Cardiac Valvular Dz 1 Flashcards
connects LA to LV
mitral valve
opens during diastole
connects LV to aorta
aortic valve
connects RA to RV
tricuspid valve
connects RV to pulmonic artery
pulmonic valve
primary means to non-invasively study cardiac function and valvular disease
Transthoracic Echocardiography
sound waves in TTE used to (4 results)
- images of heart structures
- direction and velocity of blood flow
- filling of heart and perfusion of myocardium
- pressure gradient
indications for TTE
valvular disease, syncope, DOE
heart failure and pulmonary HTN
infective endocarditis
evaluation of TIA/Stroke
TEE
posterior structures of heart
esp. good for LA, L atrial appendage, mitral valve, aorta
indications for TEE
- infective endocarditis (esp PVE)
- aortic dissection
- Detection of LA mass or thrombus
- when pt factors preclude TTE
valvular heart disease
etiologies
congenital or acquired
due to rheumatic fever, now due to degeneration of the valve
Rheumatic heart disease
immune mediated illness affects multiple systems
initiated by untreated streptococcal infection
antibodies against strep proteins cross react with protein self antigens
attack heart, joints, vessels to produce inflammation
myocarditis secondary to rheumatic fever
may result in severe ventricular dilation
all three layers of heart may be effected
results in poor LV contractility and deformation of valvular apparatus
effect of poor LV contractility
myocarditis
HFrEF (syncope, DOE)
can’t move blood forward so back up into lungs
effect of deforming valvular apparatus
myocarditis
regurgitation
valve is stretched apart
acute rheumatic fever will also cause valve leaflets…
to become red and swollen with small sterile vegetations
inflammatory changes heal with fibrosis
causes stenosis and regurgitation in same valve
fibrosis of valvular disease causes
fibrosis of leaflets (hard)
fusion of leaflet commissures
contracting valve leaflets
shortening chordae
s/s of acute rheumatic fever
- febrile illness
- arthritis
- carditis
- skin lesions
- chorea
febrile illness in acute rheumatic fever
history of suggestive strep pharyngitis
mc in kids 4-10 yrs of age, M=F
arthritis in acute rheumatic fever
migratory poly arthritis of mid-large joints (hips, elbows, knees)
lasting about 4 weeks, responsive with ASA
carditis in acute rheumatic fever
pericardial friction rub
new heart murmurs
any heart valve - aortic> mitral> R heart
visible on ECHO
treatment of rheumatic fever
Penicillin to eradicate the strep
prophylaxis PCN injections for 10+ yrs to prevent recurrent strep infections
ASA used for treatment of severe and pericarditis
epidemiology of aortic stenosis
more common in men
more common in older patients
more common in comorbid dyslipidemia
pathophys of aortic stenosis
degenerative
wear/tear + deposition of calcium causes leaflets to become more rigid and fuse at commissures
when does aortic stenosis become symptomatic?
60-70s with bicuspid AORTIC
70-80s with tricuspid aortic
bc the trileaflet allow blood to move thru easier so more degeneration must take place
etiologies of aortic stenosis (3)
- congenital abnormal valve with superimposed calcification
- calcification and degeneration of normal valve
- rheumatic disease
aortic sclerosis
thickened valve leaflets without stenosis
aortic stenosis
measurable outflow obstruction and reduced valve area
hemodynamics of AS
valve damage leads to LV outflow obstruction
ventricle increases speed and strength of contraction to compensate (increased AFTERload)
LV hypertrophy = stiffness = diastolic dysfunction
eventually DILATION occurs = systolic dysfunction
moderate stenosis is a valve
1.0-1.5 cm
critical aortic gradient/stenosis
> 40 mmHg and <1.0 cm
symptomatic AS when?
occurs when valve decreases to <1.0 cm
initial symptoms are non specific
dyspnea on exertion, exertional dizziness, exertional angina
Symptoms of AS and why? (3)
- angina (decreased diastole = decreased coronary filling)
- syncope (outflow decreased, results in decreased perfusion)
- dyspnea/HF (backing up into pulmonary circuit)
AS murmur/ PE
harsh, blowing crescendo decrescendo murmur, best heard at RUSB, 2nd ICS, radiates to neck
s4 gallop
apical pulse, diminished and delayed carotid
diagnosis of AS
ECHO
determine cause, calculate area and gradient to understand severity
AS treatment
once symptomatic it is surgical treatment
can give low dose diuretics and ACEI
avoid activity, daily weight and HF s/s
pharm CI for AS
low dose BB (can be Used from some) reduce contractility and should avoid in HF and AS
vasodilators (reduce coronary perfusion) - hydrazine, nonDHP CCB, NTG
surgical treatment of AS (list)
AVR w/ prosthetic or mechanical valve +/- CABG
TAVR
balloon aortic valvuloplasty
TAVR
transcatheter replacement of valve, used in patients with high risk of open heart surgery
balloon tipped catheter goes in, pushes open valve and mechanical one is placed
Aortic regurgitation etiologies (Leaftlet issue) (5)
rheumatic heart disease
congenital abnormaliteit
infective endocarditis
medications (diet med(
connective tissue disorder
Aortic regurgitation etiologies (apparatus distortion)
dilation
cardiomyopathy, AS, or aortic root
aortic regurgitation hemodynamics
LV dilation and hypertrophy @ same time
blood leaks back into LV during aorta so ventricle dilates and hypertrophies to move thru large volumes
causes myocyte damage which causes systolic failure therefore backing up into lungs
AR symtpoms
largely asymptomatic due to LV compensation
normal to increased EF
- symptoms of increased LV filling pressures (Palpitations, pounding HB, atypical chest pain)
- reduced CO causes fatigue and weakness
- LV dysfunction = PND, orthopnea, DOE
ANgina due to oxygen demand of hypertrophy LV and decreased flow
SIGNS of AR
blowing, high pitched diastolic decrescendo murmur (LLSB)
widened pulse pressure
arterial pulse bounding
S3 gallop
AR treatment
monitoring of LV function and size via serial echo (6mo-1yr)
vasodilators (ACEI or nifetapine)
CI BB due to their prolongation of diastole (increased amount of blood regurged)
valve surgery is indicated for:
- ALL symptomatic AR
- AR and systolic dysfunction (EF < 55%)
- AR and enlarging LV (>55 mm end systolic)
ascending aorta may also req. graft replacement (aortic root)
acute AR causes
infective endocarditis
ascending aortic dissection
pathophys of ACUTE AR
LV unable to dilate accommodate regurgitant volume
immediate reduction of effective CO, causing rapid pulmonary congestion
symptoms of acute AR
pulmonary edema
crackles/rales (Wet lungs)
HoTN
AMS
Dypsnea
cyanosis
oliguria
signs of acute AR
S3
cardiogenic shock
low pitched, short diastolic murmur
diagnose with ECHO
acute AR treatment
vasopressors and inotropic support until valve replacement can be performed
