Clinical Valvular Heart Disease

Question 1

What are murmurs?

Answer 1

turbulent flow heard across a valve that results from structural alterations of any one or all of the components of the valve apparatus.

Question 2

What are the components of the valve?

Answer 2

leaflets
chordae tendinea
annulus
papillary muscles

Question 3

What is a murmur caused by a primary lesion?

Answer 3

a murmur caused by an intrinsic abnormality of the valve apparatus.

Question 4

What is a murmur caused by a secondary lesion?

Answer 4

a murmur caused by a chamber dilation.

Question 5

What are 4 ways we can diagnose valvular heart disease?

Answer 5

1. EKG
2. Chest radiography
3. Echocardiography
4. Cardiac catheterization

Question 6

What will an EKG show with right atrial enlargement?

Answer 6

tall P waves (2.5 blocks) in lead II

Question 7

What will an EKG show with left atrial enlargement?

Answer 7

P wave in V1 will be >1 block wide and tall.

Question 8

*What bacteria is associated with acute rheumatic heart disease?

Answer 8

Streptococcus pyogenes (aka. group A strep)

Question 9

Which valve is most commonly affected in acute rheumatic fever?

Answer 9

mitral valve

Question 10

What can cause Tricuspid regurgitation (insufficiency)?

Answer 10

• leaflet abnormalities (may be secondary to endocarditis or rheumatic heart disease)
• Ebstein’s anomaly= most common congenital form
• ischemia of the papillary muscles
• RV dilatation (may be due to left heart failure or pulmonary hypertension)
• carcinoid

Question 11

What directions do the colors on the doppler correspond to?

Answer 11

red= towards
blue= away

Question 12

***What is Ebstein’s anomaly?

test question

Answer 12

a congenital malformation in which there is apical displacement of the septal and posterior tricuspid valve leaflets leading to ATRIALIZATION of the right ventricle (there is variable degree of malformation and displacement of the anterior leaflet). AKA the tricuspid valve is deeper into the ventricle than it should be.

Question 13

What can carcinoid syndrome cause?

Answer 13

• due to an excess secretion of SEROTONIN that can cause right heart failure, wheezing, dyspnea, palpitations, low BP, fatigue, dizziness, and diarrhea.

Question 14

What does serotonin do in excess from carcinoid syndrome?

Answer 14

vasodilation and may increase platelet aggregation, which may result in DIC :(

Question 15

When is surgery indicated in patients with tricuspid regurgitation?

Answer 15

only if it is SEVERE and if:

• they are undergoing left-sided valve surgery.
• symptomatic with severe isolated primary tricuspid regurg.
• they have structural deformity of the valve, or if it is destroyed by bacterial endocarditis, or when ventricular dilation is uncontrolled with medical therapy.

Question 16

**What is the coronary blood supply to the posteriomedial papillary muscle of the mitral valve?
(test question)

Answer 16

single blood supply from the POSTERIOR DESCENDING branch of the dominant RCA.
This is associate with INFERIOR wall infarctions.

Question 17

**Rupture of which mitral valve papillary muscle is associated with the most cases?

Answer 17

posteromedial papillary muscle.

Question 18

**What is the coronary blood supply to the anterolateral papillary muscle of the mitral valve?
(test question)

Answer 18

from obtuse marginal branches of the LCX and from diagonal branches of the LAD

Question 19

What are the most common causes of organic mitral regurgitation?

Answer 19

• MVP syndrome
• rheumatic heart disease
• CAD
• infectious endocarditis
• drugs
• collagen vascular disease
• ruptured papillary muscle
• ruptured chordae tendineae

Question 20

What are the grades of murmurs?

Answer 20

Grade:
1= not readily heard
2= between 1 and 3 
3= readily heard
4, 5= can feel a thrill
6= don't even need a stethoscope to hear it!

Question 21

What should your suspicion be if there is hyperdynamic systolic function of the left ventricle on a TTE with acute heart failure?

Answer 21

severe mitral regurgitation

Question 22

Is TTE or TEE better for mitral valve morphology?

Answer 22

TEE due to color of flow jet.

Question 23

What is the treatment for acute severe mitral regurgitation?

Answer 23

Surgery

Question 24

**What is the most common cause of mitral stenosis?

Answer 24

rheumatic fever

Question 25

What other some minor causes of mitral stenosis?

Answer 25

• Fabry’s disease
• Whipple’s disease
• SLE
• mucopolysaccharidoses of Hunter-Hurler phenotype
• malignant carcinoid disease

Question 26

What conditions can simulate the physiology of mitral stenosis?

Answer 26

• severe nonrheumatic mitral annular calcification
• infectious endocarditis w/ large vegetation
• left atrial myxoma= benign tumor of connective tissue.
• ball valve thrombus
• cor triatriatum

Question 27

Do more men or women tend to have a bicuspid aortic valve?

Answer 27

men but only 1-2% of the population has them.

Question 28

What will pts with a bicuspid valve develop over time?

Answer 28

severe aortic stenosis

Question 29

***What is the triad of symptoms for aortic stenosis?

Answer 29

syncope, angina, dyspnea

Question 30

What other congenital abnormalities may be associated with bicuspid aortic valve?

Answer 30

• coarctation of the aorta
• patent ductus arteriosus
• hypoplastic left heart syndrome

Question 31

What are the 3 aortic stenosis etiologies?

Answer 31

1. congenital (unicuspid or bicuspid)
2. calcific (due to degenerative changes)
3. rheumatic

Question 32

What is the leading indication for aortic valve replacement?

Answer 32

calcific aortic stenosis

Question 33

What will you hear with aortic stenosis?

Answer 33

late peeping high-pitched murmur at the right sternal border.

Question 34

If left ventricular pressure= 186/18
aortic pressure= 162/75
CO= 5.5
how do you calculate aortic valve area, and severity of disease?

Answer 34

CO/ sqr(peak to peak gradient)

peak to peak= 186-162= 24
sqr of 24= about 5
CO=5.5
5.5/5= 1.1 (this is moderate severity since it falls within 1.0-1.5; severe would be