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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
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What is an congenital parachute MV?
a unifocal attachment of the chordae to a single papillary muscle
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What arrhythmia is common with longstanding MS?
A-Fib
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What is hemoptysis?
coughing up bloody septum
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When does pulmonary congestion occur with MS?
usually develops when MVA is 1.1- 1.5 cm2
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What is Ortner's syndrome?
hoarsness
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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
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What is the murmur of MS?
a diastolic rumble, opening snap
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5 Complications of MS
- 1.) LA thrombus due to stasis in LA
- 2.) Embolization
- 3.) A-Fib
- 4.) Pulmonary hypertension
- 5.) Vegetations
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When is surgery done for MS?
Patient is symptomatic and MVA is less than 1.0 cm2.
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What are two types of surgery to fix MS?
1.) closed MV commissurotomy
2.) open heart valve replacement
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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
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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
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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
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Will the LV appear normal size with MS?
yes
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What is another name for diastolic "doming" of the anterior MV?
"hockey-stick"
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What is concordant motion the MV?
Anterior motion of the posterior leaflet in diastole.
(the posterior leaflet is pulled anteriorly when the valve opens)
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What measurement is considered LA dilated?
> 4 cm
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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
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What velocity is considered to be stenotic with the MV?
> 1.5 m/s
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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
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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
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What way out of the 4 ways to Quantitate for MS is the most accurate?
Why?
Planimetry
Not influenced by hemodynamics, only by image limitations.
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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.
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A greater Pressure Half Time collates with what?
Smaller MVA and more severe MS.
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A lesser Pressure half Time collates with what?
Larger MVA and less severe MS.
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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.
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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.
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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.
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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.
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What pathology is quantitated with color?
Which is with doppler?
Color = AI, PI, TR, MR
Doppler = stenosis
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Where in the protocol is the Pressure Half Time measured for MS?
4 chamber with CW
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When is pressure half time not to be used?
Is meant to be used?
on prothetic valves
Native vessels
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When we look at the E-F slope on MV what are we looking at?
looking at the drop in pressure and flow
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What are the Pressure Half Time pit-falls?
anything that will alter the pressure in the LV or change LV compliance
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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
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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
- Women
- 1.) cyanosis due to increase LA pressure
- 2.) pulmonary HTN
- 3.) heart failure
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What does MAC stand for?
What can it cause?
Mitral Annular Calcification
MS
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What diseases may be associated with MAC?
Are they volume or pressure overload conditions?
- 1.) HTN
- 2.) AS
- 3.) Hypertrophic cardiomyopathy
Pressure overloads
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What are some predisposing factors of MAC?
- 1.) advanced age
- 2.) female gender
- 3.) stress on mitral valve annulus
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What is an Parachute MV?
What can it cause?
A unifocal attachment of the chordae to a single or dominant papillary muscle.
MS
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What is Rheumatic fever?
a diffuse, inflammatory disease that is caused by group A-B-Hemolytic streptococcus.
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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.
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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.
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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.
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Does Rheumatic Fever affect children? (2)
1.) Yes. Occurs in 5-15 year olds.
2.) May occur 2 to 3 weeks after infection
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How many people who have streptococcal throat infection will get rheumatic fever?
3%
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What must the patient have to get Rheumatic fever?
fever 104 degrees by day two
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What are 5 major criteria for diagnosing Rheumatic disease?
- 1.) Arthritis
- 2.) Carditis
- 3.) Chorea
- 4.) Subcutaneous nodules -rare
- 5.) Erythema marginatum
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What is arthritis?
an inflammation of the joints
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What is carditis?
inflammation of the heart lining- Pericardium
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What will be present with carditis? (2)
1.) MR
2.) Erythema marginatum
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What is Chorea?
Who gets it more often?
produces involuntary movement of and facial grimaces.
not often in adults expect for pregnant women.
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What are subcutaneous nodules?
Nodules that develop on elbows, knees or wrists.
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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
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For minor Criteria diagnosing Rheumatic fever?
- Have to have both of these!!!
- 1.) Fever > 104
- 2.) Positive cultures for streptococcus.
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Acute Rheumatic affects what valves the most?
What valve the least?
MV and AV the most
PV and TR the least
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What should you look for with Acute Rheumatic Fever?
1.) MR
2.) pericardial effusion
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