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Plumbing Issues with MS (6 steps)
- 1.) stenotic MV
- 2.) obstruction of flow from LA to LV
- 3.) increased pressure in the LA causes LA to enlarge
- 4.) blood begins to back up into the right side
- 5.) increases the right heart pressures
- 6.) right sided hypertrophy
What is an congenital parachute MV?
a unifocal attachment of the chordae to a single papillary muscle
What arrhythmia is common with longstanding MS?
What is hemoptysis?
coughing up bloody septum
When does pulmonary congestion occur with MS?
usually develops when MVA is 1.1- 1.5 cm2
What is Ortner's syndrome?
What are some signs and symptoms of MS? (8)
- 1.) Progressive dyspnea
- 2.) Fatique
- 3.) Chest pain
- 4.) Syncope
- 5.) Hemoptysis
- 6.) Nocturnal cough
- 7.) Ortner's syndrome
- 8.) palpitations
What is the murmur of MS?
a diastolic rumble, opening snap
5 Complications of MS
- 1.) LA thrombus due to stasis in LA
- 2.) Embolization
- 3.) A-Fib
- 4.) Pulmonary hypertension
- 5.) Vegetations
When is surgery done for MS?
Patient is symptomatic and MVA is less than 1.0 cm2.
What are two types of surgery to fix MS?
1.) closed MV commissurotomy
2.) open heart valve replacement
What is a commissurotomy?
When can it not be done/performed? (3)
procedure to break apart the commissures.
- Patient has:
- 1.) severe MR
- 2.) valve calcification
- 3.) LA thrombus
How is a commissurotomy performed?
Risk to patient?
Percutaneous ballon mitral valvutomy performed in cath lab. A balloon catheter through the ASD and then inflate the balloon when it is in the valve. It splits the commissures.
Patient may end up with ASD
What are 7 2D findings of MS?
- 1.) thickening of the MV
- 2.) Diastolic "doming" of the anterior MV
- 3.) Fusion at the commissures of MV causing doming.
- 4.) Concordant motion of MV
- 5.) Enlarged LA
- 6.) Normal LV
- 7.) Enlarged right heart
Will the LV appear normal size with MS?
What is another name for diastolic "doming" of the anterior MV?
What is concordant motion the MV?
Anterior motion of the posterior leaflet in diastole.
(the posterior leaflet is pulled anteriorly when the valve opens)
What measurement is considered LA dilated?
> 4 cm
What are 9 M-Mode findings of MS?
- 1.) thickened MV leaflets
- 2.) decreased E-F slope of anterior MV leaflet
- 3.) Concordant motion of the posterior MV leaflet
- 4.) Decreased a wave
- 5.) reduced d-e amplitude/not as bright
- 6.) enlarged LA
- 7.) flying W = pulmonary HTN
- 8.) enlarged RV
- 9.) LV is normal size
What velocity is considered to be stenotic with the MV?
> 1.5 m/s
What are 5 Doppler findings of MS?
- 1.) CW > 1.5 m/s
- 2.) shallow E-F slope
- 3.) increased P 1/2 time
- 4.) spectral broadening
- 5.) A wave small or absent
What are 4 ways to Quantitate for MS?
And which ones measure for MVA?
- 1.) Planimetry - MVA
- 2.) Pressure half-time - MVa
- 3.) Mean Gradient
- 4.) Continuity Formula - MVA
What way out of the 4 ways to Quantitate for MS is the most accurate?
Not influenced by hemodynamics, only by image limitations.
Why is the P 1/2 Time longer with MS?
because of the small opening it takes longer for the pressure to drop to half its initial value.
A greater Pressure Half Time collates with what?
Smaller MVA and more severe MS.
A lesser Pressure half Time collates with what?
Larger MVA and less severe MS.
What 3 things can cause an overestimation of MVA using planimetry?
- 1.) angle of the ultrasound beam is not perpendicular
- 2.) gain settings on machine are too low
- 3.) an image is taken through the domed portion of the ALMV rather than through the leaflets.
What are 3 things that can cause an underestimation of MVA using planimetry?
- 1.) Receiver gain too high
- 2.) Lack of lateral resolution
- 3.) Areas of calcification at orifice making margins difficult to see.
If we are overestimating the MVA with planimetry what are we doing with the measure of MVA?
Making it look better than what it is.
If we are underestimating the MVA with planimetry what are we doing with the measure of MVA?
Making it look worse than what it is.
What pathology is quantitated with color?
Which is with doppler?
Color = AI, PI, TR, MR
Doppler = stenosis
Where in the protocol is the Pressure Half Time measured for MS?
4 chamber with CW
When is pressure half time not to be used?
Is meant to be used?
on prothetic valves
When we look at the E-F slope on MV what are we looking at?
looking at the drop in pressure and flow
What are the Pressure Half Time pit-falls?
anything that will alter the pressure in the LV or change LV compliance
What are 4 things that will change the LV pressure and compliance and affect Pressure Half Time?
- 1.) AI
- 2.) A-Fib
- 3.) AS
- 4.) Stiff non-compliant ventricle
What is Lutembacher's Disease?
Don't know if?
More common in...
Could cause (3)
- Patient has MS and an ASD which causes RVVO.
- Rheumatic or congenital
- 1.) cyanosis due to increase LA pressure
- 2.) pulmonary HTN
- 3.) heart failure
What does MAC stand for?
What can it cause?
Mitral Annular Calcification
What diseases may be associated with MAC?
Are they volume or pressure overload conditions?
- 1.) HTN
- 2.) AS
- 3.) Hypertrophic cardiomyopathy
What are some predisposing factors of MAC?
- 1.) advanced age
- 2.) female gender
- 3.) stress on mitral valve annulus
What is an Parachute MV?
What can it cause?
A unifocal attachment of the chordae to a single or dominant papillary muscle.
What is Rheumatic fever?
a diffuse, inflammatory disease that is caused by group A-B-Hemolytic streptococcus.
How does Rheumatic fever affect the heart?
fibrotic changes cause fusion of the cusps at the commissures leading to shortening, thickening and fusion of the chordea producing a funnel shape valve.
Where does Rheumatic fever first affect and than spread to?
starts at the tips and spreads towards the annulus.
than spreads to the chordae and throughout the apparatus.
When does Rheumatic fever affect adults? (3)
- 1.)15 to 20 years after having rheumatic fever.
- 2.) Patients in their 30's or 40's
- 3.) Probably had it in their teens.
Does Rheumatic Fever affect children? (2)
1.) Yes. Occurs in 5-15 year olds.
2.) May occur 2 to 3 weeks after infection
How many people who have streptococcal throat infection will get rheumatic fever?
What must the patient have to get Rheumatic fever?
fever 104 degrees by day two
What are 5 major criteria for diagnosing Rheumatic disease?
- 1.) Arthritis
- 2.) Carditis
- 3.) Chorea
- 4.) Subcutaneous nodules -rare
- 5.) Erythema marginatum
What is arthritis?
an inflammation of the joints
What is carditis?
inflammation of the heart lining- Pericardium
What will be present with carditis? (2)
2.) Erythema marginatum
What is Chorea?
Who gets it more often?
produces involuntary movement of and facial grimaces.
not often in adults expect for pregnant women.
What are subcutaneous nodules?
Nodules that develop on elbows, knees or wrists.
What is Erythema marginatum? (4)
- 1.) Skin rash that is on the chest, abdomen, and inner arms and thighs.
- 2.) Is not itchy.
- 3.) Occurs in 2-10% of patients
- 4.) Occurs only if patients also have carditis
For minor Criteria diagnosing Rheumatic fever?
- Have to have both of these!!!
- 1.) Fever > 104
- 2.) Positive cultures for streptococcus.
Acute Rheumatic affects what valves the most?
What valve the least?
MV and AV the most
PV and TR the least
What should you look for with Acute Rheumatic Fever?
2.) pericardial effusion