11 12 2014 Valvular Heart Disease Flashcards
common presentation of Acute Rheumatic Fever
autoimmune cross-reactivity between bacterial and cardiac antigens.
chills, fever, fatigue, and migratory arthralgias (joint pain)
Common complications of Acute Rheumatic Fever
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
High pitched blowing of uniform intensity starting immediately after S1 –> S2
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)
Crescendo- decrescendo murmur
Midsystolic (systolic ejection) murmurs
* occurs when blood is ejected across aortic or pulmonic outflow tracts
AS, PS
* Aortic Stenosis starts later than MR
begins in S1 and ends in midsystole
Early systolic murmur
Often due to TR that occurs in absence of pulmonary hypertension
Can also occur in patients with acute MR
High pitched murmurs at the Left ventricular apex.
Start after S1 and end before or at S2
Mid to late systolic murmurs
Tetherin and malcoaptation of the mitral leaflets.
OR
Mitral prolapse
High pitched, Decrescendo murmur starting right after S2 but stops before S1
Early diastolic murmur
AI ( Aortic insufficiency/ Regurgitation)
PI ( Pulmonary insufficiency/ Regurgitation)
Low pitch, usually follow an opening snap after S2. Decrescendo / dies out during mid-diastole, then gets louder as it nears S1.
Mid-Late diastolic murmur
Mitral Stenosis
Tricuspid Stenosis
Presytolic murmur/ late diastolic murmur
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
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.
Continuous Murmurs
- 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
3 most common causes of mitral stenosis
- Rhematic fever
- Calcification
- endocarditis
What does Rheumatic fever do to Mitral valve?
- Acute and recurrent inflammation
- Leaflet thickening and calcification
- Commissural fusion
- Chordal fusion/ shortening
Symptoms occur when MV area drops to Pulmonary circuit
Pathophysiology of Mitral Stenosis
Left Atrial Enlargement
Atrial Fibrillation
Thrombus Formation due to stasis from AF
Pulmonary hypertension
Symptoms from Early/ Mild MS
- Dyspnea (SOB)
- exercise, emotional stress, fever, AF, Anemia, Hyperthyroidism
Symptoms/ presentation of Late/ Severe MS
- 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
Mitral Stenosis
- S1 sound
- Sound of murmur (pitch and timing)
- Heard best?
- EKG associations
1. Loud S1 (early) "Snapped back" Soft S1 (late)
- Opening snap after S1 ( sharp high pitched), low pitched mid diastolic rumble (decrescendo), followed by pre systolic accentuation murmur ( because atria is contracting harder)
- Loudest at valve opening; heard best with bell at apex in Left, lateral decubitus position
- Left Atrial Enlargement
Right ventricular hypertrophy
Prominent T-waves in some leads
Mitral Stenosis treatment
- Medication
- Other options
- 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
- Percutaneous Balloon Mitral Valvuloplasty
- tears open fused commisures
OR
(surgery:)
Open mitral commissurotomy/ MV replacement
Causes for Mitral Regurgitation (MR)
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
Pathophysiology of MR
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
Acute MR causes what?
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
Chornic MR causes what? (two phases)
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
Presentation of Chronic MR
Fatigue and weakness (due to decrease in CO) Dyspnea Orthopnea PND - paroxysmal nocturnal dyspnea Abdominal girth Edema
MR
murmur if chronic MR
- 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
MR (acute)
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
Medical treatment for Acute MR
Medical Treatment for chronic MR
- 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
Mitral Valve Prolapse
- what it is?
- Murmur sound?
- Causes?
- Symptoms?
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
Aortic Stenosis:
- common cause in adults?
- Calcification of a normal or congenital deformed valve.
- cause reduction in leaflet movement - Rheutmatic AS = fusion of the commissures
- Congenital malformation
