Essential Revision Notes for MRCP Third Edition - PasTest

CardiologyMitral balloon valvuloplastyValvuloplasty using an Inoue balloon requires eithera trans-septal or a retrograde approach and is usedonly in suitable cases where echo shows that:• The mitral leaflet tips and valvular chordae arenot heavily thickened, distorted or calcified• The mitral cusps are mobile at the base• There is minimal or no mitral regurgitation• There is no left atrial thrombus seen on TOE1.3.3 Mitral regurgitation (MR)The full structure of the mitral valve includes theannulus, cusps, chordae and papillary musculature,and abnormalities of any of these can cause regurgitation.The presence of symptoms and increasingleft ventricular dilatation are indicators for surgeryin the chronic setting. Operative mortalities are2%–7% for valvular replacements in patients withNYHA grade II–III symptoms. Various techniqueshave revolutionised mitral valve surgery, transformingoutcomes from being no better than medicaltherapy with replacement to almost normal withrepair. In skilled surgical hands the repair is tailoredto the precise anatomical abnormality.Functional MR is a term used to describe MR that isdue to stretching of the annulus secondary to ventriculardilatation.Main causes of MR• Myxomatous degeneration• Functional, secondary to ventriculardilatation• Mitral valve prolapse• Ischaemic papillary muscle rupture• Congenital heart diseases• Collagen disorders• Rheumatic heart disease• EndocarditisIndicators of the severity of MR• Small-volume pulse• Left ventricular enlargement due to overload• Presence of S3• Atrial fibrillation• Mid-diastolic flow murmur• Precordial thrill, signs of pulmonaryhypertension or congestion (cardiac failure)Signs of predominant MR in mixed mitralvalve disease• Soft S1; S3 present• Displaced and hyperdynamic apex (leftventricular enlargement)• ECG showing LVH and left axis deviationMitral valve prolapseThis condition occurs in 5% of the population andis commonly over-diagnosed (depending on theechocardiography criteria applied). The patients areusually female and may present with chest pains,palpitations or fatigue, although it is often detectedincidentally in asymptomatic patients. Squatting increasesthe click and standing increases the murmur,but the condition may be diagnosed in theabsence of the murmur by echo. Often there ismyxomatous degeneration and redundant valvetissue due to deposition of acid mucopolysaccharidematerial. Antibiotic prophylaxis before dentalor surgical interventions should be recommendedfor those with a murmur. Mitral valve prolapse isusually eminently suitable for mitral valve repairalthough this should only be undertaken if theseverity of the regurgitation associated with thecondition justifies it (see above). Several conditionsare associated with mitral valve prolapse (see overleaf),and patients with the condition are prone tocertain sequelae.Sequelae of mitral valve prolapse:• Embolic phenomena• Rupture of mitral valve chordae• Dysrhythmias with QT prolongation• Sudden death• Cardiac neurosis15