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Summary Cardiology - Internal medicine
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1. Diseases of the mitral valve: Mitralstenosis.De nition: Mitral stenosis is a narrowing of the mitral valve ( normal size: 3-6 cm2) resulting in
decreased diastolic lling of the left ventricle.
Etiology:
- rheumatic fever after streptococcal- A- infection
- calci cation of the heart valve
- congenital
Pathopyhsiology, pathogenesis and clinics:
- Impairment of the blood- ow through the narrowed mitral valve opening during diastole;
I stage:
- Hypertrophy, soon followed by dilatation of the left atrium;
- Symptoms: supra ventricular extrasystoles, soon followed by atrial brillation or utter;
- Peripheral hypoperfusion:
- Symptoms: easy tiredness, fatigue;
- Increased pressure in the pulmonary veins and lung congestion:
- Symptoms: shortness of breath, often cardiac asthma.
II stage:
- Increased pressure in the pulmonary artery (= pulmonary edema), causing hypertrophy and
dilatation of the right ventricle with relative tricuspid valve insu ciency
- followed by dilatation of the right atrium and congestion in the peripheral circulation.
- Symptoms: heaviness in the right hypochondrium due to congestion in the liver, swollen legs,
in severe cases generalized edema (dropsy), peripheral cyanosis. However the
breathlessness is a little bit relieved.
- hepatosplenomegaly, edemas, ascites, peripheral cyanosis
Diagnosis:
Physical examination
- General inspection
- I stage: Facies mitralis (dilated cyanotic capillaries on the cheeks)
- II stage: added peripheral cyanosis, high neck veins, enlarged and painful liver in severe
cases ascites (last two – examination of abdomen).
- Lungs:
- I stage: congestion – decreased vesicular breathing with crepitations (ronchi in pulmonary
edema).
- II stage: possibly added pleural e usion in the right or both sides.
- Heart:
- I stage: possible diastolic fremisman, usually tachyarrhythmia, accentuated I sound, sound
of mitral valve opening (in diastole) followed by diastolic murmur with presystolic
acceleration. The pre- systolic acceleration is caused by the atrial systole and disappears
when the patient is in arrhythmia – atrial brillation or utter. The murmur is heard over the
apex (V intercostals space about 1 cm medially from the medioclavicular line), best when
the patient is lying on his left side and it does not propagate.
- II stage: added decreased I. sound and systolic murmur caused by the relative tricuspid
insu ciency. They are best heard on the tricuspid valve point (V intercostals space to the
left or to the right of the sternum). Accentuated II sound on the pulmonary valve (II
intercostals space next to the sternum);
Labs
- eventual rheumatic activity, endocarditis, estimation of renal function ( creatinine),
electrolytes ( potassium)
Spirometry: restrictive type respiratory failure
Blood gases: hypoxemia with normo- or hypocapnia
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, ECG
- usually tachyarrhythmia due to atrial brillation with hypertrophy of the right ventricle
- In the early stage, when the patient is with sinus node rhythm, hypertrophy of the left atrium
would be found (P-mitrale), prolonged and abnormal P-waves in the left leads (I, AVL, V5 and
V6)
Radiography:
- two photos: lateral and PA
- enlargement of LA with normal LV
- later: enlargement of right ventricle and atrium
Echocardiography:
dilated left atrium, right ventricle and right atrium, narrowed mitral valve opening often with
calcinosis, insu ciency of the tricuspid valve (with doppler technique), increased pressure in the
left atrium and in the pulmonary artery, especially important is the gradient between the pressure
in the left atrium and the left ventricle which determinates the grade of the stenosis (mild stenosis
mean gradient under 5 mmHg, opening over 1,5 cm2, moderate – mean gradient 5-10 mmHg,
opening 1-1.5 cm2, severe mean gradient over 10 mmHg, opening under 1 cm2);
Catherization:
- usually through the right femoral vein, measuring the pressure in the pulmonary artery and the
tricuspid insu ciency.
- Left side catheterization can also be performed for measuring the gradient of the mitral valve.
DD:
- endocarditits
- other heart disorders
- liver disorders in case of hepatosplenomegaly, ascites and edema
- renal disorders
Complications
- thromboembolism in patient with atrial brillation, (in the lungs from the right atrium; in the
brain, limbs, kidneys etc, from the left atrium)
- atrial brillation
- bacterial endocarditis
- cardiac cirrhosis
- pulmonary brosis
Treatment:
Pharmaceutical
- diuretics to decrease uid build up
- beta- blockiert slow heart rate
- cardiac glycosides in case of impairment of left or right ventricular function
- anticoagulation in case of permanent atrial brillation to reduce risk of blood clot formation: e.g.
heparin, rivaroxabam, warfarin
Surgical
- mitral valve replacement
- mitral valve reconstruction
- mitral valve plasty
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, 2. Diseases of the mitral valve: Mitral regurgitation.
De nition: Inability of the mitral valve to fully close during systole.
Etiology:
- degenerative changes
- mitral valve prolapse
- secondary insu ciency due to dilation of LV
- ischemia with rupture of tendinae
- past rheumatic fever
- past infectious endocarditis
Pathophysiology/ Pathogenesis/ Clinics:
- The mitral valve is unable to close completely during systole which is causing re ux of blood
from the left ventricle into the left atrium.
- Other causes for mitral valve insu ciency are the prolapse (congenital disease), rupture of
chorda tendinea or papillary muscle (could be complication of myocardial infarction often
causing pulmonary edema and cardiac shock), endocarditis and all cases with excessive
enlargement of the left ventricle causing relative mitral insu ciency such as myocarditis,
cardiomyopathy, ischemic heart disease etc.
- I stage – dilatation of the left ventricle and the left atrium
- Symptoms: ventricular and supraventricular extrasystoles, atrial brillation or utter, but it
appears later than in patients with mitral stenosis.
- Increased pressure in the pulmonary veins and congestion in the lungs;
- Symptoms: shortness of breath, sometimes with cardiac asthma but usually milder and
rarer than in patients with mitral stenosis;
- Peripheral hypoperfusion;
- Symptoms: easy tiredness, fatigue;
- II stage – pathopysiology and symptoms are the same as in patient with mitral stenos. In similar
grade of the valve lesions the right-side heart failure appears later in patient with mitral
insu ciency than in those with mitral stenosis.
Diagnosis
Physical examination
- I stage
- General inspection and lungs – same as mitral stenosis;
- Heart – enlarged area of relative dullness to the left, displaced ictus cordis to VI or even VII
intercostals space left of the medioclavicular line
- Often absolute arrhythmia, but extrasystolic arrhythmia is also possible.
- Decreased I sound with holosystolic murmur
- The later is best heard on the apex, but also on the Erb point (left III and IV intercostals
space next to the sternum) and propagates toward the left armpit.
- II stage – the same additions as in patients with mitral stenosis;
Lab tests same as mitral stenosis.
ECG – possibly P-mitrale in patients with sinus rhythm, later atrial brillation with absolute
arrhythmia and ventricular extrasystoles are also common. Hypertrophy of right ventricle;
Radiography
the same technique as in patients with mitral stenos
The di erence is that in this case the left ventricle is also dilated (as are the left atrium,
the right ventricle and atrium).
Echocardiography
dilatation of both ventricles and atria
insu ciency of both mitral and later of the tricuspid valve
later decreased ejection fraction
increased pulmonary pressure.
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, Catheterisation
left (through right femoral artery) measurement of the mitral valve insu ciency and
estimation of the function of the left ventricle
right – measurement of pulmonary pressure and the tricuspid insu ciency.
DD:
- endocarditis
- other heart disorders
- liver failure due to ascites, edema etc.
- renal disorders
Complications:
- thromboembolism in patient with atrial brillation, (in the lungs from the right atrium; in the
brain, limbs, kidneys etc, from the left atrium)
- atrial brillation
- bacterial endocarditis
- cardiac cirrhosis
- pulmonary brosis
Treatment:-> symptomatically
- diuretics to remove uid
- anticoagulants
- antihypertensive drugs
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