Mitral valve prolapse or MVP
It is also known as Barlow syndrome or systolic click murmur syndrome.
It is commonly seen with females of age group 15 - 30 years and is an autosomal dominant
condition.
It is a most common abnormality leading to primary MR.
What is the pathogenesis?
It occurs due to decreased production of type 3 collagen which leads to excessive or
redundant mitral leaflet tissue.
When we consider the causes
there are certain syndromic associations like Marfan syndrome, Ehlers-Danlos syndrome
and osteogenesis imperfecta.
Rare causes and associations include rheumatic fever, ischemic heart disease, atrial septal
defect and cardiomyopathy.
Posterior mitral leaflet is more commonly involved than anterior leaflet and the
Clinical features
the patient often presents with palpitations, chest pain and rarely syncope. Like panic
attack
Auscultation:
there is a mid to late non-ejection systolic click which occurs due to prolapse of mitral valve
into the left atrium.
What is the typical site of murmur?
If posterior leaflet is involved, murmur is heard at the base of the heart and
If the anterior leaflet is involved, it radiates to axilla and back.
Less Blood More Murmur (accentuated) hence this murmur increase on standing & Valsava
maneuver B/s on these time decrease VR & decrease Blood goes to LV
Diagnosis
2D equals used typically. Which view is used? Parasternal long axis view.
the systolic displacement of belly of mitral valve by at least 2 mm into the left atrium
superior to the plane of mitral annulus is diagnostic of MVP.
Treatment
Surgery is done for symptomatic patients with progressive left ventricular systolic
dysfunction and TCER i.e. trans-catheter edge-to-edge repair can be done for accompanying
MR.
Tricuspid valve.
Tricuspid stenosis is generally rheumatic in origin. It does not occur as an isolated lesion,
usually occurs along with mitral stenosis. Rarely this TS can also be congenital.
TR is a very common lesion
It can be either due to primary cause or secondary cause. Secondary means functional
secondary to other diseases. So, most commonly in more than 85% cases it is secondary due
to right ventricular and tricuspid annular dilation due to multiple causes like long-standing
pulmonary hypertension which can occur with left-sided heart disease. So, these can be the
causes of secondary TR. On the other hand, primary TR can be due to rheumatic heart
disease, endocarditis, tricuspid valve prolapse similar to MVP, carcinoid, radiation, Epstein
anomaly and trauma or post-emotional trauma.
Tricuspid regurgitation is most commonly in more than 85% cases secondary or functional to
other causes.
Secondary TR is most commonly associated with severe PAH with PASP more than 55
mmhg.
When we consider the symptoms, these are usually related to the associated left valvular
lesions. But fatigue and exertional dyspnea can be symptoms owing to isolated severe TR.
Now coming on to the physical findings, it is characterized by prominent CV waves which is
due to presence of blood which is already present during the atrial diastole due to
regurgitation from the right ventricle. Also, there is associated rapid Y descent due to rapid
flow of blood from right atrium to right ventricle during ventricular diastole. Now, what is
the murmur? It is similar to the murmur of MR which is holocystolic. What is Carvalho's
sign? It is the increase in intensity of murmur of TR during inspiration. So, as we all know,
right-sided murmurs increase on inspiration. So, if the murmur of TR increases on
inspiration, it is given a particular name that is Carvalho's sign.
Severe TR is also associated with hepatic vein systolic flow reversal on color Doppler.
Treatment
medical treatment includes diuretics and aldosterone antagonists like spironolactone for
secondary hyperaldosteronism which is resulting from marked hepatic congestion. Now,
tricuspid wall surgery is indicated if the tricuspid annular dilates more than 40 mm. There is
history of right heart failure or pulmonary artery hypertension. So, this is usually done along
with the left heart surgery and not done in isolation. So, treatment includes medical and
tricuspid wall surgery which is usually done along with left heart surgery. Coming back to
your question, all of the following statements are true except more than 85% of all cases of
TR are functional and most commonly seen in association pH. True. JVP in TR has
prominent CV waves with prominent y descent. True. Severe TR is accompanied by hepatic
vein systolic flow reversal. True. Carcinoid is the most common secondary cause of TR.
False. As we have discussed that most common secondary causes are long-standing
pulmonary hypertension, remodeling post-RVMI and carcinoid is a rare primary cause. So,
this is the false statement. Moving on to the second last question of this presentation. All of
the following congenital heart disease lead to dilatation of right heart except options are
VSD, ASD, Epstein anomaly or partial anomalous pulmonary vein.
