02.17 Valvular Heart Disease Flashcards
The abnormal narrowing of the mitral valve causes the dilation of the _____, and this can lead to ____
Left atrium
Atrial fibillation
2/3 Female
Hx: exertional dyspnea, paroxysmal norturnal dyspnea, orthopnea, hemoptysis
Mitral stenosis
Opening snap
Loud S1
Diastolic rumble at the apex
MS
ECG and CXR: left atrial enlargement with normal left ventricular size
2D echo
MS
Most common etiology of MS
Rheumatic heart disease
Congenital MS
Lutembachers syndrome (+ ASD)
Etiology of MS among elderlies
Mitral annular calcification
Fibrous thickening of alveolar and pulmonary capillary walls
Pulmonary hypertension
Natural hx of MS
Pulmonary HPN
Thrombi and emboli
Pulmonary infections, infective endocarditis
D/Dx of MS
Atrial septal defect
Left atrial myxom
Mitral regurgitation
Aortic regurgictation
RVE and accentuated pulmonary markings
Widely split S2 fixed vs opening snap
No LAE
ASD
Obstructing left atrium emptying
Tumor-plop
No diastolikc murmur
Left atrial myxoma
Systolic murmur
Left ventricular hypertrophy
Mitral regurgitation
Apical mid-diastolic murmur
Aortic regurgitation
Murmur of AR
Becomes louder on handgrip and decreases with amyl nitrate
Austin Flint murmur
Prophylaxix of B-hemolytic Streptococcal infections to prevent Rheumatic fever and infective endocarditis
Penicillin
To lengthen diastolic LV filling
Heart rate controlling drugs
Treatment regimen for MS
Sodium restriction, oral diuretics
Heart rate controlling drugs
Oral anticoagulation
Penicillin
For severe cases of MS
Indicated in symtomatic patients with isolated MS
Ideal for mobile thin leaflets with no or little calcium without extensive subvavular thickening and with no or mild mr
MItral valvotomy
Used to assess if the patient is a candidate for valvotomy (score is at 8)
Wilkins score
For MS with significant MR
Distorted valves from previous transcatheter or operative manipulative
Mitral valve replacement
Frequent in males
Easy fatigue then exertional dyspnea
Characteristic holosystolic murmur at the apex with radiation to the axilla
MR
Left atrial enlargement
AFib
LVH
ECG, 2D
MR
Most accurate non invasive imaging technique
2D echo
Common etiologies of MR
Mitral valve leaflet abnormality
Mitral annulus dilatation of any cause
Ruptured chordae tendinae
Papillary muscle disorder
Medical tx for MR
Restrict physical activities Reduce sodium intake and enhance sodium exertion Increase forward CO Anticoagulants and leg binders Endocarditis prophylaxis
Indication for sugery among MR patients
When LV dysfunction is progressive (<60) and/or LV end-systolic diameter on echo is >45 mm
Surgical tx for markedly shrunken, deformed, calcified leaflets
MV replacement
Lessens problem on long-term anticoagulants and thromboembolism
Indicated for patients with ruptured chordae, annular dilatation and IE
Not suitable for MR due to myxomatous degeneration and patients with calcified annulus
MR repair with annuloplasty
Barlow’s syndrome, floppy-valve syndrome, systolic click-murmur syndrome, billowing mitral leaflet syndrome
Excessive or redundant mitral leaflet tissue
Ventricular arrhythmias
Mitral valve prolapse
Females
Most common cause of isolated severe MR requiring surgical treatment in North America
Arrhythmias
Chest pain substernal, prolonged, unrelated to exertion
MVP
In echo, systolic displacement of MVL and quantifies mitral regurgitation and LV function
MVP
Medical treatment for mvp
IE prophylaxis
Beta-blockers
Antiplatelet for patients with transient ischemic attack
Anticoagulation if recurrent TIAs
Surgical treatment for MVP
For severe asymptomatic MR, MV repair or rarely replacement is indicated
Most common cause of AS in adults
Age-related degenerative calcific AS
Most common etiology of AS
Valvular (RHD, degenerative calcification, bicuspid AV stenosis)
Subvalvular etiology of AS
Hypertrophic obstructive CM
Cardinal manifestations of acquired AS
Syncope
Heart Failure
Exertional dyspnea
Angina
LV diastolic dysfunction, with an excessive rise in end-diastolic pressure leading to ____
Pulmonary congestion
In patients without CAD, angina results from the combination of
Increased O2 needs of hypertrophied myocardium
Reduction of O2 delivery secondary to the excessvie comression of coronary vessels
Syncope is most commonly caused by the ____
Reduced cerebral perfusion that occurs during exertion
Key features of the PE in patients with AS
Palpation of the carotid upstroke
Evaluation of systolic murmur (harsh late peaking crescendo-decresdo)
Assessment of splitting of the second heart sound
Examinations for signs of heart failure
Findings in carotid upstroke
Slow rising, late-peaking, low-amplitude carotid pulse, the parvus and tardus carotid impulse
Ejection systolic murmur of AS
Late-peaking
Heard best at the base of the heart
Radiation to the carotids
Murmur that comes from the vibration of the valve and subvalvular structures which can be heard in the LV cavity
Gallavardin phenomenon
Key finding in AS
LV hypertrophy
Medical treatment for AS
Avoid strenuous physcial activity Sodium restriction Cautious admin of diuretics and digitalis in CHF Nitroglycerins to relieve angina Statins
Severe AS
<0.5 cm2/m2
Indication for surgery in AS
Severe AS
Symptomatic with LV dysfunction
Expanding poststenotic aortic root
Those who undergo CABG even if asymptomatic
Preferred in children and young adults with congenital noncalcific AS
High re-stenosis rate in calcific AS
Bridge to operation
Percutaenous Balloon Aortic Valvuloplasty
Easy fatigue then exertional dyspnea
Wide pulse pressure with bounding pulses
Diastolic decrescendo murmur at the base of the heart
Midsystolic ejection murmur at the base of the heart
Austin Flint murmur
AR
Soft, low pitched rumbling mid-diastolic bruit at the apex
Austin Flint murmur
Primary valve diseases that can cause AR
Rheumatic
Infective endocarditis
Trauma
Bicuspid valve
Primary aortic root diseases that can cause AR
Degenerataive heart disease Syphilis Marfan's syndrome Ankylosing spondyitis Aortic aneurysm with dissection Systemic hypertension Giant cell arteritis
Pulses with abrupt distension and quick collapse of peripheral pulse
Corrigan’s pulse (Water hammer pulse)
Head bobbing
De Mussets sign
Pistol shot sound on the femoral artery
Traube’s sign
Systolic murmur heard over the femoral artery when compressed proximally
Duroziez’s sign
Systolic pulsations of the uvula
Muller’s sign
Capillary pulsation
Blanching and flashing of the nail bed on light compression
Quincke’s sign
Popliteal cuff BP> bracial cuff SBP by 60mmHg
Hill’s sign
Peripheral signs of chronic AR
Corrigan's pulse De Musset's sign Traube's sign Duroziez's sign Muller's sign Quincke's sign Hill's sign
Lab exam for AR
LV hypertrophy
2D echo + myocaridal contractility and function
Cardiac catherization and angiography
Medical tx of AR
Same as HF Salt restriction Diuretics Vasodilators Penicillin
Definitive tx for AR
Surgery
Occurs when the septal leaflet is lower than the lateral leaflet which causes severe tricuspid regurgitation
Ebstein anomaly
Medical tx of TS
Intensive salt restriction
Diuretics
For surgery among px with TS, diastolic pressure gradient _____, tricuspid orifice ____
> 4mmHg
<1.5 to 2.0 cm
Most common abnormality of the PV secondary to dilatation of PV ring as a consequence of PHPN
Pulmonic regurgitation
High pitched decrescendo, diastolic blowing murmur along the left sternal border
Graham Steell murmur
