CVD - Valvular pathology Flashcards
(3) Etiology of aortic stenosis
- Congenital (bicuspid, unicuspid valve)
- calcification (wear and tear)
- rheumatic disease
Definition of aortic stenosis for:
- normal
- mild
- moderate
- severe
- critical
Normal aortic valve area = 3-4 cm2 Mild AS 1.5-3 cm2 Moderate AS 1.0 to 1.5 cm2 Severe AS less than 1.0 cm2 Critical AS less than 0.5 cm2
Pathophysiology of aortic stenosis
Outflow obstruction -> increased EDP -> concentric LVH -> LV failure -> CHF,
subendocardial ischemia
Symptoms of aortic stenosis
SAD
- syncope
- angina on exertion
- dyspnoea on exertion
PND, orthopnea, peripheral edema
O/E of aortic stenosis
- Narrow pulse pressure,
- brachial-radial delay,
- pulsus parvus et tardus,
- sustained PMI
Auscultation: crescendo-decrescendo SEM radiating to R clavicle and carotid, musical
quality at apex (Gallavardin phenomenon)
S4, soft S2 with paradoxical splitting, S3 (late)
Ix of aortic stenosis
ECG: LVH and strain, LBBB, LAE, AFib
CXR: post-stenotic aortic root dilatation, calcified valve, LVH, LAE, CHF
Echo: reduced valve area, pressure gradient, LVH, reduced LV function
Mx of aortic stenosis
- Asymptomatic: serial echos, avoid exertion
- Symptomatic: avoid nitrates/arterial dilators and ACEI in severe AS
- Surgery if: symptomatic or LV dysfunction.
Valve replacement for aortic rheumatic valve disease & trileaflet valve.
Percutaneous (transfemoral etc) valve replacement an option for those who are not good candidates for surgery
Etiology of aortic regurgitation
- supravalvular
- valular
- acute onset
- Supravalvular: aortic root disease (Marfan’s, atherosclerosis and dissecting aneurysm, connective tissue disease)
- Valvular: congenital (bicuspid aortic valve, large VSD), IE
- Acute Onset: IE, aortic dissection, trauma, failed prosthetic valve
Pathophysiology of aortic regurgitation
Volume overload -> LV dilatation -> increased SV, high sBP and low dBP -> increased
wall tension -> pressure overload -> LVH (low dBP -> decreased coronary perfusion)
Symptoms of aortic regurgitation
Usually only becomes symptomatic late in disease when LV failure develops
Dyspnea, orthopnea, PND, syncope, angina
O/E of aortic regurgitation
- pulse characterisation
- apex beat
- on auscultation
- heart sounds
Waterhammer pulse, bisferiens pulse, femoral-brachial sBP >20 (Hill’s test wide pulse
pressure), hyperdynamic apex, displaced PMI, heaving apex
Auscultation: early decrescendo diastolic murmur at LLSB (cusp pathology) or RLSB
(aortic root pathology), best heard sitting, leaning forward, on full expiration
soft S1, absent S2, S3 (late)
Ix of aortic regurgitation
ECG: LVH, LAE
CXR: LVH, LAE, aortic root dilatation
Echo/TTE: quantify AR, leaflet or aortic root anomalies
Cath: if >40 yr and surgical candidate – to assess for ischemic heart disease
Exercise testing: hypotension with exercise
Mx of aortic regurgitation
- Asymptomatic: serial echos, afterload reduction (e.g. ACEI, nifedipine, hydralazine)
- Symptomatic: avoid exertion, treat CHF
- Surgery if: NYHA class III-IV CHF; LV dilatation and/or LVEF
Etiology of mitral stenosis
Rheumatic disease most common cause
congenital (rare)
Definition of mitral stenosis
Severe MS is mitral valve area (MVA) less than 1.2 cm2
Pathophysiology of mitral stenosis
MS -> fixed CO and LAE -> increased LA pressure -> pulmonary vascular resistance
and CHF; worse with AFib (no atrial kick), tachycardia (decreased atrial emptying time)
and pregnancy (increased preload)
Symptoms of mitral stenosis
SOB on exertion, orthopnea, fatigue, palpitations, peripheral edema, MALAR FLUSH,
pinched and blue facies (severe MS)
O/E of mitral stenosis
- arrhythmia involved
- auscultation
- heart sounds
- any added sound
AFib, no “a” wave on JVP, left parasternal lift, palpable diastolic thrill at apex
Auscultation: mid-diastolic rumble at apex, best heard with bell in left lateral decubitus
position following exertion
Loud S1, OPENING SNAP following loud P2 (heard best during expiration),
long diastolic murmur and short A2-OS (opening snap) interval correlate with worse MS
Note: Mitral stenosis has an opening snap before diastolic murmur. C.f. Mitral valve prolapse has a CLICK before its systolic murmur.
Ix of mitral stenosis
ECG: NSR/AFib, LAE (P mitrale), RVH, RAD
CXR: LAE, CHF, mitral valve calcification
Echo/TTE: shows restricted opening of mitral valve
Cath: indicated in concurrent CAD if >40 yr (male) or >50 yr (female)
Mx of mitral stenosis
Avoid exertion, fever (increased LA pressure), treat AFib and CHF, increase diastolic filling time (β-blockers, digitalis)
Surgery if: NYHA class III-IV CHF and failure of medical therapy
(many) Etiology of mitral regurgitation
Mitral valve prolapse, congenital cleft leaflets, LV dilatation/aneurysm (CHF, DCM,
myocarditis), IE abscess, Marfan’s
syndrome, HOCM, acute MI, myxoma, mitral valve annulus
calcification, chordae/papillary muscle trauma/ischemia/rupture (acute), rheumatic
disease
Pathophysiology of mitral regurgitation
Reduced CO -> increased LV and LA pressure -> LV and LA dilatation -> CHF and pulmonary HTN
Symptoms of mitral regurgitation
Dyspnea, PND, orthopnea, palpitations, peripheral edema
O/E of mitral regurgitation
- apex beat
- auscultation
Displaced hyperdynamic apex, left parasternal lift, apical thrill
Auscultation: holosystolic murmur at apex, radiating to axilla ± mid-diastolic rumble, loud S2 (if pulmonary HTN), S3
Ix of mitral regurgitation
ECG: LAE, left atrial delay (bifid P waves), ± LVH
CXR: LVH, LAE, pulmonary venous HTN
Echo: etiology and severity of MR, LV function, leaflets
Swan-Ganz Catheter: prominent LA “v” wave
Rx of mitral regurgitation
Asymptomatic: serial echos
Symptomatic: decrease preload (diuretics), decrease afterload (ACEI) for severe MR and poor surgical candidates; stabilize acute MR with vasodilators before surgery
Surgery if: acute MR with CHF, papillary muscle rupture, NYHA class III-IV CHF, AF, increasing LV size or worsening LV function, earlier surgery if valve repairable (>90% likelihood) and patient is low-risk for surgery
Most get valve repair (lower rate of IE, no anticoagulation) rather than replacement.
Etiology of tricuspid regurgitation
RV dilatation, IE (particularly due to IV drug use), rheumatic disease, congenital (Ebstein anomaly), carcinoid
Symptomsof tricuspid regurgitation
Peripheral edema, fatigue, palpitations
O/E of tricuspid regurgitation
- JVP
- […] sign
- auscultation
“cv” waves in JVP, +ve abdominojugular reflux, Kussmaul’s sign, holosystolic murmur at LLSB accentuated by inspiration, left parasternal lift
Ix of tricuspid regurgitation
ECG: RAE, RVH, AFib
CXR: RAE, RV enlargement
Echo: diagnostic
Mx of tricuspid regurgitation
Preload reduction (diuretics)
Surgery if: only if OTHER surgery required (e.g. mitral valve replacement)
Pathophysiology of tricuspid regurgitation
RV dilatation -> TR -> further RV dilatation -> right heart failure
Etiology of pulmonary stenosis
Usually congenital, rheumatic disease (rare), carcinoid syndrome
Pathophysiology of pulmonary stenosis
Increased RV pressure -> RV hypertrophy -> right heart failure
Symptoms of pulmonary stenosis
Chest pain, syncope, fatigue, peripheral edema
O/E of pulmonary stenosis
Systolic murmur at 2nd left intercostal space accentuated by inspiration, pulmonary
ejection click, right-sided S4
Mx of pulmonary stenosis
Balloon valvuloplasty if severe symptoms
Ix of pulmonary stenosis
ECG: RVH
CXR: prominent pulmonary arteries enlarged RV
Echo: diagnostic
(many) Etiology of mitral valve prolapse
Myxomatous degeneration of
chordae, thick, bulky leaflets that crowd orifice, associated with Marfan’s syndrome, pectus excavatum, straight back syndrome, other MSK abnormalities; less than 3% of population
Pathophysiology of mitral valve prolapse
Mitral valve displaced into LA during systole; no causal mechanisms found for
symptoms
Symptoms of mitral valve prolapse
Prolonged, stabbing chest pain, dyspnea, anxiety/panic, palpitations, fatigue, presyncope
O/E of mitral valve prolapse
Ausculation: mid-systolic CLICK (due to billowing of mitral leaflet into LA; tensing of redundant valve tissue); mid to late systolic murmur at apex, accentuated by Valsalva or squat-to-stand maneuvers
Note: midsystolic CLICK in mitral valve prolapse (c.f. opening snap in mitral stenosis before diastolic murmur)
Ix of mitral valve prolapse
ECG: non-specific ST-T wave changes, paroxysmal SVT, ventricular ectopy
Echo: systolic displacement of thickened mitral valve leaflets into LA
Mx of mitral valve prolapse
Asymptomatic: no treatment; reassurance
Symptomatic: β-blockers and avoidance of stimulants (caffeine) for significant palpitations, anticoagulation if AFib
Mitral valve surgery (repair favoured over replacement) if symptomatic and significant
MR
