Clinical Discussion Of valve diseases Flashcards
Aortic stenosis etiology
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
Tricuspid valve stenosis etiology
Usually in elderly >65yrs
Often caused by degenerative calcification or radiation treatments
In rare cases, caused by rheumatic fever
Law of Laplace reminder
LV wall stress = (LV pressure x Radius)/ 2(LV wall thickness)
Pulsus parvus et tardus
Slowing of the carotid pulse compared to the radial pulse
- found in aortic stenosis
Aortic stenosis Physical exam findings
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*
How to grade aortic stenosis
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
Aortic stenosis non-surgical Tx
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*
Aortic stenosis surgical Tx
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
Aortic regurgitation etiology
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)
Aortic regurgitation symptoms and signs
- Sudden left HF
- dyspnea
- orthopnea
- massive decrease in BP
- LVH and dilation
- pulmonary edema
- edema in the lower extremities
Aortic regurgitation Physical exam findings
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
Regurgitation fraction
(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%
Mitral stenosis etiology
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.
Mitral valve stenosis signs and symptoms
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
Physiological complications with Rheumatic heart disease mitral stenosis
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
Enlarged right ventricle can cause what specifically in a physcial exam?
Parasternal lift or diastolic thrill feel at the cardiac apex when the patient is in left lateral recumbent
Treatment of mitral valve stenosis
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
Mitral regurgitation etiology
Results from an abnormality of the mitral valve apparatus
- leaflets
- annulus
- chordae tendineae
- papillary muscles
- subjacent myocardium
Causes can be organic or function issues
Functional mitral regurgitation etiologies
Causes include:
- ischemic cardiomyopathy
- dilated cardiomyopathy
- HCM
- left atrial dilation
Organic mitral regurgitation etiologies
Causes include:
- Rheumatic heart disease
- Infective endocarditis
- collagen vascular disease
- papillary muscle dysfunction
- spontaneous chordal rupture
- surgical trauma
Mitral regurgitation signs and symptoms
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
Mitral regurgitation physical findings
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
Mitral regurgitation tx
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
Surgical Tx for mitral regurgitation
Transcatheter mitral valve repair/replacement
- similar to TAVR
