Mitralvalvedisease

Themitralvalveseparatestheleftatriumandtheleftventricleoftheheartandisafibrousstructure
linedbyendocardium.
Itconsistsof
1. Themitralannulus,
2. Theleafletsofwhichcomprisealargeanteriorandasmallposteriorleaflet.
3. Thechordaetendineaeandthepapillarymuscles.
Abnormalitiesinanyofthesestructurescancausemitralvalvedysfunction.
Theleafletsaretetheredtotheleftventriclebythechordaetendineae.Chordae
tendineaeareattachedtopapillarymusclesandpreventprolapseofthemitralvalveleafletto
preventrefluxofbloodintotheleftatrium.

MitralStenosis
Etiology
1. Rheumaticfeveristhemaincauseofmitralstenosis(Seefigure1)
2. Lesscommoncausesofmitralstenosisinclude:
o Severecalcificationofthemitralannulus
o Bacterialendocarditis
o Congenitalheartdisease(parachutemitralvalve)
o Rarely,systemiclupuserythematosisandrheumatoidarthritis

Figure1.Rheumaticmitralstenosis

Pathophysiology
1.Thenormalareaofthemitralvalveorificeisabout4to6cm2.Undernormalconditions,anormal
mitralvalvewillnotimpedetheflowofbloodfromtheleftatriumtotheleftventricleduring
(ventricular)diastole,andthepressuresintheleftatriumandtheleftventricleduringdiastolewillbe
equal.Theresultisthattheleftventriclegetsfilledwithbloodduringearlydiastole,withonlyasmall
portionofextrabloodcontributedbycontractionoftheleftatrium(the"atrialkick")duringlate
ventriculardiastole.

2.Whenthemitralvalveareagoesbelow2cm2,thevalvecausesanimpedimenttotheflowofblood
intotheleftventricle,creatingapressuregradientacrossthemitralvalve.Thisgradientmaybe
increasedbyincreasesintheheartrateorcardiacoutput.

3.Asthegradientacrossthemitralvalveincreases,theamountoftimenecessarytofilltheleftventricle
withbloodincreases.Eventually,theleftventriclerequirestheatrialkicktofillwithblood.Astheheart

rateincreases,theamountoftimethattheventricleisindiastoleandcanfillupwithblood(calledthe
diastolicfillingperiod)decreases.
4.Whentheheartrategoesaboveacertainpoint,thediastolicfillingperiodisinsufficienttofillthe
ventriclewithbloodandpressurebuildsupintheleftatrium,leadingtopulmonarycongestion.

5.Whenthemitralvalveareagoeslessthan1cm2,therewillbeanincreaseintheleftatrialpressures
(requiredtopushbloodthroughthestenoticvalve).

6.Sincethenormalleftventriculardiastolicpressuresisabout5mmHg,apressuregradientacrossthe
mitralvalveof20mmHgduetoseveremitralstenosiswillcausealeftatrialpressureofabout25
mmHg.Thisleftatrialpressureistransmittedtothepulmonaryvasculatureandcausespulmonary
hypertension.

7.Pulmonarycapillarypressuresinthislevelcauseanimbalancebetweenthehydrostaticpressureand
theoncoticpressure,leadingtoextravasationoffluidfromthevasculartreeandpoolingoffluidinthe
lungs(congestiveheartfailurecausingpulmonaryedema).

8.Theconstantpressureoverloadoftheleftatriumwillcausetheleftatriumtoincreaseinsize.Asthe
leftatriumincreasesinsize,itbecomesmorepronetodevelopatrialfibrillation.Whenatrialfibrillation
develops,theatrialkickislost(sinceitisduetothenormalatrialcontraction).

9.Inindividualswithseveremitralstenosis,theleftventricularfillingisdependentontheatrialkick.The
lossoftheatrialkickduetoatrialfibrillationcancauseaprecipitousdecreaseincardiacoutputand
suddencongestiveheartfailure.
Symptoms
Patientswithmitralstenosismaypresentwithexertionaldyspnea,paroxysmalnocturnaldyspnea,
fatigue,atrialarrhythmias,embolicevents,anginalikechestpain,hemoptysis,orevenrightsided
heartfailure.
Previouslyasymptomaticorstablepatientsmaydecompensateacutelyduringexercise,emotional
stress,pregnancy,infection,orwithuncontrolledatrialfibrillation.
Physicalexamination
Thepatientwithmitralstenosismayhavemalarflush.Theremaybeankleorsacraledema.
Jugularvenouspressuremaybeelevated.Prominentawavesmaybeduetopulmonary
hypertension.Systolicvenouspulsationsmaybepresentwithseveretricuspidregurgitation.In
caseofatrialfibrillation,lossofawavesinjugularvenouspulseisevident.
Onpalpation,theapexoftheheartisrightventricularandtapping.Adiastolicthrillisusually
palpable.Aleftparasternalheavemaybepalpableduetorightventricularhypertrophy.A
diastolicshockisfeltoversecondleftintercostalsspaceifthereisseverepulmonary
hypertension.
ThecharacteristicfindingsofMSonauscultationinclude(seefigure2)
o Firstheartsoundisunusuallyloudandmaybepalpable(tappingapexbeat)becauseof
increasedforceinclosingthemitralvalve.
o Ifpulmonaryhypertensionsecondarytomitralstenosisissevere,theP2(pulmonic)
componentofthesecondheartsound(S2)willbecomeloud.
o Anopeningsnapwhichisahighpitchedadditionalsoundmaybeheard,whichcorrelates
totheforcefulopeningofthemitralvalve.
o Amiddiastolicrumblingmurmurwillbeheardaftertheopeningsnap.Themurmuris
bestheardattheapicalregionandisnotradiated.Sinceitislowpitcheditshouldbe
pickedupbythebellofthestethoscope.Rollingthepatienttowardsleft,aswellas
isometricexercisewillaccentuatethemurmur.

o Thelongerthedurationofthediastolicmurmuris,themoreseverethestenosisis
expectedtobe.
o TheshorterthetimeintervalfromS2toopeningsnap(S2OSinterval)is,themoresevere
thestenosiswillbe.

Figure2.SpectrumofClinicalSignsinMitralStenosis
Diagnosis
ECG:
Severityofmitralstenosis
Inmildmitralstenosis:ECGmay
Degreeofmitralstenosis Meangradient Mitralvalvearea
benormal.
Inthestageofpulmonaryvenous Mildmitralstenosis
<5
>1.5cm2
congestion,Pwaveisbroadand
Moderatemitralstenosis 5 10
1.01.5cm2
notched:(Pmitrale).
Instageofpulmonaryarterial
Severemitralstenosis
>10
<1.0cm2
hypertension,signsofright
ventricularenlargementarepresent.
AtrialfibrillationmaybeseenasabsentPwaveswhicharereplacedbyfineorcoarsefibrillatory
waves.
Chestradiography:
Signsofleftatrialenlargement.
Signsofpulmonarycongestion.
Signsofrightventricularhypertrophy

Echocardiography:SeeFigure3
CharacteristicfindingsofMSincludevalvethickening,restrictedvalveopening,anterior
leafletdoming,andfusionoftheleafletsatthecommissures.
ThetransmitralgradientasmeasuredbyDopplerechocardiographyisthegoldstandardinthe
evaluationoftheseverityofmitralstenosis.Themeanpressuregradientacrossthemitral
valveonDopplerechocardiography(echo)inMSisatleast5mmHg;inseverestenosis,itis
usuallyhigherthan10mmHg.
Echocardiographyalsoallowsassessmentofpulmonaryarterypressure,detectionofother
valvedisease,visualizationofleftatrialthrombus,andidentificationofimportant
differentialdiagnoses,suchasleftatrialmyxoma.
Transesophagealechocardiography(TEE)issuperiortotransthoracicechocardiography
(TTE)atidentifyingleftatrialthrombusinpatientswhoarebeingconsideredfor
percutaneousmitralballoonvalvotomyorcardioversion.

Fig.3a.Twodimensionalechocardiographyshowing
Valvularmitralstenosis

Fig.3b.Mean pressure gradient of 13.8

mm Hg across mitral valve by
continuous wave Doppler

Fig.3c.Transesophageal echocardiography
showing left atrial thrombus and smoke

Treatment
Medicaltreatment:Medicaltreatmentisdirectedtowardthefollowing:
Alleviatingpulmonarycongestionwithdiuretics.
Treatingatrialfibrillation.Ventricularratemaybecontrolledwithdigitalis,calciumchannel
antagonists(verapamilordiltiazem)and/orbetablockers.DCcardioversionmaybecarried
outincasesofrecentatrialfibrillation,ifnoatrialthrombiarevisualized(on
transesophagealecho).

Anticoagulationinpatientswhoareatincreasedriskofarterialembolicevents.
Anticoagulationmaybestartedwithunfractionatedheparinandcontinuedwithoral
warfarin.
Antibiotictherapyisimportantforthesecondarypreventionofrheumaticcarditis.Patients
withahistoryofrheumaticfeverareathighriskofrecurrence.Longtermsecondary
prophylaxis,preferentiallywithpenicillin,isthereforerecommendedforallpatientswitha
historyofrheumaticfever.
Surgery&invasiveintervention
ThreeinvasiveoptionsareavailableforpatientswithMS:
o Percutaneousmitralballoonvalvotomy(PMBV)
o Surgicalmitralcommissurotomy
o Mitralvalvereplacement(MVR)
Percutaneousmitralballoonvalvotomy
Inexperiencedcenters,PMBVistheinitialprocedureofchoiceandshouldbeconsideredfor(1)
symptomaticpatients(NYHAfunctionalClassesIItoIV)withmoderateorsevereMSand(2)
asymptomaticpatientswithmoderateorsevereMSandpulmonaryhypertension.
PMBVisacatheterbasedtechniqueinwhichaballoonisinflatedacrossthestenoticvalveto
splitthefusedcommissuresandincreasethevalvearea.TheMVAtypicallydoublesinsize,and
hemodynamicaswellasclinicalimprovementsareseenimmediately.Theresultsare
comparablewiththoseachievedwithopenmitralcommissurotomy,butitislessinvasiveand
lesscostly.
Themitralvalvemorphologyisanimportantpredictorofsuccessfulballoonvalvotomy.The
followingfactorsadverselyaffecttheresultsofPMBV:
o Severevalvecalcification
o Severevalvethickeningandfibrosis
o Markedsubvalvularaffection
o Presenceofmorethanmildmitralregurgitation
o Presenceofleftatrialthrombi
Openmitralcommissurotomy
Itinvolvestheuseofcardiopulmonarybypassandthesurgicalrepairofadiseasedmitralvalveby
directvisualization.Openmitralcommissurotomymaybeconsideredinthefollowingcases:
o Presenceofaleftatrialthrombus
o Significantmitralregurgitationifthevalveanatomyissuitable.
o Patientswhohaveotherconcomitantvalvulardisease
o Patientswithcoronaryarterydiseasethatrequiressurgery
Mitralvalvereplacement(figure4):indicatedforpatientswith:
i.Calcifiedvalvesthatcannotbetreatedbyvalvotomyorcommissurotomy
ii.Thosewithsignificantmitralregurgitationthatisnotsuitableforrepair
Surgeryformoderatetoseveremitralstenosisisindicatedforsymptomaticpatients(NYHA
functionalClassIIIorIV)wherePMBVisunavailableorcontraindicated.

Fig.4. Prosthetic bileaflet mitral valve

prosthesis

MitralRegurgitation
Causes:
1. Rheumaticfever.
2. Ischemicheartdisease
3. Papillarymuscleruptureordysfunction.
4. Mitralvlaveprolapse.
5. Infectiveendocarditis.
6. Calcificationofmitralannulus.
7. Congenitalascleftmitralvalve.
8. Cardiomyopathy
Pathophysiology:
SignificantMRleadstovolumeoverloadoftheleftventricle,becauseithastoaccommodateboth
thestrokevolumeandregurgitantvolumewitheachheartbeat.
Duringsystole,bloodregurgitatesfromleftventricletoleftatriumleadingto:
o Decreasedeffectiveleftventricularstrokevolume.
o Increasedleftatrialpressureandsize.
o Pulmonarycongestionandlateronpulmonaryhypertension.
Progressionofmitralregurgitationleadstoleftventriculardilatationandaggravatesmitral
regurgitation.Leftatrialenlargementpredisposesthepatienttoatrialfibrillationandarterial
thromboembolism.InlongstandingMR,patientsmaydeveloppulmonaryhypertensionandcongestive
heartfailure.
Clinicalpicture:
Patientswithchronic,severemitralregurgitationmayremainasymptomaticforyears
becausetheregurgitantvolumeloadiswelltoleratedasaresultofcompensatory
ventricularandatrialdilation.Whensymptomsdodevelop,themostcommonaredyspnea,
fatigue,orthopnea,paroxysmalnocturnaldyspnea,andpalpitationscausedbyatrial
fibrillation.
AcutesevereMR,asoccurswithchordalruptureorpapillarymusclerupture,isalmost
alwayssymptomaticbecausethesuddenregurgitantvolumeloadinthenondilatedleft
ventricleandatriumleadstopulmonaryvenoushypertension,congestionandacute
pulmonaryedema.
Signs:
Signsofleftventricularhypertrophy.
Systolicthrilloverapex.
Muffledfirstheartsound.
ThirdheartsoundS3maybeheard.
Harshpansystolicmurmuroverapexpropagatedtoaxilla,incaseofrupturedchordaetendinae
murmurmaybecooing(seagullquality);incaseoffailmitralcusps,murmurmaybemusical.
Incaseofseveremitralregurgitation,shortmiddiastolicrumblingmurmurmaybehearddueto
augmentedbloodflowfromleftatriumtoleftventricle.
Investigations:
ECG:
Signsofleftatrialandleftventricularenlargement.
Chestradiography:
Increaseinleftatrialsize,leftventricularenlargement,signsofpulmonarycongestion.
Echocardiography(figure5):
Visualizationofmitralleaflets,papillarymusclesandchordaetendinae.
Leftventriculardimensionsandfunctions
Degreeofmitralregurgitation.

Fig.5. Color Doppler flow showing severe

mosaic jet filling most of the left atrial cavity in
a patient with severe mitral regurgitation

Treatment
Medicaltreatment:
InpatientswithacutesevereMR,afterloadreductionwithintravenousnitroprussideand
nitroglycerinreducestheregurgitantfractionandpulmonarypressures.
Inpatientswithchronicasymptomaticmitralregurgitationcausedbyprimaryvalvedisease,
thereisnoevidencefortheroutineuseofmedicationindelayingtheneedforsurgeryor
preventingleftventriculardysfunction.Themanagementofthesepatientsisfocusedon
decidingontheappropriatetimingofsurgery,beforethedevelopmentofirreversibleleft
ventriculardysfunction.
Patientsshouldbefollowedupevery6to12monthstoassessforsymptomsandto
measureleftventricularsize,function,andseverityofMRbyechocardiography.
Surgicaltreatment:Surgeryisindicatedfor
(1)symptomaticpatientswithsevereprimaryMR
(2)asymptomaticpatientswithsevereprimaryMRandevidenceofLVdysfunction.
Thestandardindicationsforsurgeryinasymptomaticpatientsarean
o LVendsystolicdimensionofmorethan4.0cm
o ArestingLVejectionfractionoflessthan60%
o Pulmonaryhypertension
o Developmentofatrialfibrillation
Thetwoavailablesurgicaloptionsaremitralvalverepairandmitralvalvereplacement.Mitralvalve
repairistheprocedureofchoiceinthesurgicalmanagementofMRcausedbydegenerativevalve
diseaseandinsomecasesofMRcausedbyinfectiveendocarditisandischemicheartdisease.

MitralValveProlapse
o Mitralvalveprolapseisatypeofmyxomatousvalvedisease.Mitralvalveprolapse(MVP)is
thesystolicbillowingofoneorbothmitralleafletsintotheleftatriumduringsystole.The
tissueofthemitralvalveleafletsandchordaeareabnormallyredundant,sothatastheheart
beats,themitralvalvebowsorflopsbackintotheleftatrium(Seefigure6).
o Thosewithmitralvalveprolapsemaynothaveanyregurgitation(leakyvalve)ortheymayhavea
rangeofseverityfromamildleaktoaveryfloppy,leakyvalve.
o Themajorityofpeoplehavenoleakoramildleak.Inthiscase,MVPisnotacauseforconcern.A
smallpercentageofpeoplewithmitralvalveprolapsehavesevereMVP,requiringfurther
treatment.
o Mitralvalveprolapseisverycommon,affectingaboutthreetofivepercentofthepopulation.
o Femalesareaffectedtwiceasoftenasmales.
o Mitralvalveprolapsecanbeseeninchildren,teens,andadults.


Figure6.Mitralvalveprolapsedwithbillowingoftheposteriorleafletintotheleftatrium
Clinicalpicture:
MostpatientswithMVPareasymptomatic.
Multiplenonspecificsymptoms(atypicalchestpain,dyspnea,palpitations,anxiety,andsyncope)
andclinicalfindings(lowbodyweight,lowbloodpressure,andpectusexcavatum)were
associatedwithMVPandtermedmitralvalveprolapsesyndrome..
TheclassicfindingsofMVPonphysicalexaminationareamidsystolicclick,withalatesystolic
murmur,heardbestatthecardiacapex.
Diagnosis:
TwodimensionalechocardiographyisthemostimportanttestfordiagnosingMVP.The
diagnosisismadewhenthereisdisplacementofoneorbothmitralleafletsby2mmormoreinto
theleftatriumduringsystole.

Management:
Asymptomaticpatientsrequirenospecifictreatmentandtheyshouldbereassuredoftheir
excellentprognosis.
Betablockersareusefulforalleviatingsymptomsofpalpitations,anxiety,andchestpainin
certainpatients.
Patientswithseveremitralregurgitationorhighriskfeaturesshouldbereviewedwithan
echocardiogramyearlyormoreofteniftheirclinicalconditionwarrantsit.
InMVPpatientswithseveremitralregurgitation,theindicationsformitralvalvesurgeryare
similartothoseforpatientswithothercausesofsevereregurgitation.Whensurgeryis
required,mitralvalverepairisusuallytheprocedureofchoice.

TricuspidValveDisease.

o Thetricuspidvalveapparatusincludesleafletsorcusps,chordaeandpapillarymuscles,and
tricuspdannulus.Ingeneral,thetricuspidvalvehasthreedistinctleafletsdescribedas
septal,anterior,andposteriorandthreesetsofpapillarymuscles.
o Tricuspidvalvediseaseisgenerallyclassifiedasprimary(i.e.intrinsic)valvepathologyor
secondary.Thelatterissecondarytoleftheartdiseaseandresultingrightventricular
hypertension,dilatation,anddysfunction.ItisalsodescribedasfunctionalTR.
o Thecommoncausesofrightventricular(RV)hypertension,dilatationandfailurearefrom
leftheartdiseaseinformofadvancedmitral,aorticandleftventricularmyocardial
disorders.Thus,TRismostcommonlysecondarytoconditionsaffectingtheleftheart,andis
causedbyannulardilatationandleaflettethering.
o
EtiologyofPrimaryTricuspidValveDisease
1.Rheumaticvalvedisease,generallyinassociationwithrheumaticmitraldisease
3.Infectiveendocarditis
4.Carcinoidheartdisease
5.Congenital(Ebsteinanomaly)

EtiologyofSecondaryorFunctionalTricuspidValveDisease
1.Rightventriculardilatation
2.Rightventricularhypertension(i.e.,pulmonaryhypertension)
3.Rightventriculardysfunctionwithcardiomyopathy.

ClinicalPresentations
Thefunctionalderangementmaybeinformof(1)pureorpredominanttricuspidstenosis,(2)pure
orpredominanttricuspidregurgitation,or(3)mixed.
Symptoms
Generallythesymptomsofleftheartdiseasepredominateinthosewithsecondarytricuspid
valvedisease.
Thesymptomsspecifictoadvancedtricuspidvalvediseasearerelatedto
(a)Decreasedcardiacoutput,forexample,fatigue;
(b)Rightatrialhypertension,forexample,livercongestionresultinginrightupper
quadrantdiscomfort,orgutcongestionwithsymptomsofdyspepsia,indigestion,orfluid
retentionwithlegedemaandascites.
PhysicalSigns
Theseincludesignsrelatedtotricuspidvalvediseaseandthosesecondarytochronicvenous
congestion,thatis,legedema,ascites.
Tricuspidstenosis
SlowVtoYdescentandprominent"a"waves.
Liverisenlargedwithafirmedge,andpulsatileinpresystole.
Auscultationrevealsalowtomediumpitcheddiastolicrumblewithinspiratory
accentuation.
Tricuspidregurgitation
ProminentCVwaveorsystolicwaveinvenouspulse.
Parasternalliftfromrightventricularenlargement.
Livershowssystolicpulsations,isenlargedandoftentender.
Cardiacauscultationrevealsaholosystolicmurmurwhichisaugmentedwithinspiratory
effort(Carvallosign).

Diagnosis
Electrocardiogram
Therearenospecificmarkersoftricuspidvalve(TV)disease,althoughthefollowingcluesmaybe
present:(1)rightventricular(RV)hypertrophyand"strain"withrightaxisdurationand(2)right
atrialenlargementwithprominentPwaves.
ChestRadiograph
Cardiomegalyassociatedwithprominentrightheartbordersmaybenoted.Therearenospecific
findingstosuggestadiagnosisoftricuspidvalvedisease.
Echocardiography
TwodimensionalechocardiogramwithcolorflowDopplerevaluationprovidesthemostaccurate
andcomprehensivelaboratorytestinevaluationofTVdisease.TheTVmorphologyhelps
differentiateprimaryfromsecondaryTR.Itsseveritymaybesemiquantitatedbasedonextentof
theregurgitationjetpenetrationintotherightatriumandinferiorvenacava.
CommonPrimaryTricuspidValveDiseases
RheumaticTricuspidValveDisease
o Rheumaticinvolvementofthetricuspidvalveisfarlesscommonthanthemitralandthe
aorticvalves.
o Isolatedrheumatictricuspidvalvediseaseisrare.However,clinicallysignificanttricuspid
valvedisease,inassociationwithmitraland/oraorticvalvedisease,isreportedbetween10
and20%ofpatients.
o Thetricuspidvalveisthickenedandtheleafletsarecontractedwithfibrosis.Commissural
fusionisoftenpresent.Theresultingclinicalsyndromeisoneofmixedstenosisand
regurgitation.
o TreatmentofrheumaticTVdiseaseconsistsofvalverepairwithannuloplastywhenthevalve
dysfunctionisnotsevere.However,inpresenceofseveredisease,valvereplacementwitha
lowprofilemechanicalorabioprostheticvalveisindicated.
InfectiveEndocarditis
o Infectiveendocarditisofthetricuspidvalveisnotuncommonamongdrugaddictsusing
intravenousdrugs.
o Itmayalsobeobservedinpatientswithlongtermintravenouslines.
o Theclinicalpresentationisoneofgeneralsystematicsymptomssuchasfever,weightloss,
anemia,andfatigue,orofpulmonaryembolism,orofrightheartfailurewithhepatic
congestion,peripheraledemaandascites.
o Thediagnosticconfirmationismadebyechocardiographiclesionssuggestiveofvegetations
andpositivebloodcultures.
CarcinoidHeartDisease
o Carcinoidtumorsarisingintheintestinaltractwithsecondarylivermetastasesare
commonlyassociatedvalvularpathology.
o Themostcommonlyaffectedvalveisthetricuspidvalvefollowedbythepulmonaryvalve.
Theleftsidedcardiacvalvesaresparedunlessarighttoleftshuntthroughpatentforamen
ovaleoratrialseptaldefectispresent
o Thepathologyofthevalveconsistsofthickeningwithfibrosisandmarkedlyrestricted
motion.Thevalveleafletsareheldpartiallyopenduringsystoleanddiastole.Theopening
resultsinobstructedinflow.
o Thus,therearesignsoftricuspidstenosisandregurgitation,withthelatterpredominating.
o Theclinicalfeaturesarethoseofthecarcinoidtumorandrightheartfailure.
EbsteinAnomaly
TheEbsteinanomalyisacongenitallesionoftricuspidvalvethatischaracterizedbyapical
displacementoftheseptalleafletofthetricuspidvalve,alarge,saillikeanteriorleafletthatresults
inatrializationoftheRVinflow.Functionally,avariabledegreeofTRisobserved.Therightheart
chambersaremarkedlydilated.Arighttoleftshuntatatriallevelmaybepresentifatrialseptal
defectcoexists.

MCQ
1. InpuremitralregurgitationS1is
a. Normal
b. Accentuated
c. Decreased,soft
2. FeaturesofleftatrialenlargementinXRayinclude
a. Doubledensity
b. Elevationofleftbronchus
c. Posteriordisplacementoftheesophagus
d. Alloftheabove
3. Inmiddiastolicmurmursduetoincreasedflowacrossatiroventricularvalves,the
commonaccompanimentis
a. LoudS1
b. LoudS2
c. S3
d. S4
4. Middiastolicmurmursduetoincreasedflowacrossatiroventricularvalvesoccurin
a. Mitralregurgitation
b. VSD
c. PDA
d. Alloftheabove
5. Whichofthefollowingisnotamiddiastolicmurmur
a. CareyCoombmurmur
b. AustinFlintmurmur
c. GrahamSteellmurmur
d. Mitralstenosis
6.Holosystolicmurmursareusuallycausedbyallexcept
a. Mitralregurgitation
b. Tricuspidregurgitation
c. VSD
d. Pulmonarystenosis
7.Inapatientwithmitralstenosisandmitralregurgitation,mitralregurgitationissaidtobe
dominantinpresenceofallexcept
a. SoftS1
b. S3
c. DominantVwaveinjugularvenouspulse
d. RVapex
8Acutemitralregurgitationcanoccurdueto
a. Infectiveendocarditis
b. Myocardialinfarction
c. Cheattrauma
d. Alloftheabove

9Amiddiastolicmurmurmaybeheardinanyofthefollowingconditions
a. Mitralstenosis
b. Atrialmyxoma
c. Mitralannularcalcification
d. Parachutemitralvalve
e. Alloftheabove
10Systemicembolizationinpatientswithmitralstenosismostcommonlyoccursfrom
a. Leftatrialmuralthrombi
b. Leftatrialappendagethrombi
c. Vegetationsonthemitralvalve
d. Leftventricularapicalthrombi
11Aprominentawaveinjugularveinsofpatientswithmitralstenosisindicates
a. Significanttricuspidregurgitation
b. Signficantmitralregurgitation
c. Pulmonaryhypertension
d. Leftatrialenlargement
12Theventricularrateinpatientswithrapidatrialfibrillationcanbecontrolledwith
a. Betablockers
b. Digoxin
c. Calciumchannelblockers
d. Amiodarone
e. Alloftheabove
13Theprocedureofchoiceforpatientswithuncomplicatedmitralstenosiswithpliable,
mobile,relativelythin,minimallycalcifiedmitralleafletswithminimalornosubvalvularstenosisis
a. Mitralvalvereplacement
b. Percutaneousballoonmitralvalvuloplasty
c. Surgicalopenmitralcommissurotomy
d. Alloftheabove
14AlltheseconditionscancauseprimarytricuspiddiseaseEXCEPT:
a. Rheumaticheartdisease
b. Infectiveendocarditis
c. Ebsteinanomaly
d. Carcinoidheartdisease
e. Leftventricularfailure
15AllthesearetypicalfindingsinseveretricuspidregurgitationEXCEPT:
a. ThejugularvenouspulseexhibitingprominentCVwaveorsystolicwave.
b. Thereisoftenaparasternalliftfromrightventricularenlargement.
c. Thelivershowssystolicpulsations,isenlargedandoftentender.
d. Ascitisandicterusinthesclera
e. Longmiddiastolicrumblewithaccentuationoffirstheartsoundwhichislocalizedtothe
lowersternalborder

16Surgeryisindicatedinpatientswithmitralregurgitation,whoare:
a. Symptomaticwithseveremitralregurgitation
b. AsymptomaticwithseveremitralregurgitationandLVdysfunction
c. Symptomaticpatientwithpulmonaryhypertension
d. Severemitralregurgitationcomplicatedbyatrialfibrillation
e. Alloftheabove
17Allthesefindingsmaysuggestseveremitralregurgitationexcept:
a. Fourthheartsoundovertheapex
b. Downwardandoutwarddisplacedleftventricularapex
c. Thirdheartsoundovertheapex
d. Presenceofpulmonarycongestioninchestxrayfilm
e. Alloftheabove