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YA - Interactive seminars/University lectures > CVD - Valvular pathology > Flashcards

CVD - Valvular pathology Flashcards

1
Q

(3) Etiology of aortic stenosis

A
  • Congenital (bicuspid, unicuspid valve)
  • calcification (wear and tear)
  • rheumatic disease
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2
Q

Definition of aortic stenosis for:

  • normal
  • mild
  • moderate
  • severe
  • critical
A 
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
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3
Q

Pathophysiology of aortic stenosis

A

Outflow obstruction -> increased EDP -> concentric LVH -> LV failure -> CHF,
subendocardial ischemia

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4
Q

Symptoms of aortic stenosis

A

SAD

  • syncope
  • angina on exertion
  • dyspnoea on exertion

PND, orthopnea, peripheral edema

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5
Q

O/E of aortic stenosis

A
  • 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)

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6
Q

Ix of aortic stenosis

A

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

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7
Q

Mx of aortic stenosis

A
  • 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

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8
Q

Etiology of aortic regurgitation

  • supravalvular
  • valular
  • acute onset
A
  • 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
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9
Q

Pathophysiology of aortic regurgitation

A

Volume overload -> LV dilatation -> increased SV, high sBP and low dBP -> increased
wall tension -> pressure overload -> LVH (low dBP -> decreased coronary perfusion)

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10
Q

Symptoms of aortic regurgitation

A

Usually only becomes symptomatic late in disease when LV failure develops

Dyspnea, orthopnea, PND, syncope, angina

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11
Q

O/E of aortic regurgitation

  • pulse characterisation
  • apex beat
  • on auscultation
  • heart sounds
A

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)

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12
Q

Ix of aortic regurgitation

A

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

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13
Q

Mx of aortic regurgitation

A
  • 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
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14
Q

Etiology of mitral stenosis

A

Rheumatic disease most common cause

congenital (rare)

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15
Q

Definition of mitral stenosis

A

Severe MS is mitral valve area (MVA) less than 1.2 cm2

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16
Q

Pathophysiology of mitral stenosis

A

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)

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17
Q

Symptoms of mitral stenosis

A

SOB on exertion, orthopnea, fatigue, palpitations, peripheral edema, MALAR FLUSH,
pinched and blue facies (severe MS)

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18
Q

O/E of mitral stenosis

  • arrhythmia involved
  • auscultation
  • heart sounds
  • any added sound
A

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.

19
Q

Ix of mitral stenosis

A

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)

20
Q

Mx of mitral stenosis

A

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

21
Q

(many) Etiology of mitral regurgitation

A

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

22
Q

Pathophysiology of mitral regurgitation

A

Reduced CO -> increased LV and LA pressure -> LV and LA dilatation -> CHF and pulmonary HTN

23
Q

Symptoms of mitral regurgitation

A

Dyspnea, PND, orthopnea, palpitations, peripheral edema

24
Q

O/E of mitral regurgitation

  • apex beat
  • auscultation
A

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
25
Q

Ix of mitral regurgitation

A

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

26
Q

Rx of mitral regurgitation

A

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.

27
Q

Etiology of tricuspid regurgitation

A

RV dilatation, IE (particularly due to IV drug use), rheumatic disease, congenital (Ebstein anomaly), carcinoid

28
Q

Symptomsof tricuspid regurgitation

A

Peripheral edema, fatigue, palpitations

29
Q

O/E of tricuspid regurgitation

  • JVP
  • […] sign
  • auscultation
A

“cv” waves in JVP, +ve abdominojugular reflux, Kussmaul’s sign, holosystolic murmur at LLSB accentuated by inspiration, left parasternal lift

30
Q

Ix of tricuspid regurgitation

A

ECG: RAE, RVH, AFib
CXR: RAE, RV enlargement
Echo: diagnostic

31
Q

Mx of tricuspid regurgitation

A

Preload reduction (diuretics)

Surgery if: only if OTHER surgery required (e.g. mitral valve replacement)

32
Q

Pathophysiology of tricuspid regurgitation

A

RV dilatation -> TR -> further RV dilatation -> right heart failure

33
Q

Etiology of pulmonary stenosis

A

Usually congenital, rheumatic disease (rare), carcinoid syndrome

34
Q

Pathophysiology of pulmonary stenosis

A

Increased RV pressure -> RV hypertrophy -> right heart failure

35
Q

Symptoms of pulmonary stenosis

A

Chest pain, syncope, fatigue, peripheral edema

36
Q

O/E of pulmonary stenosis

A

Systolic murmur at 2nd left intercostal space accentuated by inspiration, pulmonary
ejection click, right-sided S4

37
Q

Mx of pulmonary stenosis

A

Balloon valvuloplasty if severe symptoms

38
Q

Ix of pulmonary stenosis

A

ECG: RVH
CXR: prominent pulmonary arteries enlarged RV
Echo: diagnostic

39
Q

(many) Etiology of mitral valve prolapse

A

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

40
Q

Pathophysiology of mitral valve prolapse

A

Mitral valve displaced into LA during systole; no causal mechanisms found for
symptoms

41
Q

Symptoms of mitral valve prolapse

A

Prolonged, stabbing chest pain, dyspnea, anxiety/panic, palpitations, fatigue, presyncope

42
Q

O/E of mitral valve prolapse

A

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)

43
Q

Ix of mitral valve prolapse

A

ECG: non-specific ST-T wave changes, paroxysmal SVT, ventricular ectopy

Echo: systolic displacement of thickened mitral valve leaflets into LA

44
Q

Mx of mitral valve prolapse

A

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

YA - Interactive seminars/University lectures (87 decks)

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