Lec 12 Valvular Heart Disease II

Question 1

What usually causes aortic stenosis?

Answer 1

usually age related degenerative calcific changes = senile changes due to “wear and tear”

Question 2

What is area of arotic valve normally? when symptoms of aortic stenosis?

Answer 2

normal: 3-4 cm2

symptoms = when valve area 1/4th normal < 1cm2

Question 3

What are the 2 types of aortic stenosis and which most common?

Answer 3

• supravalvular
• valvular = most common!!
• subvalvular

Question 4

What are congenital causes of aortic stenosis? Who gets it?

Answer 4

• congenital aortic stenosis or congenital bicuspid valve

– if pt < 70 yo more likely to have congenital cause

Question 5

What are acquired causes of aortic stenosis?

Answer 5

• degenerative calcification = most common “wear and tear”
• rheumatic heart disease [have mitral also]
• rare causes like SLE, postradiation, etc

Question 6

What is pathophysiology of aortic stenosis?

Answer 6

• blood can’t flow from LV to aorta during systole
• high LV pressure = increased afterload
• compensatory LV concentric hypertrophy
• over time LV function declines

Question 7

What are 3 classical symptoms of severe atrial stenosis? [mnemominc]

step1

Answer 7

SAD

• syncope [exertional]
• Angina
• Dyspnea on exertion [sign of CHF]

Question 8

What are physical exam findings of atrial stenosis? heart sounds?

Answer 8

• systolic ejection murmur = crescendo-decrescendo sound; peaks later with more severe stenosis
• weakened [parvus] and delayed [tardus] upstroke of carotid artery pulsations = slow rising pulse and smaller pulse amplitude
• soft and split 2nd heart sound, S4 gallop due to LVH

Question 9

How is timing of systolic ejection murmur peak associated with severity of atrial stenosis

Answer 9

later peak = more severe stenosis

Question 10

What is natural history of aortic stenosis?

Answer 10

may have 20+ years of asymptomatic stage then onset of symptoms with HF/syncope/angina leading to death in severe AS

Question 11

What tests useful in aortic stenosis?

Answer 11

echo: tells you LV wall thickness, most valuable test

cardiac catheterization: confirm severity AS

Question 12

What valve area measurements for mild, moderate, severe aortic stenosis in cm2?

Answer 12

mild > 1.5
moderate: 1-1.5
severe < 1

Question 13

What is treatment for aortic stenosis?

Answer 13

• infective endocarditis prophylaxis in dental procedures
• mechanical problem so limited medical treatment
• vasodilators contraindicated in severe AS
• surgical replacement = definitive treatment

Question 14

What are indications for surgery in aortic stenosis?

Answer 14

• any symptomatic pt with severe AS
• any pts with decreasing EF
• any pts undergoing CABG with moderate or severe AS

Question 15

What is aortic regurgitation?

Answer 15

leaking of blood into left ventricle during diastole

- due to ineffective aortic valve

Question 16

What is the pathophysiology of aoritc regurgitation? compensatory mech?

Answer 16

• blood regurgitates back into LV during diastole = pressure and volume overload in LV
• compensatory mech over time: LV dilation and LVH

Question 17

What is etiology of acute aortic regurgitation?

Answer 17

• aortic dissection –> aortic root dilation

- endocarditis

Question 18

What is etiology of chronic aortic regurgitation

Answer 18

abnormalities of valve leaflets

• bicuspid aortic valve
• rheumatic fever
• infective endocarditis

Question 19

What happens in acute AR?

Answer 19

• LV normal size and noncompliant
• volume load of regurgitation –> high LV diastolic pressure –> transmitted to LA/pulmonary –> pulmonary edema + dyspnea

can be a surgical emergency requiring immediate valve replacement

Question 20

What happens in chronic AR?

Answer 20

• compensatory adaptations
• LV dilates and to lesser degree increases thickness, eccentric hypertrophy
• less of an increase in diastolic pressure in LV _ high stroke volume = bigger systolic P and smaller diastolic P
• bigger pulse pressure [difference betwen arterial systolic and diastolic Ps]

Question 21

What is treatment for acute AR?

Answer 21

• can be true surgical emergency
• give positive inotrope [dopamine, dobutamine] or vasodilator [nitroprusside]
• avoid beta blockers

Question 22

What are progressive symptoms of aortic regurgitation?

Answer 22

• dyspnea: exertional, orthopnea, PND
• nocturnal angina
• palpitation due to increase force of contraction

Question 23

What are physical findings of aortic regurgitation?

Answer 23

• wide pulse pressure
• on auscultation: diastolic blowing murmur on left sternal border; systolic ejection murmur due to increase flow across aortic valve; austin flint murmur at apex in very severe

Question 24

What is austin flint murmur?

Answer 24

mid-diastolic rumbling murmur at apex during mid-diastole

reflects turbulence of blood flow through mitral valve during diastole due to downward displacement of mitral anterior leaflet by regurgitant stream of blood from aortic regurgitation

Question 25

What do you see on CXR/echo/aortography in aortic regurg?

Answer 25

CXR: chronic= enlarged cardiac silhouette, aortic root enlargement Echo: measure degree of AR and identify cause Aortography: confirm severity of disease

Question 26

What is treatment of aortic regurg?

Answer 26

- infective endocarditis prophylaxis in dental procedures - medica: vaosdilators [ACEIs] improve stroke volume and decrease regurg if pt symptomatic or has HTN - surgical = definitive treatment if any symptoms or EF below 50%

Question 27

What is classic clinical scenario of degenerative [rather than congenital] atrial stenosis?

Answer 27

pt presents later on >60/70 and has concurrent coronary artery disease

Question 28

What happens to LV in aortic stenosis?

Answer 28

pressure overload [try to eject and has both aortic stenosis and system vascular resistance to overcome

Question 29

What are compensatory mech in aortic stenosis?

Answer 29

- hypertrophy of LV to decrease wall stress

Question 30

What happens to LV in mitral regurgitation?

Answer 30

volume overload [some blood from LV goes back to LA so then get even more preload in LA that goes to LV in the next contraction]

Question 31

What happens to LV in mitral stenosis?

Answer 31

volume underload [not as much blood can get from LA to LV]

Question 32

What happens to LV and aortic pressures in aortic stenosis?

Answer 32

gradient after aortic valve opens = LV has higher pressure than aorta and can't equilibrate gradient develops when aortic valve opens and increases in early systole to reach peak then goes down

Question 33

What heart sounds in aortic stenosis?

Answer 33

- 1st hear sound - then may have ejection sound [ES] - diamond shaped [crescendo-decrescendo] ejection murmur [systole] - may have quiet/absent S2 or paradoxical splitting S2 - then may have S4

Question 34

How do you determine severity of aortic stenosis?

Answer 34

late peaking of systolic murmur = more severe aortic stenosis = LV needs to work harder to force blood through valve absent S2 tends to occur in late peaking

Question 35

What is paradoxical splitting? step1

Answer 35

occurs in aortic stenosis [or left BBB] - normally S2 = A2 then P2 and splitting increases with inspiration because P2 later in paradoxical splitting: A2 delayed; P2 before A2 and splitting decreases with inspiration because P2 closer to A2

Question 36

What is different HCM vs AS sounds?

Answer 36

``` HCM = murmur starts right at S1 = holosytolic AS = maay have splitting of first sound = loud ejection sound [ES] then crescendo-decrescendo murmur starts after ```

Question 37

When can you hear S4?

Answer 37

when left ventricular hypertrophy --> systemic hypertension, aortic stenosis, hypertrophic cardiomyopathy

Question 38

Which of these 3 spares isovolumic contraction? - aortic stenosis - hypertrophic obstructive cardiomyopathy - mitral valve regurgitation

Answer 38

aortic stenosis!

Question 39

What is valve area, mean gradient, and jet velocity in severe aortic stenosis?

Answer 39

valve area: < 1.0 cm2 mean gradient: >40 mmHg jet velocity: > 4 m/sec

Question 40

Why should you avoid vasodilator in aortic stenosis?

Answer 40

drop BP may get syncope

Question 41

What is normal LV pressure?

Answer 41

120

Question 42

What is normal LA pressure?

Answer 42

10

Question 43

What happens to LV in aortic regurgitation?

Answer 43

volume AND pressure overload

Question 44

What compensatory mech if volume overload LV? type of hypertrophy?

Answer 44

dilation | = eccentric hypertrophy

Question 45

What compensatory mech if pressure overload LV? type of hypertrophy?

Answer 45

hypertrophy | = concentric hypertrophy

Question 46

Which valvular disease causes biggest left ventricles?

Answer 46

aortic regurgitation!!

Question 47

What is etiology of acute aortic regurgitation?

Answer 47

endocarditis | aortic dissection

Question 48

What treatment of acute aortic regurgitation?

Answer 48

true surgical emergency!! - give positive inotrope = dopamine, dobutamine - give vasodilator = nitroprusside - avoid beta blockers

Question 49

Should you give balloon pump in acute aortic regurg?

Answer 49

NO!!! Don't do it!!

Question 50

What is etiology of chronic aortic regurgitation?

Answer 50

- bicuspid aortic valve - rheumatic heart disease - infective endocarditis

Question 51

What do you see in carotid pulse of aortic regurgitation?

Answer 51

dancing carotids = low diastolic pressure = aamplification of dicrotic notch at time of aortic vavle closure and second pul

Question 52

Which murmurs increase with inspiration? expiration?

Answer 52

murmurs of right heart increase with inspiration | murmurs of left hear increase with expiration

Question 53

What are symptoms of acute regurgitation?

Answer 53

asymptomatic until 40s or 50s | progressive symptoms: dyspnea [+ signs of LH failure], nocturnal angina, palpitations [due to forced contraction]

Question 54

What are physical findings of aortic regurgitation?

Answer 54

wide pulse pressure | hyperdynamic + displaced apical impulse

Question 55

What do you hear on auscultation in aortic regurgitation?

Answer 55

- diastolic decrescendo blowing murmur at left sternal border [main murmur] - austin flint murmur at apex - systolic ejection murmur = due

Question 56

What is austin flint murmur?

Answer 56

- sounds like mitral stenosis = blood flowing back = fluttering of mitral valve - low pitched apical mid-diastolic rumble - occurs in aortic regurgitation

Question 57

What is corrigan pulse?

Answer 57

- sign of aortic regurgitation | - high amplitude, abruptly collapsing pulse

Question 58

What is quincke pulse?

Answer 58

exaggerated reddening and blanching of nail beds | sign of aortic regurgitation

Question 59

What should you think it pt comes in VDRL positive with heart problems?

Answer 59

they have syphilis = historically classic cause of aortic root dilation/regurgitation need aortic valve replacement