Echo 2 > C8: Mitral Stenosis > Flashcards

C8: Mitral Stenosis Flashcards

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1
Q

define MS

A

incomplete opening of the MV during diastole w/ thickened MV leaflets

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2
Q

which valve does rheumatic fever effect first

A

MV

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3
Q

3 layers of the MV leaflets

describe them

A

from ventricle side to atrial side:

fibrosa: provides structural support and stiffness when valve is closed
spongiosa: provides flexibility, contains less dense tissue
atrialis: smooth layer composed of endocardial cells that line the whole atria

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4
Q

which MV leaflet is more complex

how

A

AML, one layer extends mediallu towards the AV to form the aorto-mitral curtain

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5
Q

do both MV leaflets cover the same area of the valve orifice

A

yes, approx…. AML is longer and occupies up 1/3 of the MV annulus, PML is shorter and occupies 2/3 of MV annulus

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6
Q

how are the MV scallops labeled

A

lateral to medial, 1-3

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7
Q

which MV leaflet is more susceptible to MAC

A

PML

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8
Q

3 functions of chordae tendinae

how many are there

A

anchoring the valve
maintain ventricular geometry
prevent prolapse during systole

120

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9
Q

main function of pap muscles

A

contract during systole to hold the valve closed

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10
Q

describe the position and structure of the PM pap muscle

A

on the inferior wall of the LV (seen from PSAX adjacent to the septum)

has 2 bodies that trifurcate into 3 heads

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11
Q

blood supply for PM pap muscle

A

posterior descending A

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12
Q

describe the position and structure of the AL pap muscle

A

on the anterolateral wall of the LV (seen from PSAX near LV free wall)

had 1 body that bifurcated into 2 heads

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13
Q

blood supply for AL pap muscle

A

left anterior descending A and circumflex A

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14
Q

which pap muscle is more susceptible to complications from ischemia or infarction

A

PM pap muscle because it only has 1 artery supplying it

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15
Q

4 etiologies on MS

A
  1. rheumatic fever
  2. degenerative (MAC)
  3. congenital
  4. masses
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16
Q

describe how rheumatic fever causes MS

A

inflammation causes swelling and then scarring of the leaflets, starts at the leaflet tips… will eventually lead to calcifications

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17
Q

how are the commissures effected w/ rheumatic MS

chordae?

A
  • theyre thickened and fibrosed

- matted and shortened (think rheu’matted’ fever)

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18
Q

characteristic appearance of MV w/ rheumatic MS

A

fish mouth

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19
Q

describe how degeneration (MAC) causes MS

A

calcification of the MV annulus that usually starts at the posterior basal annulus and progresses inwards to the leaflets

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20
Q

which area of the MV is usually spared w/ MAC

A

leaflet tips

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21
Q

MAC is associated w/ which conditions

A 
HTN
diabetes
hypercalcemia
age
Marfan's syndrome
renal dialysis
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22
Q

describe the congenital causes of MS

A

usually involves subvalvular apparatus like a single pap muscle

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23
Q

term for a single pap muscle

A

parachute MV

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24
Q

what types of masses may cause MS

A

large MV vegetation from bacterial endocarditis

large LA myxoma

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25
describe the pathophysiology of MS in the heart
reduce opening of MV leads to increased LA pressure, this increases PV, lung and PA pressure and evetually increases RVSP and RA press which leads to TR
26
describe the pathophysiology of MS in body
increase RH press leads to increase venous press w/ hepatomegaly, pedal edema, sometimes distended JVs
27
which arrhythmia is common w/ severe MS
A fib
28
symptoms of MS are similar to which other condition
backwards HF
29
w/ MS, does LV and LA pressure equalize during diastasis why
no, you'll lose diastasis and will see forward flow into the LV instead theres a smaller opening for blood to pass through so press takes longer to drop
30
what kind of murmur is heard w/ MS
diastolic rumble at apex
31
3 symptoms of MS
dyspnea reduced execise capacity (SOBOE) fatigue
32
what factors can make the symptoms of MS worse
``` any increase in HR or CO: fever anemia preg hyperthyroidism rapid arrhythmia ```
33
complications of MS
``` a fib atrial enlargement blood clots and thromboembolism hempotysis endocarditis ```
34
what is hempotysis
frothy, bloody sputum in the lungs
35
w/ MS would you measure the thickness of the valve leaflets how do you do this
yes zoom on the MV, scroll until valve is at maximal opening and well seen, measure both leaflets
36
4 important doppler parameters to grade MS severity
mean trans-mitral press gradient (important) - trace VTI MV area - measure PHT pulmonary artery pressures MR also do continuity equation
37
rheumatic MS 2D appearance
commissural fusion: leads to doming of the AML and restricts the movement of the PML restricted motion
38
whats the characteristic MV appearance of rheumatic MS
hockey stick
39
w/ the MV have the double bump w/ MS
no
40
norm value for MV leaflet thickness
1-2 mm
41
characteristic of severe MAC
posterior shadowing in and behind the LA
42
can the chordae be effected by MAC
yes
43
another term for MAC
mitral sclerosis
44
what is a cor triatriatum sinister
a perforate LA membrane that impedes flow of blood from LA to LV and causes a gradient b/w the LA and LV
45
are there any symptoms unique to cor triatriatum sinister
no, same as other types of MS
46
is the MV usually norm w/ cor triatriatum sinister
yes
47
what does the severity of the cor triatriatum sinister depend on
the size of the perforation(s) in the membrane, eg. how easily blood can get through
48
describe a LA myxoma
most common primary tumor in the heart, most are benign... often attached to the fossa ovalis w/ a peduncle/foot
49
US appearance of a LA myxoma
globular, fine speckld appearance
50
what can happen if a LA myxoma is large
prolapse into the MV during diastole and cause functional MS
51
what is a parachute MV associated w/ which syndrome
a single pap muscle that often placed too far superior in the LV shone's syndrome
52
5 anomalies of shone's syndrome
``` supravalvular ring parachute MV subAO stenosis bucuspid AV Ao coarctation ```
53
how do you do MV planimetry is it accurate
zoom on the MV in PSAX and trace around the blood tissue interface can be the most accurate method to quantify MS if done properly
54
what does the accurate on MV planimetry depend on
ability to clearly see the orifice tracing orifice directly at leaflet tips gain settings operator skill
55
if you transect the MV above the leaflet tips, how will that effect MV planimetry
will underestimate its severity
56
MS on M-mode
reduced excursion on MV, loss of double bump and diastasis, tracing will be brighter
57
when is the only time we do colour on the MV in PSAX
if theres MR
58
is you have MS, would your MV inflow PW be accurate for assessing diastolic dysfunction what should you do
no, MS will cause the flow to be high velocity reply on TDI tracing instead
59
PW will alias over what velocity
2m/s
60
how do we get MV mean press gradient how does the machine calculate it
use CW through the MV inflow and trace the waveform... machine will give you the mean PG by applying 4(v^2) to each point on the trace and avg the values... this is done b/w the waveform is not parabolic and the PG varies throughout diastole
61
how can HR effect the MV mean press gradient value what about preload
Lower HR will result in a smaller waveform for mean PG is underestimated can be over or underestimated w/ changes in preload
62
MV mean press gradient value for mild MS severe
mild: < 5 mmHg severe: >10 mmHg
63
how does MS effect PHT
the rate of atrial emptying in slowed due to a narrowed orifice which prolongs the decline on early diastolic PG b/w the LA and LV... PHT will be prolonged
64
how are MV area and PHT related
inversely... press fall slower w/ a more stenotic valve b/c the PG is maintained for longer
65
formula for MV area
MV Area = 220 / PHT
66
how is DT effected w/ MS
prolonged, press fall slower w/ a more stenotic valve b/c the PG is maintained for longer
67
as MS gets more severe, how can the MV inflow A wave change
gets merged w/ the e wave
68
how do we measure MV area w/ the continuity method
calculate SV through the AV/a control valve using the LVOT and LVOT VTI, then we can measure the VTI of the MV inflow and extrapolate and MV area from that
69
can you use to continuity method to measure MS if you have mod-severe MR or AR
no, use PHT instead, or PISA, or use a different valve for the control valve
70
continuity equation formula for MV area
MVA = (pie (r^2) x VTI) of LVOT / VTI of MV you need LVOT diameter LVOT PW trace MV CW trace
71
2 sources of error when calculating MV area w/ continuity equation
incorrect measurement of LVOT area | incorrect doppler angle
72
continuity equation to measure MV area is less accurate in which conditions when would you not use this meathod
significant MR, AR ASD or other intracardiac shunt
73
which method for measuring MV area is the quickest
PHT
74
does TTE or TEE have better sensitivity for blood clots
TEE. TTE has high specificity but low sensitivity
75
why is it important to measure RVSP w/ MS
it tells you how the heart in handling the MS
76
can MS cause pulmonary hypertension is it reversible
yes at first, longstanding PHT causes irreversible increases and wont resolve even w/ MV surgery
77
what does timing of MV surgery depend on
LV/LA and Rv function
78
pharmacologic treatment for MS
beta blockers diuretics anticoagulation anti-arrhythmics you would try these before surgery
79
surgical treatment for MS
valve repair - cant be done if the cause is calcific balloon valvuloplasty commissurotomy (causes regurg) valve replacement bioprosthetic mechanical percutaneous
80
norm MV area
4-6 cm^2
81
MV area for mild MS severe
mild: >1.5 cm^2 severe: < 1 cm^2 same as mild/severe AS
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