20. Valvular Heart Case study Flashcards
What abnormalities in the valve leaflets would cause aortic regurgitation?
Congentital
Endocarditis
Rheumatic
What could cause dilation of the aortic root that may result in aortic regurgitation?
Aortic aneurysm
Aortic dissection
Annuloaortic ectasia and SYPHILLIS
Explain the pahtophysiology of aortic regurgitation
Some of the blood that ejects from LV into the aorta during systole will return through an incompetent valve back into the LV during diastole
result is VOLUME OVERLOAD of left ventricle
What would result in volume overload of LV?
aortic regurgitation
What does the LV look like in acute Aortic regurgitation?
usually normal size with low compliance… we get quick rise in diastolic pressure that will ‘back up’ into the LA and pulmonary vasculature === congestion
Pt comes in with high left atrial pressure but normal left ventricle pressure. Fluid has backed up into the lungs.. what valve issue could cause this?
Acute aortic regurgitation
= SURGICAL EMERGENCY
What happens to the LV during chronic aortic regurgitation?
LV undergoes compensatory adaption in response to longstanding regurg
- see some volume overload and some pressure overload of LV
- Ventricle dilates over time
- Increases compliance of LV
What happens to the Left Atrium in chornic aortic regurg?
Reduced pressure to LA (as well as pulmonary vasculature)
Aortic valve Regurg: Aortic Systolic pressure Aortic Diastolic pressure Pulse pressure: L.atrial pressure:
aortic systolic pressure increases
aortic diastolic pressure decreases
pulse pressure increases
LAP increases
What will be pt complaints in aortic regurg?
dyspnea on exertion, fatigue, decreased exercise tolerance, chest pain
**Once pt complains of angina w/out surgery–> death in four years
If heart failure symptoms–> death in 2 years
Pt presents with a decrescendo Diastolic murmur: what is this and when does it present?
Hear at end of expiration when pt is leaning forward in the left upper boarder… heard during diastole and murmur during diastole is always abnormal
Heard in Aortic Regurgitation
What kind of pulse pressure do we expect on exam in pt with aortic regurg?
Widened pulse pressure: diastolic blood pressure is less than half of the systolic BP
Ex: 140/50
hyperdynamic pulses, head bobbing, water hammer pulse Quinckes pulse and Duroziezs murmur are all signs of
Aortic regurg.
What differences do we expect to see on CXR btwn acute aortic regurg and chronic?
Chronic: see enlarged LV
Acute: not so much big LV but see pulmonary congestion
TX for acute aortic regurgitation?
Surgical emergency; immediate surgical replacement
Tx for severe chronic aortic regurg:
–asymptomatic and normal LVEF (>50%)
periodic follow up and echo. Consider afterload reduction w/ Ca+ channel blocker or ACE inhibitor if pt is HTN
Tx for severe chronic aortic regug:
-if asymptomatic and low LVEF (<50%)
refer for surgery for valve replacement
Tx for severe chronic aortic regurg:
-If symptomatic and normal LVEF
refer for surgery for valve replacement
Myxomatous disease, Rheumatic valve disease, endocarditis and congenital clefting are examples of what type of mitral valve regurgitation
Organic primary
Ischemic CM, Dilated CM, and Hypertrophic CM are excamples of what type of mitral valve regurg?
Functional Secondary
Mitral valve regurgitation causes:
Volume overload state of the heart
Organ systems respond most adversely to:
degree of change or rate of change in mitral regurg
rate of change
–mitral regurg is tolerated well until becomes severe; pts can tolerate severe mitral regurg if it develops slowly over time
What happens to the LA in Chronic mitral valve regurg?
Dilated LA with normal pressure and increased compliance
What happes to the LA in acute mitral regurgitation?
High LA pressure causing pulmonary edema
What type of compliance do we see in acute mitral regurg?
normal LA compliance and size (but increased LA pressure)
What effect does acute mitral regurg have on pulmonary venous pressure?
Increase pulm venous pressure
What do we see on catheterization during acute mitral regurg?
Prominent V waves on catheterization
During Chronic mitral regurg, what do the LA and pulmonary venous pressures look like?
More normal than in acute mitral regurg
What affect does chronic mitral regurg have on CO?
Decreases CO
Affect of chronic mitral regurg on LV?
Increased LV size
What effect does chronic mitral regurg have on systole?
eventual systolic dysfnx
You hear a holosytolic murmur at the apex of the heart… you suspect?
mitral regurgitation
What are the most common symptoms with mitral valve regurgitation?
exertional symptoms are most common
-heart can change without symptoms
Pt comes in with mitral regurg… how do you manage the pt?
You make decisions based on development of symptoms and loss of LV systolic function
*repair is better then replacement
Course of tx for acute mitral regurgitation
Stabilize the patient with diuretics and vasodilators
and also depending on the cause, consider emergent
surgery for management.
Pt has chronic mitral regurg. She is asymptomatic, what tx would you recommend?
What is she became symptomatic?
continue to monitor if not severe
– If symptomatic and severe mitral regurgitation, see
about repair or replacement of the valve (repair is
preferred if it is possible.)
.
Pt has chronic mitral regurg with severe left ventricular dysfunction, what is your tx recommendation?
little can be done at this point
Anterolateral portion of the papillary muscle provides chordae to the
anterolateral ½ of both mitral leaflets.
Posteromedial portion provides chordae to the
posteromedial ½ of both mitral leaflets
Which has a dual blood supply… the posteromedial portion or the anterolateral portion of the papillary muscles?
The posteromedial portion receives its blood supply
from the right coronary artery while the anterolateral
portion receives a dual blood supply
Most common cause of mitral stenosis?
rheumatic fever
Less common causes of mitral stenosis
-Congenital stenosis
- Calcification of the mitral annulus
- Endocarditis with large vegetations obstructing valve
orifice
What is considered MVS?
MVA of less then 2 cm
What symptoms would we expect to see in mild mitral stenosis?
Dyspnea and reduced exercise capacity… no symptoms at rest, only with exertion or anything that increases the heart rate
What symptoms would we expect to see in severe mitral stenosis?
severe mitral stenosis, shortness of breath occurs
at rest, patients develop symptoms of heart failure with
orthopnea, paroxysmal nocturnal dyspnea.
• Can also develop signs of right sided heart failure with
jugular venous distention, hepatomegaly, ascites, edema.
• Rare symptoms that can occur:
– Hoarseness
– hemoptysis
jugular venous distention, hepatomegaly, ascites, edema. are all symptoms of
right sided heart fail
Pt presents with SOB upon exercise. You hear an opening snap and murmur. Dx?
Early stages of mitral stenosis
Your attending asks you how you can tell the difference between early and late mitral stenosis when listening to heart tones..
Both early and late will have an opening snap and murmur but late mitral stenosis will also present with an RV lift
Severe MVS has an
MVA:
MVG:
MVA: less/= 1 cm
MVG>/= 10 mmHg
Your attending just diagnosed a pt with mitral valve stenosis and has decided to use diuretics to tx… why?
Pt must have signs of vascular congestion… Diuretics if there are symptoms of vascular congestion
Pt was diagnosed with mitral valve stenosis and is presenting with A-fib as well… what medication do you recommend?
If atrial fibrillation has developed, treat with beta
blockers, calcium channel blockers (verapamil,
diltiazem) or digoxin
• Chronic anticoagulation if atrial fibrillation is present
What two surgical options are available for mitral stenosis?
balloon angioplasty or valve replacement
What is the most common etiology for aortic stenosis
calcific degeneration
When do you suspect bicuspid vs tricuspid calcific degeneration in pt with aortic stenosis?
If patient < 65, probably a bicuspid valve
If patient > 65, probably tricuspid valve
Pt presents with aortic stenosis at 25… what’s the cause?
AS before 30 is almost always congnenital
Rheumatic involvement in the heart attacks which valve?
mitral
what happens to LVP and LAP in aortic stenosis
LVP increases (normal is 120/10) and LAP increases
What key findings do we see in physical exam in aortic stenosis>
Sustained LV impulse No/little LV displacement
• Pulsus Parvus et Tardus of the carotid impulse
(weakened and late)
• Absent A2 or Paradoxically split A2
• Murmur is systolic crescendo decrescendo
( Later peaking/worse stenosis)
• Heard at the base of the heart or the right upper
sternal border, radiates to the carotid arteries
What do we see on CXR in patient with aortic stenosis?
Little Cardiac enlargement by CXR due to LVH
• Post-stenotic dilation of the ascending aorta
• Calcification of the aortic valve.
What type of murmur is heard in aortic stenosis
Murmur is systolic crescendo decrescendo
( Later peaking/worse stenosis)
Pt has aortic stenosis… what findings do we expect to see on EKG?
will show left ventricular hypertrophy
Pt has severe aortic stenosis if
valve area:
valve area index:
valve area less then 1.0
valve area index less then 0.6
Pt has severe aortic stenosis if
jet velocity:
mean gradient:
jet velocity: greater then 4
mean gradient less then 40
When do we intervene in pt with aortic stenosis?
When symptoms devo
Pt has aortic stenosis and is experiencing angina… what is our mean survival?
if they have syncope?
CHF?
5 yrs for angina
3 yrs for syncope
2 yrs for CHF
What is our only life-prolonging tx for pts with aortic stenosis?
to replace the valve. Current standard is surgical, but there is also percutaneous being studied.
