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_MS2 Cardio > 8/14- Valvular Heart Disease 1 > Flashcards

8/14- Valvular Heart Disease 1 Flashcards

1
Q

What is stenosis?

A

Narrowing of valve that limits blood flow

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2
Q

What is insufficiency?

A

Leak across a valve that allows retrograde blood flow (aka regurgitation)

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3
Q

What are the determinants of blood flow through valves?

A
  • Pressure difference
  • Orifice geometry (valve area)
  • Time of blood flow through the valve

Also:

  • Fluid rheology
  • Chamber stiffness
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4
Q

What is the pathophysiology behind valvular heart disease?

A

Valve injury causes overload

  • Acute overload -> pulmonary edema
  • Chronic pressure/volume overload -> hypertrophy

Hypertrophy-> Heart failure

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5
Q

Regurgitation causes what type of overload? Results in?

A

Regurgitation -> Volume overload -> Eccentric Hypertrophy

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6
Q

Stenosis causes what type of overload? Results in?

A

Stenosis -> Pressure overload -> Concentric hypertrophy

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7
Q

What are some consequences of valvular heart disease (concentric or eccentric hypertrophy)?

A

Congestive Heart Failure

  • SOB
  • PND
  • Orthopnea
  • Rales
  • JVD
  • Edema

Arrythmias

  • VT/Vfib (risk of sudden cardiac death, esp AS)
  • A fib (with ALL, more with MS and MR) Infective endocarditis Embolism
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8
Q

What type of valvular heart disease most often causes VT/Vfib and sudden cardiac death?

A

Aortic stenosis

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9
Q

What type of valvular heart disease most often causes Afib?

A

Mitral stensosis and mitral regurgitation (although all can)

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10
Q

What underlies infective endocarditis? Consequences?

A

A structurally abnormal valve + turbulence is at risk for bacterial growth. May damage valves further with worsening regurgitation

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11
Q

For who is endocarditis prophylaxis routinely recommended?

A
  • Prior Hx of endocarditis
  • Prosthetic valves
  • Cardiac transplant with valvular disease
  • Congenital heart disease: cyanotic CHD or repaired with a prosthetic material in under 6 mo
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12
Q

What conditions make an embolism (systemic/cerebral) more likely?

A

Systemic and cerebral most likely with:

  • Afib
  • Large atria
  • Large LV (e.g. DCM)
  • Low EF
  • Endocarditis (vegetations can break off)
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13
Q

Where are mitral valve murmurs best heard? Radiate?

A

Mitral valve

  • Best heard at apex (about 5th ICS)
  • Radiate to axilla
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14
Q

Where are aortic valve murmurs best heard? Radiate?

A

Aortic valve

  • Best heard at base of heart over aortic area (2nd R ICS)
  • Radiate to carotids/neck
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15
Q

In what state of the valve due stenotic and insufficient valves cause problems?

A

Stenosis: with normal flow across valve [systole]

Insufficiency: when valve is (supposed to be) closed [diastole]

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16
Q

List all the systolic murmurs

A
  • Aortic stenosis
  • Mitral insufficiency
  • Tricuspid insufficiency (less common)
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17
Q

List all the diastolic murmurs

A
  • Aortic insufficiency
  • Mitral stenosis
  • Tricuspid stenosis (less common)
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18
Q

Breakdown causes of aortic stenosis by age?

A

“Young” pts (under 70)

  • Mostly bicuspid (earlier clinical onset, 50s)
  • Rheumatic disease
  • Degenerative*

Older pts (>70)

  • Mostly degenerative
  • BIcuspid
  • Rheumatic disease

*Senile calcific “degenerative” later onset (70s-80s)

19
Q

Average onset of bicuspid aortic valve stenosis/

A

Earlier (50s)

20
Q

Average onset of senile calcific “degenerative” aortic valve stenosis?

A

Later (70s-80s)

21
Q

What is shown here?

A

Bicuspid aortic stenosis

  • Two cusps
22
Q

What is shown here?

A

Senile calcific aortic stenosis

  • Three cusps
23
Q

Explain the mechanics of aortic stenosis causing murmur. What kind of heart failure

A

Obstruction to LV outflow

  • Pressure gradient between LV and aorta
  • LV pressure overload results in concentric LVH over time -> diastolic dysfunction (earlier) -> systolic dysfunction (later)
  • Acceleration of systolic flow produces a systolic crescendo-decrescendo murmur at base radiation to neck
24
Q

Explain the pressure gradient across the aortic valve in aortic stenosis?

A
  • LVP > aortic P in systole
  • Pressure in LV remains higher than aorta all through systole until it finally relaxes
25
Q

What are some key physical exam findings of aortic stenosis?

A

Murmur:

  • Systolic, crescendo-decrescendo
  • At base (R and possibly L 2nd-3rd ICS), radiating into neck
  • Coarse

Slow, weak carotid upstroke

PMI forceful, sustained

Soft S2 (if calcified, doesn’t close quickly) with delayed A2 (takes longer for LV to empty)

  • Single S2 or paradoxically split S2
26
Q

What is the classical clinical triad of aortic stenosis?

A

Think of initials: A-S-D

- Angina/chest pain

- Syncope/SCD

- Dyspnea/CHF

27
Q

What causes the angina/chest pain in aortic stenosis?

A
  • Demand increases (LVH)
  • Subendocardial flow decreases (high LV diastolic pressures)
  • +/- coronary artery stenosis
28
Q

What causes heart failure in aortic stenosis?

A
  • Hypertrophy with fibrosis
  • Chamber stiffness increases
  • Diastolic failure first, later systolic failure
29
Q

What causes syncope/sudden death in aortic stenosis?

A

Exercise-induced: fixed small orifice, so unable to increase CO

Unprovoked:

  • Arrhythmia: Vtach or Vfib
  • AV block
30
Q

Describe the natural history of aortic stenosis (length of symptoms, survival…)

A

Long initial asymptomatic course

Once symptoms occur, prognosis worsens

Survival is:

  • Worst with HF
  • Better with syncope
  • Best with angina (ASD triad)
31
Q

Treatment for aortic stenosis? When done?

A

Valve replacement

  • For severe, symptomatic aortic stenosis
32
Q

What is acute aortic insufficiency?

A

Injury to aorta or leaflets -> sudden diastolic retrograde flow into LV resulting in heart failure

  • No time for compensation
33
Q

What is chronic aortic insufficiency?

A

The pathophysiology and leak evolve slowly over years

  • Allows compensation by LV dilation
  • Delays the onset of symptoms of heart failure
34
Q

Causes of acute aortic insufficiency?

A

Aorta issues:

  • Dissection!
  • Trauma

Cusp issues:

  • Infection
  • Trauma
35
Q

Causes of chronic aortic insufficiency?

A

Aorta issues:

  • Marfan’s (heritable)
  • Inflammatory: syphilis
  • Annulo-aortic ectasia

Cusp issues: (more common)

- Bicuspid valve

- Rheumatic disease

  • Late sequelae of infection
  • Prolapse
  • Degenerative/senile
36
Q

What are some key features (heart sound wise) of aortic regurgitation?

A

Diastolic regurgitation

  • Causes LV volume overload

Diastolic murmur

  • Due to regurgitation of blood into the LV

Murmur duration

  • Shorter in acute than chronic b/c pressures “equalize” faster in acute AI
37
Q

How to calculate % regurgitation?

A

regurgitation/totalSV

= regurgitation/(regurg + forward)

38
Q

Describe LVP and AoP during aortic insufficiency

A
  • Pressure difference between LVP and AoP during diastole is pretty significant; decreases with regurgitation back through aorta
  • Quicker P equalization causes shorter murmur (earler diastole) (pic h)
39
Q

What is the phathophysiology/consequences of acute aortic insufficiency?

A

Recall: acute AI = sudden disatolic leak

  • LV enlarges, but only minimally (not enough time)
  • Acute increase in volume in small chamber -> significant increases in LV diastolic ps

Acute pulmonary edema results

Effective forward CO is reduced acutely

  • > low BP
  • > circulatory collapse (shock)
40
Q

What is pathophysiology/consequences of chronic aortic insufficiency?

A

Recall: chronic AI = progressive leak over years

  • LV eccentric hypertrophy (LV dilation): compensatory increase in SV
  • Diastolic BP drops due to AI, systolic P may rise (increased SV), causing a WIDE pulse pressure (SBP-DBP)
  • Systolic function declines over years (less forward, more regurgitant volume)
  • Further LV dilation and untimely CHF results
41
Q

Key clinical findings of acute vs. chronic AI?

  • BP
  • CHF
  • PMI
  • Murmur
  • EKG
  • Echo
A

BP

- Acute: normal or low

- Chronic: wide pulse pressure, bounding pulse (large volume)

CHF?

- Acute: Severe CHF signs

- Chronic: No CHF signs

PMI:

- Acute: normal position

- Chronic: displaced, enlarged

Murmur:

- Acute: short early diastolic murmur

- Chronic: long diastolic murmur

EKG:

- Acute: no LVH

- Chronic: LVH

Echo:

- Acute: No LVH; Al jet

- Chronic: Eccentric LVH, Al jet

42
Q

Treatment for aortic regurgitation?

A

- MIld/moderate: vasodilators (to decrease afterload, unload ventricle, and increase SV)

- Severe: valve and/or aortic root repair or replacement

- Acute: surgical emergency

43
Q

Key Points of AI

A
44
Q

Key points of AS

A

_MS2 Cardio (35 decks)

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