11 12 2014 Valvular Heart Disease

Question 1

common presentation of Acute Rheumatic Fever

Answer 1

autoimmune cross-reactivity between bacterial and cardiac antigens.

chills, fever, fatigue, and migratory arthralgias (joint pain)

Question 2

Common complications of Acute Rheumatic Fever

Answer 2

carditis (associated with tachycardia), decreased left ventricular contractility

Pericardial fiction rub (transinet murmur of mitral or aortic regurgitation

Mid-systolic murmur of at cardiac apex

Question 3

High pitched blowing of uniform intensity starting immediately after S1 –> S2

Answer 3

Holosystolic/ Pansystolic Murmur

• generated when there is a flow between chambers that have widely different pressure gradients ( LA to LV)

Begin right after S1 and last all the way to S2
- high pitched “blowing” in quality

• regurgitations
  MR, TR, and VSD (ventricular septal defect)

Question 4

Crescendo- decrescendo murmur

Answer 4

Midsystolic (systolic ejection) murmurs
* occurs when blood is ejected across aortic or pulmonic outflow tracts

AS, PS
* Aortic Stenosis starts later than MR

Question 5

begins in S1 and ends in midsystole

Answer 5

Early systolic murmur

Often due to TR that occurs in absence of pulmonary hypertension

Can also occur in patients with acute MR

Question 6

High pitched murmurs at the Left ventricular apex.

Start after S1 and end before or at S2

Answer 6

Mid to late systolic murmurs

Tetherin and malcoaptation of the mitral leaflets.

OR

Mitral prolapse

Question 7

High pitched, Decrescendo murmur starting right after S2 but stops before S1

Answer 7

Early diastolic murmur

AI ( Aortic insufficiency/ Regurgitation)
PI ( Pulmonary insufficiency/ Regurgitation)

Question 8

Low pitch, usually follow an opening snap after S2. Decrescendo / dies out during mid-diastole, then gets louder as it nears S1.

Answer 8

Mid-Late diastolic murmur

Mitral Stenosis
Tricuspid Stenosis

Question 9

Presytolic murmur/ late diastolic murmur

Answer 9

Right before S1 and stops when S1 occurs

Begin during period of ventricular filling that follows atrial contraction

Usually due to mitral or tricuspid stenosis

-can also be duet o left or right atrial myxoma

Question 10

Murmur begins in systole, peaks at S2 and decrescendo until right before S1.

vs.

To- and Fro murmur:

Crescendo - decrescendo from S1 –> S2 and then Peak at S2 and decrescendo until mid diastole.

Answer 10

Continuous Murmurs

1. Patent Ductus Arteriosis

Can also be caused by:
- Mammary souffle, AV fistulas, Venous hum

To and Fro:
Aortic stenosis + aortic regurgitation
Pulmonic Stenosis + pulmonic regurgitation

Question 11

3 most common causes of mitral stenosis

Answer 11

1. Rhematic fever
2. Calcification
3. endocarditis

Question 12

What does Rheumatic fever do to Mitral valve?

Answer 12

• Acute and recurrent inflammation
• Leaflet thickening and calcification
• Commissural fusion
• Chordal fusion/ shortening

Symptoms occur when MV area drops to Pulmonary circuit

Question 13

Pathophysiology of Mitral Stenosis

Answer 13

Left Atrial Enlargement
Atrial Fibrillation
Thrombus Formation due to stasis from AF
Pulmonary hypertension

Question 14

Symptoms from Early/ Mild MS

Answer 14

• Dyspnea (SOB)

- exercise, emotional stress, fever, AF, Anemia, Hyperthyroidism

Question 15

Symptoms/ presentation of Late/ Severe MS

Answer 15

• Decrese CO
• dyspnea at rest
• fatigue
• Pulmonary congestion: orthopnea, PND (gasping for air at night)
• Right heart failure = edema in legs/feet, JVP, and palpable heptaomegaly, ascites

Question 16

Mitral Stenosis

1. S1 sound
2. Sound of murmur (pitch and timing)
3. Heard best?
4. EKG associations

Answer 16

1. Loud S1 (early) "Snapped back"
Soft S1 (late)

2. Opening snap after S1 ( sharp high pitched), low pitched mid diastolic rumble (decrescendo), followed by pre systolic accentuation murmur ( because atria is contracting harder)
3. Loudest at valve opening; heard best with bell at apex in Left, lateral decubitus position
4. Left Atrial Enlargement
   Right ventricular hypertrophy
   Prominent T-waves in some leads

Question 17

Mitral Stenosis treatment

1. Medication
2. Other options

Answer 17

• Diuretics to treat congestion and edema
• medications to slow heart rate:
  
  • Calcium blockers, Beta blockers, Digoxin
• Anti-arrhythmetics to prevent Atrial Fibrillation
• Coagulants to prevent thrombosis from AF

2. Percutaneous Balloon Mitral Valvuloplasty
   - tears open fused commisures

OR
(surgery:)
Open mitral commissurotomy/ MV replacement

Question 18

Causes for Mitral Regurgitation (MR)

Answer 18

Mitral Valve Prolapse
Rheumatic heart Diseaes
CAD
Drugs
Mitral Annular Calcification
Infective endocarditis
Collagen disease ( Marfan)
LVH -- dilation of annulus
Ruptured chordae tendineae or papillary muscle

Question 19

Pathophysiology of MR

Answer 19

portion of LV stroke volume is ejected back into LA

• increase LA pressure
• Decreased CO
• Increased volume of preload – regurgitant volume + pulmonary venous return
  - myofibers stretch = increase LV stroke volume
• LA pressure = prominent V wave

Question 20

Acute MR causes what?

Answer 20

Hemoynamic changes that are not tolerated because there was no time for compensatory LV and LA dilation

• increase ventricular preload leads to decreased stroke volume and pulmonary congestion
  = Pulmonary EDEMA

Question 21

Chornic MR causes what? (two phases)

Answer 21

Compensatory : LA and LV stretches (eccentric hypertorphy) to accommodate increase in volume

Ejection Fraction (EF) is maintained

Decompensated phase:
Volume overload causes sufficient dilation to push the LV onto the downward portion of Frank-Staling curve
= deterioration of systolic function
Decline of forward cardiac output and symptoms of heart failure

Question 22

Presentation of Chronic MR

Answer 22

Fatigue and weakness (due to decrease in CO)
Dyspnea
Orthopnea
PND - paroxysmal nocturnal dyspnea
Abdominal girth
Edema

Question 23

MR

murmur if chronic MR

Answer 23

1. Apical (Apex) holosystolic murmur that radiates to the axilla (bc of LVH).

Murmur is high pitched “blowing” that starts right after S1 – no gaps.

Murmur intensifies with SVR maneuvers (clench fist)

S3 – volume overload of LV

• LA and LV enlargement
  Lead II and V1

Question 24

MR (acute)

Answer 24

Pulmonary Edema – crackles/ rales

Murmur has a decrescendo quality due to the rapid equilibration between LV and LA pressures in systole caused by the relative reduced compliance of LA

Question 25

Medical treatment for Acute MR

Medical Treatment for chronic MR

Answer 25

• Diuretics (pulmonary edema)
• Vasodilators – reduce systemic vascular resistance and augment forward cardiac output

Chronic:

• Diuretics
• Vasodilators less useful
• SURGERY!!
  
  • MV repair is treatment of choice
  • MV replacement with preservation of part or all of the mitral apparatus
  • MV replacement with removal of the mitral apparatus

Question 26

Mitral Valve Prolapse

1. what it is?
2. Murmur sound?
3. Causes?
4. Symptoms?

Answer 26

Systolic billowing of 1 or both mitral leaflets into the left atrium with or without MR.

Appears as a mid systolic click that stays constant until S2 – click due to tensing of chordae tendineae – late systolic murmur at apex
* click and murmur occur later when there is an increase in systemic venous resistance (squatting)

Primary MVP can be familial = autosomal dominant inheritance
- thickened leaflets and issue with chorine tendinae

Usually asymptomatic; but if get symptoms:
- chest pain and palpitations

Question 27

Aortic Stenosis:

1. common cause in adults?

Answer 27

• Calcification of a normal or congenital deformed valve.
  - cause reduction in leaflet movement
• Rheutmatic AS = fusion of the commissures
• Congenital malformation