Lecture 6: Valvular Disorders Part 2 Flashcards
How can we differentiate between a Stage C1 vs a C2 murmur?
C2 has abnormal LV function, which typically requires an Echo.
Who is tricuspid stenosis more common in?
Females
What is tricuspid stenosis typically associated with?
AS or MS
What are the primary causes of tricuspid stenosis?
- Rheumatic heart disease (worldwide)
- US: carcinoid disease or prosthetic valve degen
- Can also be caused by congenital anomalies or leaflet tumors/vegetations.
Carcinoid disease is a cancer that presents with multilocation tumors.
Since it is rarely isolated, a congenital deformity is the most likely etiology if it does present isolated.
What are the primary S/S of tricuspid stenosis?
- JVD/elevated JVP
- Peripheral pitting edema
- Fatigue
- Hepatomegaly
- Ascites
What are the PE findings of tricuspid stenosis?
- Increased sound on inspiration
- Opening snap may be heard
- Soft, high-pitched, diastolic rumbling murmur along lower left sternal border.
- Signs of right-sided HF.
- Pulsatile liver coinciding with atrial contraction
- Pitting edema
The right side of the heart receives more blood during inspiration.
What might be expected on an EKG and CXR for tricuspid stenosis?
- Right atrial enlargement
- Cardiomegaly
What are the medications used to treat tricuspid stenosis?
- Diuretics (loops)
- Aldosterone antagonist for liver congestion or ascites.
- TVR if patient is symptomatic.
Bumetanide/torsemide is preferred over lasix for bowel edema specifically.
What is the typical cause of tricuspid regurg?
- Dilation of the RV and tricuspid annulus
- RV dilation is caused by pulmonary HTN, LV failure, PV stenosis, severe PVR, cardiomyopathy, and sarcoidosis
TV annulus is saddle-shaped, resulting in it becoming elliptical as the RV fails/dilates.
I imagine it getting stretched wide
What is the difference between the papillary muscles and chordae tendinae of the TV vs the MV?
- TV has smaller papillary muscles and less chordae tendinae.
- MV is more able to handle increased pressure.
How does TR typically present?
- If pulmonary HTN is not present, compensates well.
- With pulmonary HTN, fatigue, ascites, and peripheral edema are common.
R sided HF is known as cor pulmonale.
How does a murmur present for tricuspid regurg?
- High-pitched, holosystolic at left sternal border
- Accentuated by inspiration OR leg-raising.
Leg-raising increases venous return
How is TR managed?
- Treat underlying cause and RHF symptoms.
- Repair for pts with persistent symptoms.
- Replacement for underlying leaflet pathology. (No AC if no Afib)
RHF is a low-pressure symptom, so it generally doesn’t cause severe symptoms.
What is the typical etiology of pulmonic stenosis?
- PS is most commonly an isolated, congenital defect.
Fusion of pulmonary leaflets leading to RVH.
Rarely caused by rheumatic disease.
Purely stenosis = isolated
What are the two genetic syndromes that usually cause PS?
- Noonan syndrome
- Trisomy 13
These syndromes often present with a myriad of deformities.
What is the typical presentation of PS due to a congenital abnormality? Due to other causes?
- Congenital is usually severe PS and presents with severe cyanosis on birth.
- Other causes often result in mild-mod PS and present asymptomatically.
What PE findings are typical of PS?
- Systolic ejection murmur best heard at left upper sternal border.
- Increases with inspiration
- Radiates to left shoulder
- S1 followed by opening click that is LOUD on expiration.
- RV lift on palpation of precordium.
How is mild PS managed? Mod? Mod-Sev?
- Mild: Asymptomatic, no intervention.
- Mod: symptomatic requires balloon valvuloplasty or replacement.
- Mod-Severe: Balloon valvuloplasty or replacement.
What typically causes pulmonic regurg?
- Dilation of the PV annulus 2/2 pulmonary HTN
Describe the murmur of pulmonic regurg.
- Diastolic
- High-pitched
- Blowing quality
- Best heard at 2nd left ICS.
What secondary diagnostic studies can help with suspected pulmonic regurgitation?
- Cardiac MRI
- CT Chest
What is the most likely EKG finding for pulmonary regurgitation?
RBBB
When is PV replacement indicated for pulmonic regurg?
Intractable RV failure.
Low-pressure system, so symptoms arent as common.
What are the benefits and cons of a mechanical valve?
- Extremely durable.
- However, high thromboembolic risk and requires lifelong anticoagulation.
Can only use warfarin!!!!!!!! 2.5-3.5 INR
Normal INR for something like a DVT is 2-3.
What are the pros and cons of a prosthetic valve?
- 10 year duration usually.
- Lower risk for thromboembolic risk.
- Usually only uses baby asa for AC.
Less management/AC, but may require replacement in the future.
What is the most common cause of acute rheumatic fever?
GABHS
How does RHD typically occur?
Child with a recent strep infection 2-4 weeks ago and had an abnormal immunologic reaction.
Takes time between infection and development of vegetation.
When does acute rheumatic fever tend to occur age-wise?
4-9.
What is the pathophysiology of RHD?
- Pancarditis (diffuse inflammation)
- Exudative pericarditis
- Lymphocytic infiltration of myocardial tissue. (may also result in necrosis)
What is the hallmark histiologic finding of RHD?
Aschoff body from the myocardium.
Collection of myocytes and macrophages surrounded by fibrous tissue.
What characterizes valvulitis and what valve is most commonly affected?
- Verrucous lesions on leaflet edge.
- MV is most commonly affected, then AV.
What are the major criteria for Jones Criteria?
- Carditis
- Polyarthritis (joint pain)
- Chorea (movement disorder)
- Erythema marginatum (rash)
- Subcutaneous nodules
J O N E S
J = Joints
O = heart (carditis)
N = nodules
E = erythema marginatum
S = sydenham chorea (sudden chorea)
What are the minor criteria for Jones criteria?
- Fever (38C or 100.4F)
- Arthritis
- Previous rheumatic fever or known RHD.
CAFE PAL
C = CRP inc
A = Arthralgia
F = Fever
E = Elevated ESR
P = Prolonged PR Interval
A = Anamnesis of Rheumatism
L = Leukocytosis
What is diagnostic for Jones criteria?
- 2 Major
- OR
- 1 Major + 2 minor
- AND
- Must have evidence of recent GABHS infection (for both)
To fully confirm, need echo as well.
Echo must demonstrate both morphological valvular involvement of MV +/- AV and doppler for pathologic valve regurg.
What is carditis?
- Pleuritic chest pain
- Friction rub
- HF
How is RHD treated?
- PCN for strep infection.
- Salicylates for fever and arthritis (Minor)
Salicylates include aspirin usually.
How long is RHD prophylaxis?
- up to 10 years
- PCN G 1.2mil units IM monthly
- Oral PCN or erythromycin.
If RHD has appeared once, recurrence is common, so prophylaxis is needed.
