Clinical Discussion Of valve diseases

Question 1

Aortic stenosis etiology

Answer 1

Usually in patients 40-60yrs

1/3 is actual stenosis, 1/3 is regurgitation

Affects 1% of population

Presents with a classic triad (may not have all three though)

1) Dyspnea
- most common symptom and if untreated = 2yrs of life expectancy due to CHF

2) Syncope
- 2nd most common symptom and if untreated = 3 yrs life expectancy due to CHF

3) Angina

Question 2

Tricuspid valve stenosis etiology

Answer 2

Usually in elderly >65yrs

Often caused by degenerative calcification or radiation treatments

In rare cases, caused by rheumatic fever

Question 3

Law of Laplace reminder

Answer 3

LV wall stress = (LV pressure x Radius)/ 2(LV wall thickness)

Question 4

Pulsus parvus et tardus

Answer 4

Slowing of the carotid pulse compared to the radial pulse

- found in aortic stenosis

Question 5

Aortic stenosis Physical exam findings

Answer 5

1) Pulsus parvus et tardus
2) high pitched crescendo-decrescendo murmur mid systolic ejection w/ paradoxical splitting of S2
3) pulmonary edema
4) lower extremity edema
5) hepatosplenomegaly
* May not have all of these*

Question 6

How to grade aortic stenosis

Answer 6

Severity is based on peak velocity and the aortic valve area through an echocardiography

Mild:

1) >1.5cm AVA
2) 2.6-3.0 m/s velocity

Moderate:

1) 3-4 m/s velocity
2) 1-1.5cm AVA

Severe:

1) <1.0cm AVA
2) >4.0 velocity

Question 7

Aortic stenosis non-surgical Tx

Answer 7

Asymptomatic patients = just monitor and follow

Inoperable cases =

• digoxin for potential CHF
• also use diuretics for volume control
• also use nitroglycerin for angina if present
• DONT use vasodilators*

Question 8

Aortic stenosis surgical Tx

Answer 8

1) Surgical aortic valve replacement via Ross procedure
- use autologous pulmonic valve to replace the aortic valve via homograft
- increases on average 10yrs of survival

2) Transcatheter Aortic valve replacements (TAVR)
- used only in elderly with severe calcified valves that are inoperable
- similar to stunting except replaces the aortic valve with a cow or pig heart valves

3) Percutaneous Aortic Balloon valvuloplasty (PABV)
- used in children/young adults with mild stenosis Or used in conjunction with TAVR
- place a catheter with a balloon through the valve and inflat it to increase the valve space

Question 9

Aortic regurgitation etiology

Answer 9

Caused by various things however often one of the following

1) infections
2) congenital inflammation
3) degenerative caused by trauma
4) Aortic root abnormalities

Causes increased afterload and eccentric LVH
- this can result in cardiogenic shock and left hear failure if untreated (this requires surgery)

Question 10

Aortic regurgitation symptoms and signs

Answer 10

• Sudden left HF
• dyspnea
• orthopnea
• massive decrease in BP
• LVH and dilation
• pulmonary edema
• edema in the lower extremities

Question 11

Aortic regurgitation Physical exam findings

Answer 11

Carotid pulse is prominent

Lateral displacement of the apex of the heart

Soft high pitched decrescendo diastolic murmurs at erbs point (above clavicle near upper trunk of brachial plexus)
-louder during expiration and when patient is sitting up

Widened pulse pressure

Question 12

Regurgitation fraction

Answer 12

(Regurgitation volume)/ (Left ventricle stroke volume)

*regurgitation volume = ((left ventricle stroke volume) - (right ventricle stroke volume))

Helped to determine the severity of valve regurgitation

• mild = <20%
• moderate = 20-35%
• severe = >50%

Question 13

Mitral stenosis etiology

Answer 13

Leading causes is rheumatic fever, however the following are also possibilities:

• congenital valvular diseases
• mitral calcification
• SLE
• RA
• Infective endocarditis
• Left atrial thrombi

Some patients may not present w/ symptoms for decades
- most common age for symptoms starting in this case is 40yrs and older.

Question 14

Mitral valve stenosis signs and symptoms

Answer 14

1) dyspnea (presents w/ orthopnea and/or paroxsysmal nocturnal dyspnea
2) coughing/fatigue
3) pulmonary HTN
4) interstitial edema (especially in lower extremities)

5) LVH and RVH
- along with it see ascites and hepatomegaly
- also right pleural effusion

6) RHF (if untreated)
7) ECG may show persistent A. Fib
8) mallar flushing (red) w/ blue facies (purple/blue) (Severe only)
9) prominent Jugular venous pulse (severe only)
10) hemoptysis (coughing up blood (only found in severe untreated MV stenosis))
11) inverted T waves and prolonged QT

Question 15

Physiological complications with Rheumatic heart disease mitral stenosis

Answer 15

Increases turbulent flow through the valve and high pressure within the LA and LV
- causes concentric LVH and shortness of breath due to decreased valve area

Question 16

Enlarged right ventricle can cause what specifically in a physcial exam?

Answer 16

Parasternal lift or diastolic thrill feel at the cardiac apex when the patient is in left lateral recumbent

Question 17

Treatment of mitral valve stenosis

Answer 17

If patient is known to have Rheumatic Heart disease, can use prophylactic penicllins

Anticoagulants are often used to prevent formation of L atrial thrombus and emboli events from mitral stenosis

BBs can also be used if mitral stenosis is present in patients w/ experience symptoms and elevated HR

If pulmonary HTN is present, use diuretics and restrict salt consumption to relieve symptoms

Question 18

Mitral regurgitation etiology

Answer 18

Results from an abnormality of the mitral valve apparatus

• leaflets
• annulus
• chordae tendineae
• papillary muscles
• subjacent myocardium

Causes can be organic or function issues

Question 19

Functional mitral regurgitation etiologies

Answer 19

Causes include:

• ischemic cardiomyopathy
• dilated cardiomyopathy
• HCM
• left atrial dilation

Question 20

Organic mitral regurgitation etiologies

Answer 20

Causes include:

• Rheumatic heart disease
• Infective endocarditis
• collagen vascular disease
• papillary muscle dysfunction
• spontaneous chordal rupture
• surgical trauma

Question 21

Mitral regurgitation signs and symptoms

Answer 21

1) increases blood volume in bot LV and LA
- leads to Left atrial enlargement and left ventricular hypertrophy
- also leads to systolic heart failure

2) atrial fibrillation
3) fatigue
4) exertion dyspnea and orthopnea
5) cardiac cachexia

Question 22

Mitral regurgitation physical findings

Answer 22

Acute cases:

• narrow pulse pressure
• JVD
• signs of pulmonary congestion/edema/HTN
• early systolic decresendo murmurs

Chronic/severe MR

• high pitched holosystolic murmur that spines like blowing (the murmur increases w/ valsalva maneuver/ hand gripping)
• laterally displaced heart apex
• P wave is biphasic (biatrial enlargement) in leads V2-V6

Question 23

Mitral regurgitation tx

Answer 23

Asymptomatic =

• just observation
• only use vasodilators if patient is HTN or diabetic

Mildly symptomatic =

• use nitroprusside
• DONT use ACEIs and nitrates in mild symptomatic (since these can push mild -> moderate very easily)
• if atrial fibrillation is present, use anticoagulation

Moderately symptomatic =

• BBs and diuretics are 1st line
• use ACEIs and Nitrates ONLY if ischemic heart disease or dialated CM is present

Severe symptomatic =
- surgery

Question 24

Surgical Tx for mitral regurgitation

Answer 24

Transcatheter mitral valve repair/replacement

- similar to TAVR