CHAPTER 54 VALVULAR EMERGENCIES Flashcards
T/F: Any diastolic murmur or new systolic murmur with symptoms at rest is pathologic and warrants emergent echocardiography
TRUE
GRADING for murmur
fa1nt
2uiet, but heard immediately with steth on chest wall
3oderately loud
L4WD (Loud)
5ff the steth partly
6ff the steth entirely
Mid-diastolic rumble, crescendos into S2
Loud OPENING SNAP S1 , small apical impulse, tapping due to underfilled ventricle
MITRAL STENOSIS
Harsh apical systolic murmur starts with S 1 and may end before S2
ACUTE MITRAL REGURGITATION
High-pitched apical holosystolic murmur radiating into S2
CHRONIC MITRAL REGURGITATION
Mid-systolic CLICK may be followed by a late systolic murmur that crescendos into S2
MITRAL VALVE PROLAPSE
Harsh systolic ejection murmur
AORTIC STENOSIS
High-pitched blowing diastolic murmur immediately after S2
Wide pulse pressure
AORTIC REGURGITATION
You have discovered a NEW systolic cardiac murmur, mid-systolic, grade 2, asymptomatic (no signs of cardiovascular disease, normal ECG and CXR, murmur does not increase in intensity with Valsalva or standing).
What is your next step?
No further workup!
You have discovered a NEW systolic cardiac murmur, mid-systolic, grade 3 (or Early or late systolic diastolic murmur, holosystolic) symptomatic (with signs of cardiovascular disease, abnormal ECG and CXR, murmur increases in intensity with Valsalva or standing).
What is your next step?
Echocardiography
MCC of Mitral Stenosis
Rheumatic heart disease
Typical early radiographic finding of MS
straightening of the left heart border = left atrial enlargement
Indication of anticoagulation for MS
left atrial diameter is >55 mm
atrial fibrillation,
left atrial thrombus,
history of systemic emboli
Primary treatment for symptomatic MS
percutaneous mitral commissurotomy,
MCC of Mitral regurgitation
Fibroelastic deficiency syndrome
MVP (younger pxs)
Typical cause of Acute Mitral Regurgitation
papillary muscle or chordae tendineae rupture from myocardial infarction or valve leaflet perforation from infective endocarditis
Seen in any patient with new-onset and marked PULMONARY EDEMA, especially in patients with near-normal heart size on chest radiograph or in those who do not respond to conventional therapy
Acute mitral regurgitation
Systolic billowing of one or both leaflets into the left atrium occurring with or without mitral regurgitation.
MVP
Maneuvers that decrease preload in MVP
Valsalva or standing
–> cause the click to occur earlier in diastole
Maneuvers that increase preload in MVP
squatting
Maneuvers that increase afterload in MVP
hand grips
Classic triad of aortic stenosis
dyspnea
chest pain
syncope
Severe stenosis: aortic valve area
<1.0 cm2
-asymptomatic
Classic physical examination findings for AS
- late peaking systolic murmur at the right second intercostal space radiating to the carotid
- single or paradoxically split S2, an S4
gallop - diminished carotid pulse with a delayed upstroke = pulsus parvus et tardus
In the left lateral decubitus position, listen for a mid-diastolic rumble using the bell of the stethoscope at the cardiac apex
Austin Flint murmur
“water hammer pulse”
Peripheral pulse with a quick rise in upstroke due to increased stroke volume followed by collapse from a rapid fall in diastolic pressure
“to-and-fro” femoral murmur
Duroziez sign
pulsatile head bobbing
de Musset sign
capillary pulsations visible at the proximal nail bed while pressure is applied at the tip
Quincke sign
What is avoided in acute aortic regurgitation because they block the compensatory tachycardia that is critical in maintaining cardiac output?
Beta-blockers
The least likely valve to be affected by acquired disease
PULMONIC valve
Rare and is generally accompanied by regurgitation
Tricuspid stenosis
Murmur of tricuspid valve regurgitation
soft, blowing, and holosystolic
best heard along the lower left sternal border and increases with inspiration
Associated with a rumbling crescendo decrescendo diastolic murmur occurring just before S1
best heard along the lower left sternal border, increases with inspiration, and is often preceded by an opening snap
Tricuspid valve stenosis
Harsh systolic murmur, best heard in the left second intercostal space, which increases with inspiration.
Pulmonic stenosis
Most sensitive modality for right-sided valvular heart disease
transesophageal echocardiography
More durable with lower failure rates, but have a higher risk for thromboembolic complications –> Lifelong anticoagulation is necessary to reduce the thromboembolic risk
Mechanical valves
- require an INR of 2.5 to 3.5
- bileaflet mechanical valves in the aortic position require an INR of 2.0 to 3.0
T/F: Emboli are more common from mitral rather than from aortic valves
T
Less thrombogenic but are more likely to fail and require repeat surgery. Antiplatelet therapy is recommended for all patients with prosthetic valves
Bioprosthetic valves (porcine, bovine, or human sources)
T/F: Acute onset of respiratory distress, pulmonary edema, and cardiogenic shock may be associated with mechanical valve failure, tearing of a bioprosthesis, or a large clot obstructing the valve or preventing closure
T
T/F: Patients with severe bleeding complications are best treated with fresh frozen plasma or prothrombin complex concentrate. 3 Avoid parenteral, high-dose vitamin K due to risk of overcorrection
T
