General Valvular Disease I&II - Adje Flashcards
infective endocarditis**
- contains a vegetation = mass of platelets, fibrin, microcolonies of microorganisms, and inflammatory cells***
- infection involves heart valves, low pressure side of VSD, mural endocardium damage, foreign bodies, intracardiac devices
-occur from endothelial injury with high-velocity blood flow –> develop erosion and bacteria subside on low pressure side of lesion
- fever*, heart murmur most common clinical features
- chest pain is least common*
prototypical lesion - vegetation
- organism deep in vegetation are inactive/dormant (nongrowing) and resistant to antimicrobial agents bc don’t get enough blood/O2 supply
- those on the surface can be shed into bloodstream –> brain infection
organisms that cause infective endocarditis***
- Staph, strep viridans***
- HACEK organisms
- Strep gallolyticus aka bovis***
what organism do you worry about GI tract issues and colon cancer??***
- strep gallolyticus/bovis***
- do colonoscopy
nonbacterial thrombotic endocarditis (NBTE)
- platelet-fibrin thrombus
- mitral* > aortic > tricuspid > pulmonic
- marantic endocarditis (uninfected vegetations in malignancy patients)
- bland vegetations in SLE and antiphospholipid syndrome
prosthetic valve endocarditis (PVE)**
- caused by S. aureus, CoNS, gram negative bacilli, diphtheroids, fungi
- can cause CHF and conduction system blocks (AV node)
- regurge murmurs
endocarditis - cardiovascular impantable electronic devices (CIED)
- caused by S. aureus and CoNS**
- staph usually mechicillin resistant**
most common valve involved in IV drug users??**
- tricuspid valve* bc of injecting into vein
- caused by S. aureus (MRSA)
- usually polymicrobial
clinical manifestations of endocarditis
- symptoms –> cytokine production (weight loss, fever, fatigue, malaise)**
- embolization of vegetation fragments –> infection/infarction of other tissues
- hematogenous infection during bacteremia
- immune response –> tissue injury
Duke criteria for endocarditis
-clinical + microbiologic + ECHO
-definite endocarditis
A. 2 major criteria OR
B. 1 major and 3 minor OR
C. 5 minor criteria
major criteria
- blood culture
2. evidence of endocarditis on ECHO
minor criteria***
- Predisposition: predisposing heart conditions or IV drug use
- Fever ≥38.0°C (≥100.4°F)
- Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions
- Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, rheumatoid factor
- Microbiologic evidence: positive blood culture but not meeting major criterion, or + serologic of active infection with an organism consistent with IE
what do you do if someone comes in complaining of weakness, fatigue, arthalgias with minor criteria (ex. roth’s spots on eye)?***
- order blood cultures**
- slide 24
blood cultures
- do when suspected NVE, PVE, or CIED if haven’t received antibiotics in the past 2 weeks
- 3 2 bottle cultures obtained at different venipuncture sites over 24 hr.
TEE
- can see vegetations better than with TTE
- diagnosis of choice for endocarditis
endocarditis antimicrobial therapy***
-organism specific therapies of endocarditis due to group B,C, G strep –> treat with regimen for penicillin-resistant strep**
standard oral regimen***
Amoxicillin: 2 g PO 1 h before procedure
inability to take oral meds***
Ampicillin: 2 g IV or IM within 1 h before procedure
penicillin allergy***
1. Clarithromycin or azithromycin: 500 mg PO 1 h before procedure
2. Cephalexin: 2 g PO 1 h before procedure
3. Clindamycin: 600 mg PO 1 h before procedure
penicillin allergy, not able to take oral meds***
1. Cefazolin or ceftriaxone: 1 g IV or IM 30 min before procedure
2. Clindamycin: 600 mg IV or IM 1 h before procedure
acute rheumatic fever (ARF)***
- immune mediated disease* to pharyngeal infection with GAS**, not cutaneous GAS
- molecular mimicry –> Abs cross react with human tissue
what do you see on histo with ARF?***
- Aschoff bodies***
- areas of connective or interstitial tissue inflammation
- macrophages surrounding necrotic tissue
JONES criteria***
-major criteria for ARF
- polyarthritis (migratory)
- knees, elbows
- responds to salicylates
- sterile inflammatory synovial fluid - carditis
- usually mitral valve - subcu nodules
- on body surface - erythema marginatum
- chorea
- involuntary movement
- need 2 major OR 1 major + 2 minor + evidence of GAS infection (+ throat culture, rapid antigen, rising ASO titer)
- minor criteria –> prolonged PR interval, high CRP/ESR, fever, arthalgia
carditis in ARF
- endocarditis leading to mitral or aortic valvulitis (or both)*
- tachycardia from myocarditis
- pericarditis least common –> pericardial effusion/friction rub
-if myocarditis/pericarditis and no valvular involvement = unlikely to be due to ARF***
erythema marginatum***
-pic on test**
- macular rash with pale central clearing
- on trunk/extremities, spares face
aortic stenosis
- calcified aortic valve due to aging “wear/tear”
- in rheumatic fever, always associated with mitral stenosis*
- congenital bicuspid valve –> overworked
-treat with valve replacement or TAVR (through groin)
classic triad in aortic stenosis***
- angina - 5 year (average survival)
- syncope - 3 yr
- CHF - 2 yr
clinical exam with aortic stenosis**
- carotid pulse slow to rise (pulsus parvus el tardus)
- palpable thrill in carotids (murmur radiates to neck)
- PMI: undisplacd and heaving (LVH)
- soft S2, diminished A2
- murmur: harsh systolic crescendo-decrescendo*** (best during respiration in RUSB)
- valsalva (decrease murmur), hand grip (increase murmur)
- opening snap with bicuspid AS
- gallavardin pheneomenon –> radiation of AS murmur to apex
what murmur is heard in aortic stenosis?***
- harsh crescendo-decrescendo systolic murmur often radiating to neck**
- louder at apex in older patients
clinical exam with aortic regurge***
- diastolic murmur at left 3rd intercostal space –> high pitch, blowing, decrescendo**
- S1 diminished (premature closure of MV with high LV pressure)
- wide arterial pulse pressure (water hammer)
- dicrotic pulse (bisferiens) - combined AR and AS
- quincke sign (pulsation in nail beds)
- head bobbing (musset’s sign)
- higher BP in legs than arms (Hill sign)
- systolic/diastolic murmurs in femoral artery (pistol shot/duroziez sign)
- austin flint murmur in diastole –> regurge jet displaces anterior mitral leaflet
what murmur is heart in aortic regurge??**
-high pitch, flowing decrescendo murmur at left 3rd intercostal space*
mitral stenosis clinical presentation
- dyspnea on exertion
- pulmonary congestion
- RV failure –> ascites, pedal edema, weight gain
- palpitations (Afib) due to LA dilation
- hoarseness (ortner syndrome) –> compressing laryngeal nerve
- cough
- hemoptysis (rupture bronchial vessels)
- embolisms (stroke, renal, MI)
mitral stenosis auscultation***
- opening snap following S2 (best at apex in left decubitus)**
- mid-diastolic low-pitched rumbling murmur at apex in left lateral position using the bell***
-murmur worsened with exercise
hear a diastolic murmur in patient who is hoarse and pregnant***
mitral stenosis***
what do you see with left side heart failure (ex. mitral stenosis)*
-pulmonary congestion –> kerley B lines**
when do you see large or bifid P waves?
- during mitral stenosis (P mitrale)
- LA having to work harder to push blood to LV
-also see Afib and RVH
- treat with mitral valvotomy or replacement
- treat in 3rd trimester of pregnancy with PCI balloon
mitral regurge vs. aortic regurge**
- mitral regurge –> SYSTOLIC
- aortic regurge –> DIASTOLIC
mitral regurge
- acute MI –> rupture of papillary muscle/chordae tendineae
- chronic MR –> LA has time to compensate with dilation –> minimal elevated LA pressure preventing pulmonary congeston
- also LVH to sustain volume –> exacerbates mitral regurge
-treat with valve repair or replacement
clinical presentation of mitral regurgee
acute
- severe SOB
- tachypneic/cardic
- S3 and systolic murmur at apex**
chronic
- asymptomatic
- dyspnea on exertion
- pulmonary edema –> high JVP
- high P2 and S3
mitral regurge murmur***
- S3 and systolic murmur at apex**
- pansystolic murmur** radiating into axilla
mixed mitral valve disease (MMVD)
- both mitral regurge and stenosis
- due to chronic rheumatic heart disease
- increased pressure in LA –> LAE, Afib, pulmonary HTN, RVH
