every 1-2 years (MVA >1.0-1.5 cm2) - Annually (MVA <1.0 cm2)

What diagnostic imaging is used for Mitral Valve Prolapse?

*Echocardiogram* - Indicated for the *diagnosis of MVP* - For *assessment of MR, leaflet morphology, and ventricular compensation* in asymptomatic patients with physical sings of MVP - Echocardiography can be effective for *risk stratification in asymptomatic Pts w/ physical signs of MVP* or known MVP - *Not indicated to exclude MVP* in asymptomatic patients - *Routine repetition of echocardiography is not indicated for the asymptomatic patient who has MVP and no MR or MVP and mild MR with no changes* in clinical signs or symptoms

Mitral Stenosis on EKG

*LAE* P mitrale: Lead 2 => P wider than 2.5 V1 terminal > initial

What is the pathophysiology of Chronic LA pressure overload?

*LAE* -> disrupted conduction -> A-FIB decreased CO -> stagnation of blood flow -> Intra-artrial thrombus -> *stroke*

What are CXR findings associated with Mitral Valve Prolapse?

*Normal* unless co-existing MR

What is the pathophysiology associated with Chronic Mitral Regurgitation?

*Regurgitation progresses over time* -> gradual LA dilation -> slight *↑ in LA pressure & PA pressure* -> *LV eventually hypertrophies & dilates stretches MR* annulus -> MR worsens -> ↓ systolic function -> *low forward cardiac output* -> *HF*

Treatment of Mitral Regurgitation involves __________________

*augmenting forward cardiac output* while reducing regurgitation into the LA -> *relieving pulm. congestion*

What is the pathophysiology associated with Acute Mitral Regurgitation?

*↓ Cardiac Output* -> ↑ Left Atrial pressure & volume -> Pulmonary HTN & Pulmonary Edema -> ↓ CO -> Body attempting compensation (*↑ HR/vascular resistance*) -> exacerbation of MR -> *Acute R sided HF* -> cardiac emergency

What medications are used to treat Mitral Valve Prolapse?

- *Aspirin* - Anticoagulation if AF or systemic embolism with TIA despite ASA - Treat the AF - Prophylaxis is no longer indicated/recommended for mitral valve disease including mitral valve prolapse with regurgitation

What are ECG findings associated with Mitral Stenosis?

- *LAE* (p-Mitrale) - *RVH/RAD*

What causes Pulmonary Hypertension?

- *Passive* = ↑ in pressure due to backward transmission of ↑ left atrial pressure - *Reactive* = Pulm arterial/arteriolar vasoconstriction, hypertrophy of pulmonary artery

What are CXR findings associated with Mitral Stenosis?

- *Pulmonary vascular congestion* - Prominent pulmonary arteries - Kerley B Lines - *Left atrial enlargement*

What are the 5 things that the severity of MR are based on?

- *Size of the opening* during regurgitation - The *systolic pressure gradient* between the LA and LV - *Systemic vascular resistance* opposing the LV forward flow - *LA compliance* - *Duration of regurgitation*

What is the definition of Mitral Valve Prolapse?

- Abnormal systolic displacement of one or both leaflets into the left atrium (systolic billowing) due to a disruption or elongation of leaflets, chord, or papillary muscles **Defined echocardiographically (any billowing of the mitral leaflets >2mm above the annual plane**

What are the etiologies associated with Secondary Mitral Regurgitation?

- Acute MI - Ischemic Heart Disease (CAD/Major etiology of MR) - LV systolic dysfunction - HOCM - Rheumatic fever

What are physical exam findings associated with Mitral Regurgitation?

- Apical thrill (if severe MR) - Soft S1 with wide split S2 - Loud P2 - Enlarged LV -> Leftward displacement of apical impulse

What are the signs and symptoms associated with Mitral Valve Prolapse?

- Asymptomatic -> *Key clinical manifestations are auscultatory findings that prompt an echo* - MVP Syndrome (mild to *stabbing chest Pn*, dyspnea, palpitations, fatigue, dizziness, exercise intolerance, anxiety of panic disorder) - Signs and Symptoms of *MR* if present - Embolic phenomena

What are ECG findings associated with Mitral Regurgitation?

- Atrial Fibrillation - Left atrial enlargement - Left ventricular hypertrophy

Mitral Stenosis worsens with ______________

- Atrial Fibrillation - Tachycardia - Pregnancy (increased preload)

What are CXR findings associated with Mitral Regurgitation?

- Cardiomegaly - Left atrial enlargement - Left ventricular hypertrophy - Possible mitral annular calcification

Describe Mitral Stenosis murmur

- Description: *Low pitched, rumbling, decrescendo, diastolic* murmur - Opening snap heard after S2 - Best heard at the *apex in the left lateral decubitus* position with the bell - The longer the duration the more severe the MS

Describe the murmur associated with Mitral Valve Prolapse

- Description: *Mild systolic click, late systolic* murmur - Click is thought to be caused by snapping of the mitral chord during systole when the valve bows into the atrium - Accentuated/altered by bedside maneuvers that increase/decrease volume of LV

Describe the murmur associated with Mitral Regurgitation

- Description: Loud, high-pitched, *holosystolic* murmur at *apex radiates to axilla*. Loud S2 - Best heard at *apex/LLSB - left lateral decubitus w/ diaphragm* - Should intensify with *hand grip* - May radiate to back

Describe the use of echocardiogram to evaluate Mitral Stenosis

- Diagnosis of MS - Assessment of severity mean gradient, Mitral Valve area and pulmonary artery pressure - Re-evaluation of patients with known MS and changing symptoms or signs - Serial echo in asymptomatic stable patients to assess progression of valve disease

Describe the Opening Snap murmur heard with Mitral Stenosis

- Duration indicates severity not the intensity of the murmur heard. Takes longer to empty - remember that the murmur is actually the sound of the blood flowing across the valve - The valve is stiff, so it opens quickly (snap) then decrease in sound

What are the clinical signs and symptoms of Mitral Regurgitation?

- Dyspnea - *Paroxysmal Nocturnal Dyspnea* (PND) - Orthopnea - Palpitations - *Peripheral Edema* - Arrhythmia (A Fib)

Describe Transthoracic Echocardiography use in the evaluation of Mitral Regurgitation. (Get ECHO for holosystolic)

- For *baseline evaluation of LV* size and function, RV & LA size, pulmonary artery pressure, & severity of MR in any Pt suspected of having MR - For *delineation of the mechanism* of MR - For *annual or semiannual surveillance of lV function* (estimated by ejection fraction & end-systolic dimension) in asymptomatic Pts w/ mod/severe MR - To evaluate the MV apparatus and LV function *after a change in S/Sx* - To evaluate LV size and function and MV hemodynamics in the *initial evaluation after MV replacement or MV repair*

When is pharmacologic therapy appropriate to treat MS?

- For *stabilization* prior to intervention - To treat *decompensation* due to intercurrent illness - Or for *persistent symptoms* after intervention => *Diuretics & BB* may improve Sxs in these settings

Describe Mitral Stenosis Overtime

- Lethal disease - Needs treatment with valvotomy or valve replacement - *Percutaneous mitral balloon valvotomy* (PMBV) is the *preferred procedure* unless congenital MS - Other procedures include open comissurotomy and Mitral Valve replacement

What surgical procedures are used in treatment of Mitral Regurgitation?

- MV Repair (preferred) - MV Replacement - Specialized Mitral Repair Central Referral

What are the etiologies associated with Primary Mitral Regurgitation?

- Mitral Valve Prolapse (Most common cause in US) - Infective carditis - Trauma - Rheumatic heart disease - Congenital cleft leaflets - MV annulus calcification

What is the etiology of Mitral Valve Prolapse?

- Primary *MC cause of organic severe MR in US* - Familial - Associated w/ *connective tissue d/o* -> Marfan's Syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta - Ebstein's anomaly (congenital malformation of TV and RV) - Sequela of cardiomyopathy or MI

What are the signs and symptoms of Mitral Stenosis?

- Progressive dyspnea on exertion (DOE) - Reduced exercise capacity - *Orthopnea* - Fatigue - Palpitations - *Peripheral Edema* - *Right sided heart failure* - Atrial Fibrillation - Thromboembolic Disease - Hemoptysis - *Dysphonia* - Chest pain

What is the treatment for Mitral Valve Prolapse?

- Reassurance - Advise TLC - Avoiding caffeine, ETOH, undue stress/fatigue

What etiologies are associated with Mitral Stenosis?

- Rheumatic Fever/Heart Disease (Most common) - Congenital stenosis (rare) - Severe annular calcification (rare) - Left atrial myxoma (very rare)

Describe physical activity of patients who have Mitral Stenosis?

- These patients tend to be sedentary due when active they become symptomatic - All patents should exercise, at least something low impact for their overall cardiovascular fitness - *Sudden death is rare* with MS

What are echocardiogram findings associated with Mitral Stenosis?

- Thickened MV leaflets ("Fish Mouth") - *Left atrial enlargement* - Potential left atrial thrombus

Why do you perform a *Transesophageal Echocardiogram* (TEE) in patents with Mitral Stenosis?

To assess the presence or absence of *left atrial thrombus* and to further evaluate the *severity of MS* in patients considered for percutaneous mitral balloon valvotomy