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What is the definition of MR?
is the back flow of blood into the LA in systole.
What are 4 things does the normal systolic closure of the MV depend on?
- 1.) integrated function of the mitral leaflets
- 2.) chordae tendinae
- 3.) papillary muscles
- 4.) adjacent left ventricular myocardium
9 Conditions that result in MR include:
- 1.) Rheumatic heart disease
- 2.) Mitral Valve prolapse
- 3.) CAD
- 4.) MAC or Mitral Annular Calcification
- 5.) Bacterial endocarditis
- 6.) Hypertrophic cardiomyopathy
- 7.) Connective Tissue disorders (Marfan's Syndrome)
- 8.) Any condition resulting in left ventricular enlargement
- 9.) Perforation of the mitral valve leaflet
Conditions that may cause Acute MR (3)
- 1.) Flail chordae tendinae or flail leaflet
- 2.) Ruptured chordae tendinae or papillary muscle
- 3.) Perforation of mitral valve leaflet
Symptoms of MR (6)
- 1.) Fatique
- 2.) Exertional dyspnea
- 3.) Orthopnea
- 4.) A Fib
- 5.) Soft blowing pansystolic murmur
- 6.) Displacement of a barium filled esophagus by an enlarged left atrium
Physiology of MR (4)
- 1.) LA dilated
- 2.) Pressure increases due to increase in volume.
- 3.) LV dilated and may become hyperdynamic (frank starling law)
- 4.) more force is required to eject the extra volume of blood into the aorta
What does the V wave stand for?
When does it occur?
- Ventricular systole
- Occurs: the end of ventricular contraction
- Why: the buildup of blood in the atria while the AV valves are closed during ventricular contraction.
- Ends: when the AV valves open.
Mitral Valve Prolapse Definition:
Posterior displacement of one or both mitral valve leaflets toward the left atrium.
Downward displacement occurs in late systole or throughout systole or holosystolic.
What are 4 other names for Mitral Valve Prolapse?
- 1.) Barlow's syndrome
- 2.) Floppy valve syndrome
- 3.) Systolic click-murmur syndrome
- 4.) Ballooning mitral valve
Who has MVP?
- Common with young thin women between the ages of 25 to 35 years.
- Can commonly have anorexia nervosa and be a ballet dancer.
What is important before diagnosing MVP? (3)
- Make sure it is it with echo don't rely on murmur.
- Patient will need antibacterial prophlaxis.
- Emotional burden of having a heart disease.
Symptoms of MVP (7)
- 1.) Most are asymptomatic
- 2.) Angina and sharp sticking pain
- 3.) Dyspnea may be at rest.
- 4.) Severe fatique
- 5.) Anxious
- 6.) Palpitations and arrhythmias
- 7.) Dizziness and syncope
Physical Appearance of people with MVP (5)
- 1.) May look normal
- 2.) Loss of normal thoracic kyphosis
- 3.) Pectus excavatum (depression of the sternum)
- 4.) Scoliosis (lateral curvature of the spine)
- 5.) May be very thin.
Murmur of MVP
mid to late systolic click with or without a systolic murmur
Complications of MVP (4)
- 1.) Progressive MR with worsening prolapse
- 2.) Bacterial endocarditis will more readily grow on an abnormal valve.
- 3.) TIA from emboli
- 4.) Sudden death, not common
Murmur of MR
soft blowing pansystolic murmur
Associated Abnormalities with MVP (4)
- 1.) MR
- 2.) Tricuspid prolapse
- 3.) Marfan's Syndrome (Valsalva aneurysms and dilated aorta)
- 4.) ASD's
What is the treatment for MVP? (2)
- None, expect antibiotic prophylaxis to avoid endocarditis.
- If MR severe than MVR.
What way will an MR jet be directed if an anterior leaflet prolapses?
What way will an MR jet be directed if an posterior leaflet prolapses?
What 3 things may cause a misdiagnoses of MVP?
- 1.) TDX too low = may miss the diagnoses.
- 2.) TDX too high = may give a false MVP diagnoses.
- 3.) Never diagnoses MVP when the patient has pericardial effusion. (The swinging heart will make the mitral valve look like it is prolapsing).
M-Mode Findings of MVP (DRAW IT)
When can MVP happen doing the cardiac cycle with M-Mode? (2)
1.) Late systolic prolapse
2.) Holosystolic prolapse
What M-Mode Findings should not be mistaken for MVP? (DRAW IT)
What is Latent Mitral Valve Prolapse?
When the MVP is hidden and can not be heard if patient is lying down.
When can latent MVP be heard?
- When a patient stands up or any provocative maneuver.
- Anything that reduces the left ventricular volume or creates tachycardia.
- 1.) Valsalva maneuver
- 2.) Standing from a lying position
- 3.) Amyl nitrate (a vasodilator)
What could make MVP less obvious? (4)
- 1.) Squatting
- 2.) Beta blockers such as Propranolol
- 3.) Bradycardia
- 4.) Anything that increases LV volume.
What do Beta blockers such as Propranolol do? (3)
- 1.) Decrease HR
- 2.) Decrease contractility
- 3.) Decrease cardiac output
How does CAD cause MR? (3)
- 1.) CAD causes myocardial ischemia
- 2.) which causes left ventricular dysfunction and papillary muscle dysfunction
- 3.) which causes permanent or transient MR
2D findings for MR with CAD (3)
- 1.) Enlarged LV
- 2.) Incomplete closure of mitral apparatus.
- 3.) Global or regional wall motion abnormalities causing scarring of pap muscle
M-Mode Findings for MR with CAD (2)
- 1.)Decreased D-E excursion of MV
- 2.) Early closure of AV in response to increased volume overload.
How does MAC cause MR?
Shortening of the valve leaflets due to the calcification and fibrosis of the ring and surrounding structures.
What portion of the MV is more commonly involved with MAC?
Can both be affected?
Posterior portion more common.
Both can be affected. (anterior and posterior)
What is another name for Bacterial Endocarditis?
SBE or subacute bacterial endocarditis
What bacteria is Endocarditis caused by?
Hemolytic streptococcus or staphylococcus
How does Endocarditis affect the heart? (3)
- 1.) Bacteria attacks the valves.
- 2.) Turns itself into vegetation that attack abnormal or damaged valves.
- 3.) Vegetations are usually found on the low-pressure side of the valve.
Who is most likely to present with endocarditis? (7)
- 1.) IV drug abusers
- 2.) Rheumatic heart disease
- 3.) Patients with congenital cardiac defects
- 4.) Patients post-op cardiac surgery
- 5.) Patients with MVP
- 6.) 2-4% of patients with prosthetic valves
- 7.) Bicuspid AV
Symptoms/Presentations of Endocarditis (3)
- 1.) Fever
- 2.) Changed murmur
- 3.) Positive blood cultures
Complications of Endocarditis (4)
- 1.) Embolization of fragments
- 2.) Abscessess- literally eating away of healthy tissue
- 3.) Ruptured chordae tendinae
- 4.) Severe MR
What two valves are usually involved in endocarditis?
If there is Endocarditis on the MV where will it be?
on the LA side of the MV
What is the smallest vegetation we can see with TEE?
What are 3 2D findings of Bacterial Endocarditis?
- 1.) appears shaggy, bright mass
- 2.) vegetations move with the valves, flopping
- 3.) appear on low pressure side of valve
Is there a reduction in valve motion usually seen with Endocarditis?
No reduction in valve motion is usually seen
What are 3 M-Mode findings of Bacterial Endocarditis?
- 1.) Normal motion of the mitral leaflets
- 2.) Leaflets look thickened and very bright
- 3.) Valves look shaggy
What are some causes of Chronic MR? (7)
- 1.) Cardiomyopathy
- 2.) Connective tissue disorders
- 3.) Marfan's Syndrome
- 4.) Ehler-Danlos Syndrome
- 5.) Hurlur's Syndrome
- 6.) Osterogenesis Imperfecta
- 7.) Dilated Cardiomyopathy
What is Marfan's Syndrome? (3)
- 1.) A connective tissue disorder.
- 2.) Weakens the aorta
- 3.) Can cause MVP and dilated AO ROOT
What is Ehler's-Danlos Syndrome? (3)
- 1.) A connective tissue disorder.
- 2.) Hyperelasticity of the skin
- 3.) Can cause MVP
What is Hurlur's Syndrome?
It is associated with abnormal metabolism of mucoploysaccharides which can involve the tissues of the valves
What is Osteogenesis Imperfecta? (2)
- 1.) A conditon of brittle bones.
- 2.) Can cause chordal rupture causing MR
What are some causes of Acute MR? (2)
- 1.) Frail MV
- 2.) chordae torn from papillary muscle
What are two main causes of flail leaflets?
- 1.) ruptured chordae tendinae
- 2.) ruptured papillary muscle
Which leaflet is more commonly flail?
What are some symptoms of Acute MR?
sudden onset of heart failure and usually sinus rhythm and not A Fib
harsh ejection murmur not pansystolic and blowing
What are 2D findings of Flail MV? (3)
- 1.) Seeing the tips of the leaflet in LA during systole and LV during diastole
- 2.) Coarse, disorganizated flutter of the leafelts during diastole and systole
- 3.) Normal sized LA
Will the LA be normal size with Flail MV?
yes normal size
What M-Mode finding with Flail Mitral valve?
Coarse disorganizated diastolic flutter of the mitral leaflet that is flail
What is the treatment for Flail MV? (3)
1.) Drug therapy to reduce preload.
2.) It can help reduce pulmonary congestion and stabilize the patient until surgery.
3.) Surgery is usually needed.
What can MR be confused with?
Is MR a volume overload or a pressure overload?
MR starts as a volume overload which leads to a pressure overload.
Can MR go away if it is caused by LV functioning?
Is the LA dilated with acute MR?
NO, does not have time to dilate.
How does MR affect the esophagus?
the dilated LA pushes the esophagus to the side
What happens to the LV during MR?
- 1.) LV starts to work harder b/c it's not getting the blood it should be so it is trying to maintain the CO
- 2.) LV walls will thicken after time
- 3.) will have diastolic dysfunction
What happens to CO with MR?
When does MVP happen?
Does MVP cause symtpoms?
NO MS dos.
What is the only pathology linked to anxiety?
What happens to the LV volume when you stand up with MVP?
What will happen with the murmur when standing up?
Decrease the LV volume.
Make the MVP murmur get louder.
What will happen to HR when the LV volume decreases?
What is the most common cause of MR?