Medicine Marrow Pg 351-360 (Cardiology)
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Which of the following describes a feature of very severe mitral stenosis (MS)?

  • Increased cardiac output
  • Increased pulmonary capillary wedge pressure (correct)
  • A continuous murmur
  • Left ventricular hypertrophy

    • Tricuspid regurgitation is characterized by a notable absence of pulsations.

    False

    What is absent in atrial fibrillation during mitral stenosis?

    Pre-systolic accentuation

    The duration of the mid diastolic murmur (MDM) is influenced by the amount of blood entering the left atrium (LA), leading to an increase in ____________.

    <p>left atrial pressure (LAP)</p> Signup and view all the answers

    Match the following features with their corresponding descriptions:

    <p>A2-OS = Shortening of the A2-OS interval with a noise RVH = Right ventricular hypertrophy Loud S1 = Increased velocity of contraction causing delayed closure Pre-systolic Accentuation = Due to atrial contraction at the end of MDM</p> Signup and view all the answers

    Which of the following tests is specifically used to rule out left atrial clots?

    <p>TEE (Transesophageal Echo)</p> Signup and view all the answers

    New oral anticoagulants (NOACs) are recommended for patients with mitral stenosis.

    <p>False</p> Signup and view all the answers

    What is the primary indication for the use of indefinite warfarin in patients with mitral stenosis?

    <p>Atrial fibrillation or clots</p> Signup and view all the answers

    Calcific mitral stenosis typically necessitates _______.

    <p>valve replacement</p> Signup and view all the answers

    Match the following contraindications with their corresponding situations:

    <p>Calcific mitral stenosis = Requires valve replacement Thrombus formation = Increased risk of stroke Predominant regurgitation = Not suitable for PmBV(C)</p> Signup and view all the answers

    Which murmur is associated with pulmonary regurgitation?

    <p>Graham Steele murmur</p> Signup and view all the answers

    The Austin Flint murmur commonly occurs in patients with atrial fibrillation.

    <p>False</p> Signup and view all the answers

    What is a notable chest X-ray finding in patients with mitral stenosis?

    <p>Straightening of left heart border</p> Signup and view all the answers

    The sound of _____ is loud during mitral stenosis murmurs.

    <p>S1</p> Signup and view all the answers

    Match the following findings to their corresponding murmurs:

    <p>Atrial fibrillation = Mitral Stenosis Murmur Soft S3 = Austin Flint Murmur Loud S1 = Mitral Stenosis Murmur Hyperdynamic S2 = Austin Flint Murmur</p> Signup and view all the answers

    What condition is associated with hoarseness of voice?

    <p>Recurrent Laryngeal Nerve (RLN)</p> Signup and view all the answers

    Increased Left Atrial Pressure (LAP) can lead to hypotensive shock.

    <p>True</p> Signup and view all the answers

    What clinical sign indicates a prominent 'a' wave in Jugular Venous Pressure (JVP)?

    <p>Increased central venous pressure</p> Signup and view all the answers

    The associated symptom of ___________ is often seen in Chronic Bronchitis, characterized by blood streaked sputum.

    <p>hemoptysis</p> Signup and view all the answers

    Match the following symptoms with their corresponding conditions:

    <p>Dyspnea = Pulmonary Edema Hoarseness of voice = Recurrent Laryngeal Nerve (RLN) Blood streaked sputum = Chronic Bronchitis Capillary rupture = Pulmonary Apoplexy</p> Signup and view all the answers

    What is a key characteristic of acute mitral regurgitation (MR)?

    <p>Short systolic decrescendo murmur</p> Signup and view all the answers

    The Brockenbrough phenomenon is associated with increased left atrial pressure.

    <p>True</p> Signup and view all the answers

    What immediate treatment is indicated for acute mitral regurgitation?

    <p>Nitroglycerin or sodium nitroprusside</p> Signup and view all the answers

    In mitral valve prolapse (MVP), the intensity of the murmur is __________.

    <p>unchanged or decreased</p> Signup and view all the answers

    Match the following features with their corresponding conditions:

    <p>Increased left atrial pressure = Acute MR Normal cavity size = MVP Cool extremities = Cardiogenic shock Short systolic decrescendo murmur = Acute MR</p> Signup and view all the answers

    What is the primary function of pericardial fluid?

    <p>Transmission of pressures</p> Signup and view all the answers

    The outer parietal layer of the pericardium is pain insensitive.

    <p>False</p> Signup and view all the answers

    What condition is characterized by a fall in systolic blood pressure of more than 10 mm Hg during inspiration?

    <p>Pulsus paradoxus</p> Signup and view all the answers

    Increased right heart filling causes the septum to be pushed to the left, resulting in decreased __________.

    <p>Cardiac Output</p> Signup and view all the answers

    Match the following layers of the pericardium with their respective features:

    <p>Outer Parietal = Pain sensitive Inner Visceral = Pain insensitive Pericarditis = Associated disease of the outer layer Acute Rheumatic Fever = Associated disease of the inner layer</p> Signup and view all the answers

    Which of the following signs is associated with systolic retraction of the apex?

    <p>Broadbent's sign</p> Signup and view all the answers

    Cardiac tamponade typically presents with low ECG voltage.

    <p>True</p> Signup and view all the answers

    What is the definitive treatment for constrictive pericarditis?

    <p>Pericardial resection</p> Signup and view all the answers

    The characteristic clinical sign observed in both cardiac tamponade and restrictive cardiomyopathy is __________.

    <p>Kussmaul's sign</p> Signup and view all the answers

    Match the following cardiac conditions with their characteristics:

    <p>Cardiac Tamponade = Prominent x descent Constrictive Pericarditis = Thickened pericardium with calcification Restrictive Cardiomyopathy = Pericardial knock All = Low ECG voltage</p> Signup and view all the answers

    What is the mitral valve area indicative of severe mitral stenosis?

    <p>≤1.5 cm²</p> Signup and view all the answers

    Dyspnea is significantly increased during stress or exercise in patients with mild to moderate mitral stenosis.

    <p>True</p> Signup and view all the answers

    Name one common presentation of patients experiencing mild to moderate mitral stenosis.

    <p>Orthopnea</p> Signup and view all the answers

    In mitral stenosis, a reduction in the diastolic filling time can lead to _____________ due to increased LAP.

    <p>dyspnea</p> Signup and view all the answers

    Match the following mitral stenosis symptoms with their corresponding details:

    <p>Orthopnea = Difficulty breathing while lying flat Paroxysmal nocturnal dyspnea = Sudden shortness of breath at night Pulmonary edema = Fluid accumulation in the lungs Dyspnea on tachycardia = Shortness of breath during rapid heart rate</p> Signup and view all the answers

    What is a common cause of mitral stenosis?

    <p>Rheumatic heart disease</p> Signup and view all the answers

    Mitral stenosis typically leads to a gradual decrease in life expectancy within 5 years if untreated.

    <p>True</p> Signup and view all the answers

    What structural change occurs in the mitral valve during the progression of mitral stenosis?

    <p>Commissural fusion and calcification</p> Signup and view all the answers

    The normal surface area of a mitral valve ranges from _______ cm².

    <p>4-6</p> Signup and view all the answers

    Match the mitral valve components with their descriptions:

    <p>Anterior leaflet = Attached to annulus Chordae tendineae = Attached to papillary muscle Posterior leaflet = Consists of 3 lobes Lateral papillary muscle = Helps support mitral valve function</p> Signup and view all the answers

    What is the most common etiology of Chronic Constrictive Pericarditis (CCP)?

    <p>Repeated acute viral pericarditis episodes</p> Signup and view all the answers

    Pulsus paradoxus is present in most patients with Chronic Constrictive Pericarditis.

    <p>False</p> Signup and view all the answers

    What significant hemodynamic change is observed during diastole in patients with Chronic Constrictive Pericarditis?

    <p>Dysfunction with elevation and equalization of diastolic pressure in all four chambers.</p> Signup and view all the answers

    In Chronic Constrictive Pericarditis, the pericardium becomes __________, leading to impaired ventricular filling.

    <p>rock-like</p> Signup and view all the answers

    Match the Jugular Venous Pulse (JVP) features with their descriptions:

    <p>X-descent = Sharp, rapid decline due to normal atrial relaxation during systole Y-descent = Sharp descent indicating atrial emptying during initial diastole Kussmaul's sign = Increased JVP with inspiration</p> Signup and view all the answers

    Study Notes

    Severe Mitral Stenosis

    • Increased Pulmonary Capillary Wedge Pressure (PCWP)
    • Elevated Pulmonary Artery End-Diastolic Pressure (PAEDP) leads to Pulmonary Hypertension (PHTN)
    • Right Ventricular Hypertrophy (RVH)
    • Tricuspid Regurgitation (TR)
      • Loud, palpable murmur
      • Prominent pulsations
      • Parasternal heave
      • Prominent v wave
    • Theory of Second Stenosis: Pulmonary vasoconstriction reduces blood entering the left atrium, leading to transient improvement in symptoms, but ultimately resulting in worsening Mitral Stenosis.
    • Left Ventricular (LV) failure is a leading cause of decreased cardiac output in very severe Mitral Stenosis.

    Mitral Stenosis (MS) Echocardiogram

    • Transthoracic Echocardiogram (TTE)
    • Transesophageal Echocardiogram (TEE) is used to rule out left atrial (LA) clots and tumors mimicking MS, such as left atrial myxoma.

    Mitral Stenosis (MS) Treatment

    • Indefinite warfarin for patients with atrial fibrillation (AF) and blood clots.
    • New Oral Anticoagulants (NOACs) are not indicated in MS or prosthetic valve issues.
    • Percutaneous Mitral Balloon Valvotomy (PMBV(C)) (Commisurotomy)

    Mitral Stenosis (MS) Contraindications for PMBV(C)

    • Calcific MS requires valve replacement.
    • Presence of thrombus formation.
    • Predominant regurgitation.

    Mitral Valve Replacement

    • Beta-blockers play a crucial role in managing heart rate (life-saving).

    Mitral Stenosis (MS) Murmurs

    • A2-OS:
      • A2 (closure of active valves)
      • IVR (Isovolumetric Relaxation Period)
      • Opening snap (OS)
      • Shortening of A2-OS interval is associated with the severity of MS.
    • Duration of the Murmur:
      • Begins at the end of IVR
      • Incomplete opening of the mitral valve
      • Increased Left Atrial Pressure (LAP) leads to a longer murmur duration and increased severity of MS.
      • Mid-diastolic (decrescendo) murmur (MDM)
    • Pre-Systolic Accentuation:
      • Attributed to atrial contraction at the end of MDM.
      • Absent in atrial fibrillation (AF).
    • Loud S1:
      • Due to the position of the leaflet at the end of diastole, open and at the bottom, increasing the velocity of contraction.
      • Delayed closure.

    Mitral Stenosis (MS) vs. Austin Flint Murmur

    Feature Mitral Stenosis Murmur Austin Flint Murmur
    Rhythm Atrial fibrillation frequent Generally sinus rhythm
    Apex Tapping
    S1 Loud
    S2 +++ Hyperdynamic
    S3 Absent Soft
    Pulmonary hypertension Present Absent
    ECG findings + in AR with failure
    P pulmonale Increased P wave amplitude
    P mitrale Enhanced second hump in lead II Enhanced negative deflection in VI

    Mitral Stenosis (MS) Management

    • Investigations:
      • Chest X-ray (CXR) findings: Straightening of the left heart border, possible hypoplastic aorta, dilated pulmonary artery, LVH, cavity site.
    • AHA Classification:
      • Mild: Mitral Valve Area (MVA) > 1.5 cm²
      • Moderate: MVA ≤ 1.5 cm²
      • Severe: MVA ≤ 1.0 cm²
      • Very Severe: Not defined in the provided text.
    • Note:
      • Tricuspid valve is the largest in the body.
      • Mitral Stenosis is the most common valvular abnormality in Acute Rheumatic Fever.

    Mitral Stenosis (MS) Cardiac Events

    • Cardiac Cycle During Diastole:
      • Sa (closure of Aortic and Pulmonary Valves)
      • IVR (Isovolumetric Relaxation Period): The mitral valve opens incompletely at the end of IVR.
      • Rapid Filling
      • Reduced Filling
      • Atrial Systole

    Mild to Moderate Mitral Stenosis (MS)

    • Dyspnea is common with increased PCWP, elevated LAP, tachycardia, and lowered filling time due to shortened diastole.
    • Management: Beta-blockers to maintain a low heart rate.

    Pericardium

    • Anatomy:
      • Outer Parietal: Fibrous, somatopleuric mesoderm, pain-sensitive, associated with Pericarditis.
      • Inner Visceral: Collagen + Elastic fibers, splanchnopleuric mesoderm, pain-insensitive, associated with Acute Rheumatic Fever only.
    • Pericardial fluid: 50mL.
    • Functions:
      • Transmission of pressures
      • Interventricular dependence
      • Transmyocardial filling pressure
      • Concordance of systolic pressures, Discordance of diastolic pressures during inspiration

    Mitral Regurgitation

    • Brockenbrough Phenomenon: Post-ventricular premature contraction.
    • Compensatory Pause:
    • Prolonged Filling (↑ preload):
    • Notes:*
    In HCM In MVP
    Force of Contraction ↑ ↑
    Intensity of Murmur ↑ unchanged / ↓
    Gradient ↑ ↓
    Cavity Size Normal
    Duration of Murmur ↑
    Standing/Valsalva ↓preload
    After VPC unchanged/ ↓

    Acute Mitral Regurgitation (MR) Pathogenesis

    • Papillary muscle rupture or chordae rupture
    • Acute regurgitation into a non-compliant Left Atrium, leading to:
      • Increased LAP
      • Increased PCWP
      • Dyspnea (Pulmonary edema)
    • Reduced LV systolic function.
    • Short systolic decrescendo murmur

    Chronic Constrictive Pericarditis (CCP)

    • Etiology:
      • Repeated acute viral pericarditis episodes (most common)
      • Tuberculosis (TB) (second most common)
      • IgG4 related disease
    • Pathophysiology:
      • Symmetric fibrosis, thickening and calcification = rock-like pericardium, Impaired ventricular filling.
    • Hemodynamics:
      • Normal during systole (initial ⅓)
      • Dysfunction during diastole (later ⅔)
      • Increased Right Atrial Pressure (RAP), SVC, and IVC pressure
      • Right Heart Failure (RHF) with edema, ascites, and hepatomegaly
      • Late diastole: Elevation and equalization of diastolic pressure in all four chambers, resulting in no filling.
    • Pulse:
      • Pulsus paradoxus (in 1/3 of patients).
    • Jugular Venous Pulse (JVP):
      • Prominent x descent
      • Prominent y descent
      • Kussmaul's sign: JVP increase with inspiration
    • Ventricular Pressures:
      • Square root sign
    • Pericardial Knock:
      • Early dip
      • Plateau
      • Rapid filling

    Cardiac Tamponade (CT)

    • Core Emergency
    • Abrupt rise in pericardial pressure due to fluid accumulation
    • Most common cause: Trauma

    Mitral Stenosis (MS)

    • Normal valve surface area: 4-6 cm²
    • Components:
      • Anterior annulus
      • Posterolateral commissure
      • Posterior annulus
      • Lateral papillary muscle
    • Anterior leaflet: Attached to annulus
    • Anteromedial commissure: Attached to annulus
    • Posterior leaflet: Attached to annulus (3 lobes)
    • Chordae Tendineae: Attached to papillary muscle
    • Medial Papillary Muscle: Single vessel supply involved
    • Adjacent LV myocardium
    • Etiology:
      • Rheumatic heart disease:
        • Latent period: 2 decades
        • Symptomatic without intervention: Death in 2-5 years
    • Pathology:
      • Acute Rheumatic Fever + valvulitis associated with MR (15-20 years)
      • Rheumatic heart disease (40% of patients)
    • Progression:
      • Chronic inflammation progresses to commisural fusion, calcification, and immobilization of the valve leaflet, leading to stenosis and predisposition to thrombosis.
    • Additional Notes:
      • Fish mouth deformity
      • Fish mouth appearance of the valve

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    Description

    This quiz provides an in-depth overview of severe mitral stenosis, focusing on its clinical manifestations, echocardiographic findings, and treatment options. Important concepts, such as the effects on pulmonary pressures and right ventricular hypertrophy, are highlighted to enhance understanding. Test your knowledge about this critical cardiac condition and its management.

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