Valvular Disorders: Mitral, Tricuspid, and Pulmonary Valve Stenosis and Regurgitation

Mitral Stenosis

  • Pulmonary hypertension can develop into right-sided heart failure, leading to:

    • Shortness of breath

    • Hemoptysis

    • Ascites

    • Peripheral edema

  • More prevalent in females during their third to fourth decade of life.

  • Common cause: Rheumatic fever

  • Other possible causes:

    • Aging

    • Congenital issues

    • Accidental complications from a repair

  • Symptoms range from asymptomatic to symptomatic, including:

    • Dyspnea (70% of symptomatic patients)

    • Fatigue

    • Orthopnea

    • Hemoptysis (due to pulmonary hypertension)

    • Hoarseness (due to left atrium pushing)

    • Atrial fibrillation (A-fib) is common

  • Mallor flush: Retention of carbon dioxide due to pulmonary hypertension causing low oxygen and high carbon dioxide; very rare.

  • Auscultation: Diastolic murmur; A-fib may or may not be heard.

  • Diagnostics:

    • Chest X-ray

    • EKG

    • Echocardiogram (Echo) - most important; may show a "fish mouth valve"

  • Management:

    • Treat the underlying cause.

    • Diuretics for peripheral edema and fluid retention.

    • Warfarin for A-fib.

    • Frequent echoes for monitoring (every 3-6 months to a year) in early stages.

    • Intervention (repair or replace) for stages C or D, based on stenosis severity, procedure risks, and patient's age.

    • Endocarditis prophylaxis for prosthetic valve replacement.

    • INR target for mitral valve replacement: 2.52.5 to 3.53.5 (higher than aortic valve due to increased clot risk).

Mitral Regurgitation

  • Backflow of blood through the mitral valve into the left atrium due to incomplete valve closure.

  • Can result from disease or anatomical issues, such as papillary muscle rupture post-heart attack.

  • Can be acute or chronic with primary (structural) or secondary causes.

  • Common causes:

    • Papillary muscle rupture post-MI

    • Old age

    • Congenital issues

    • Rheumatic fever

  • Symptoms: fatigue, dyspnea, orthopnea, heart failure symptoms, and A-fib.

  • Physical exam:

    • Holo-systolic or pan-systolic murmur (begins at the first heart sound and continues through systole)

  • Diagnostics: EKG, chest X-ray, echocardiogram (echo).

  • Treatment:

    • Treat the symptoms.

    • Admit for acute cases, likely requiring surgery.

    • For chronic cases: treat the cause, manage A-fib, consider surgery (repair or replacement).

Mitral Valve Prolapse

  • Floppy valve, also known as Barlow's disease.

  • Associated with degenerative disease, mitral regurgitation (early stages), and collagen abnormalities (Marfan's, osteogenesis imperfecta).

  • Typically affects thin, younger females (around 50 years old).

  • Symptoms: fatigue, dizziness, panic attacks, palpitations.

  • Physical exam: mid-systolic click (due to sudden leaflet prolapse).

  • Diagnostics: EKG, chest X-ray, echo (to confirm prolapse).

  • Treatment:

    • Reassurance.

    • Lifestyle changes (reduce caffeine and stress).

    • Beta-blockers for palpitations.

    • SSRIs for anxiety.

    • Surgical repair if necessary.

Tricuspid Stenosis

  • Narrowing of the tricuspid valve opening, restricting blood flow from the right atrium to the right ventricle; very rare.

  • Causes: rheumatic, prior tricuspid valve repair, or spread from left-sided valvular disease.

  • Results in right-sided heart failure symptoms:

    • Large liver

    • Ascites

    • Edema

  • Auscultation: diastolic murmur.

  • Diagnostics: EKG, chest X-ray, echo.

  • Treatment:

    • Diuretics to reduce fluid congestion.

    • Aldosterone inhibitors (spironolactone) for liver engorgement or ascites.

    • Valve replacement for severe cases.

Tricuspid Regurgitation

  • Backwards leakage of blood through the tricuspid valve.

  • Causes: left-sided heart issues, lung problems, pacemaker leads.

  • Physical exam: right-sided heart failure symptoms.

  • Systolic murmur loudest at the left sternal border.

  • Diagnosis: Echo.

  • Treatment: Diuretics, aldosterone antagonists, surgery (repair or replace) if necessary.

Pulmonary Stenosis and Regurgitation

  • Discussed in the context of congenital heart disease.

Murmur Diagnosis Aid: "Mister Taps"

  • Aid to differentiate between systolic and diastolic murmurs.

  • Write down "Mister Taps" (MRTAPS).

  • Draw a heart and label the bottom as "apex" and the top as "base".

  • Place MRT at the apex (bottom) and APS at the base (top).

  • MRT (Mitral Regurgitation, Tricuspid Regurgitation) and APS (Aortic Stenosis, Pulmonary Stenosis) are systolic murmurs.

  • Switching them makes them diastolic: Mitral Stenosis, Tricuspid Stenosis, Aortic Regurgitation, Pulmonary Regurgitation.

  • Best imaging study to help diagnose valvular disorders? Echo

  • Which valve is most affected in rheumatic? Mitral

  • Jones major criteria includes carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules

  • Dukes criteria is used for the diagnosis of Endocarditis.

  • Tricuspid stenosis presents with a diastolic murmur. (True)

  • Mitral Regurgitation can occur five days after MI leading to papillary rupture