Lecture 7 (Vavular)-Exam 2 Flashcards

Question

MS: treatment * What might do you need to do with patients with evidence of pulm HTN? * What are the indications for treatment?

Answer 1

Might need percutaneous Balloon Valvulotomy (in severely symptomatic patients with evidence of pulm HTN) * Performed similar to a cardiac catheterization by a cardiologist Indications * Symptomatic patients with Pulmonary HTN, episodic pulmonary edema, new-onset A.fib

Answer 2

Description * Back flow of blood into left atrium during systole Signs/symptoms * Dyspnea, SOB, orthopnea, lower extremity edema * Decreased cardiac output (CO), CHF

Answer 3

* Loud high pitched holosystolic murmur with maximum intensity at apex * Louder murmurs radiate to axilla * Accentuation of the precordial apical thrust if LVH present * S3 &S4 may be present * Concomitant HF findings may be present if severe

Answer 4

Acute Papillary Muscle dysfunction from coronary ischemia - ruptured papillary muscle or torn chordae tendinea from massive MI * The antero-lateral papillary muscle blood supply is from the LAD and the diagonal or a marginal branch of the LCX artery. The LCX or RCA (depending on dominance) provides the blood supply to the postero-medial papillary muscle. Because of its single system of blood supply, this papillary muscle is particularly prone to injury from myocardial infarction

Answer 5

* Acute ruptured cord, degeneration * Infective endocarditis * Acute rheumatic fever * Acute dilation of the LV due to myocarditis or ischemia (valve gets leaky)

Answer 6

* Mitral valve prolapse (MVP) * Mechanical failure of a prosthetic mitral valve * Myxomatous degeneration of the mitral leaflets or chordae tendineae (fancy term for wear and tear) * Non-ischemic papillary muscle dysfunction - due to LV enlargement and CHF

Answer 7

* Aggressive Treatment of HF - GDMT (ventricualr modeling to bring valve back together) * Rate control & anticoagulation if a-fib present

Answer 8

* As above but unlike chronic MR where LV & LA have slowly dilated, acute MR is poorly tolerated * Acute onset of severe LV dysfunction may lead to death if not aggressively treated * Emergency Mitral Valve Repair or Replacement

Answer 9

* Left ventricle and left atrium have slowly dilated, +/- pulmonary hypertension * May have had worsening symptoms or hospitalizations * Surgery indicated with severe symptomatic MR * New LV dysfunction * Scheduled surgery on elective basis

Answer 10

Mitro-clip * Not candiated for traditional surgery * Goes through groin with wires to fix it * Then goes through the two atria (basically creating an ASD) * Then clip it in the middle to decrease floppy but still open for some regurg Band * Mitral valve spread apart so band it back together Transcath. Replacement: * Again: another cath option * Not good for open heart, and cannot do clips

Answer 11

* Myxomatous degeneration of the mitral valve and chordae tendineae * Most common disorder affecting a heart valve. * Estimated to occur in over 15 million Americans.

Answer 12

* Myxomatous degeneration is most commonly idiopathic, but may be familial. May also be caused by connective tissue disorders and muscular dystrophies. * MVP is more common among patients with Graves' disease, von Willebrand's syndrome, sickle cell disease, and rheumatic heart disease.

Answer 13

* Auscultation reveals a **mid-systolic click** and a late systolic crescendo murmur * Heard best at apex & LLSB with patient in LLDP * Can be easily missed in supine position * **Major complication is MR with LV failure.**

Answer 14

* EKG: Usually normal * CXR: Usually normal * Echocardiography: Parasternal long axis shows degree of leaflet prolapse. Additionally, color Doppler reveals amount of MR, if present

Answer 15

* Control of arrhythmia's (ie b-blockers) * Anticoagulants for patients with a-fib or history of embolization * No surgical treatment for prolapse. If becomes severe MR then surgery

Answer 16

major causes: * Calcific aortic stenosis * Congenital bicuspid aortic valve stenosis Less common conditions: * rheumatic aortic stenosis and previous endocarditis

Answer 17

* Chronic left ventricular pressure overloading * As long as mitral valve function is intact, the pulmonary bed is protected from the overloaded pressure from aortic stenosis. * Concentric LVH allows the pressure-overloaded ventricle to maintain stroke volume with increases in diastolic pressures and patients may remain asymptomatic for years

Answer 18

* Diastolic dysfunction with the onset of heart failure symptoms (starts as this because EF is good then over time the musle fails and becomes systolic dysfunction) * Myocardial oxygen needs in excess of supply with the onset of angina. * Exertional syncope due to the inability to increase cardiac output and maintain blood pressure in response to vasodilation.

Answer 19

These classic symptoms of left ventricular outflow obstruction in a patient with AS indicate advanced disease and should be immediately evaluated: * Heart Failure * Angina (during diastolic, blood has issues coming down into the arteries) * Syncope * DOE

Answer 20

The top three are traditional measurements (not individial)

Answer 21

Dobutamine Stress Echo * Achieve gradients with increased cardiac contractility.

Answer 22

1. Asymptomatic patients with an AV area < 1.0cm 2. Patient with LV dysfunction (or symptoms of CHF)

Answer 23

* Transcatheter Aortic Valve Replacement (TAVR) * Percutaneous Balloon Valvotomy (BAV)

Answer 24

* Good for high risk patients, though limited prognosis due to high restenosis * Exercise stress test is contraindicated * Most patients should undergo cardiac cath before surgery to determine whether concomitant CAD is present. | Don’t give stress test. Send them to Cath lab to revascularize.

Answer 25

* Avoid strenuous activity in asymptomatic phase * Treat associated CHF in standard fashion but avoid afterload reduction & hypotension

Answer 26

* the sternum has been divided, the pericardium has been entered and retracted and the heart is visible. We are on bypass, meaning the cardiopulmonary bypass circuit is being used and the heart has been stopped and cooled down to limit the cardiac metabolism. The aorta has been transected and we are staring straight down into the aorta to see the aortic valve. The stenotic aortic valve leaflets have been cut out and the calcium around the annulus has also been removed. We have placed sutures through the annulus which will also be passed through the new aortic valve, whether that is mechanical or bioprosthetic. * The valve has been slid into position and the sutures have been tied down. The aorta will now be sewn back together and then the patient will be weaned from bypass and the heart rewarmed. The chest is closed and the patient is typically in the hospital for 5-7 days to recover.

Answer 27

TAVR is a transcatheter option that involves accessing the peripheral vessels to thread catheters and wires up the aorta backwards into the aortic valve position, the new valve is then deployed pushing the old aortic valve out of the way * Femoral * subclavian * Carotid * Transapical

Answer 28

Percutaneous balloon valvuloplasty for temporary (6 months) relief of symptoms in poor surgical candidates * Bridge to therapy * Destination therapy * Risk: can cause aortic insufficiency- caution in those patients with AI already present ## Footnote Ballooning or mechanical valves eventually causes AR

Answer 29

* EF should be about 60%. * Tx - catheterization and refer to valve replacement.

Answer 30

* AI causes volume overloading of the left ventricle (Increased LV EDV) * The volume overload usually is well tolerated for long periods

Answer 31

* The sequelae of aortic regurgitation reflect the severity of the diastolic leak (i.e.) left ventricular dilation and hypertrophy, with remodeling of the left ventricle to a more spherical shape. * The ejection fraction usually is preserved until the late stages of the disease.

Answer 32

* **Aneurysmal disease of the ascending aorta/aortic root** * Healed/treated/ongoing endocarditis * Rheumatic heart disease * Bicuspid congenital aortic valve * Calcific degeneration * Myxomatous degeneration * Degeneration of prosthetic valve

Answer 33

* Aortic Dissection * Infective Endocarditis * Prosthetic valve dysfunction * Aortic aneurysm/dilation/Marfan’s

Answer 34

Usually remain asymptomatic for decades, often until fourth or fifth decade of life

Answer 35

DOE, Orthopnea, PND – Typical HF symptoms * Usually after development of cardiomegaly and LV dysfunction Angina * Develops later, often during nighttime (diastole increases during nighttime – myocardium needs more O2) Palpitations/Head pounding * **Especially in supine position, pounding of heart against chest wall.**

Answer 36

Austin Flint Murmur * Mid-late diastolic apical rumble, best heard in the apex – severe AR Wide Pulse Pressure – high systole and low diastole

Answer 37

* Increased stroke volume – ejecting a larger than normal volume of blood with systole, such as in aortic regurgitation * Arteriosclerosis – stiffening of the arteries loss of compliance * Aging – arteries are less elastic * Hyperthyroidism

Answer 38

Lateral precordial narrow Q waves and left ventricular hypertrophy. The ST segment and T wave are often normal or nearly normal.

Answer 39

* Cardiomegaly * LV enlargement (“boot shaped heart”) * Dilatation of ascending aorta

Answer 40

Vasodilators (reduce SBP, improve SV, reduce regurgitant volume-decrease afterload) * **ACE-I, Nifedipine, Hydralizine, or Prazosin** Treat CHF – diuretics, spironolactone,

Answer 41

* Avoid vigorous exertion in symptomatic AI * Avoid beta blockers – prolong diastole and increase aortic regurgitation

Answer 42

Aortic Valve replacemtn * Urgent when acute AI caused by acute aortic dissection or Infective Endocarditis

Answer 43

Most common cause of primary TR is infectious endocarditis * 17% of infective endocarditis affects the TV * Seen in IV drug abuse – staph (MSSA vs MRSA) * Can get septic pulmonary emboli

Answer 44

* Leaflet perforation * Entrapment after device placement * Congenital abnormalities

Answer 45

* Moderate to severe TR generally tolerated better than MR * Intensive diuretic therapy * Treating any underlying functional etiologies (COPD or Chronic Pulmonary Emboli worsening already existing Pulmonary HTN & RVH)

Answer 46

* Is a very rate valvular abnormality * Results in an elevated gradient between the right atrium and right ventricle * Usually accompanies other valvular abnormalities

Answer 47

* Rheumatic heart disease is one of the **most common causes of TS and almost always occurs in conjunction with mitral stenosis** * Large vegetation causes relative stenosis * Carcinoid tumor or benign tumors like atrial myxomas can cause functional TS

Answer 48

TTE: thickening and distortion of the TV, valve area <1cm2, transvalvular gradient of more than 5-10mmHg

Answer 49

* Medical therapy – limited- diuretics, symptom relief * Percutaneous valvotomy (balloon)–for poor surgical candidates * Tricuspid repair/replacement (cannot repair stenois of tricuspid) * Operative mortality for isolated TS is significant (10%) and increases if performed with other valvular surgery (16%)

Answer 50

Most patients with mild pulmonary stenosis are asymptomatic, as it progresses patients typically experience DOE and or fatigue TTE is sufficient in most cases to diagnose pulmonic stenosis * Severe stenosis – peak gradient across the valve greater than 64mmHg

Answer 51

* Mid systolic high pitched crescendo-decrescendo murmur heard best at the pulmonic region and radiating slightly toward the neck * Similar to AS, but does not radiate as widely

Answer 52

Moderate or severe stenosis (gradient >50 mm Hg) requires surgical (or balloon) valvuloplasty

Answer 53

Pulmonic regurgitation is extremely common, happening to between 30% and 75% of the population (some sources suggest it’s even higher). However, the leak is almost always too small to cause any symptoms

Answer 54

* More significant PR caused by: Pulmonary HTN (older adults) and surgical repair of tetralogy of Fallot (children, young adults) * Less common causes: infective endocarditis, idiopathic pulmonary artery dilation, and congenital valvular heart disease

Answer 55

Pathophysiology * Dilatation of ring of PV by Pulmonary HTN of any cause Symptoms * Usually related to primary disease * Right HF symptoms * RV strain

Answer 56

* Primary tumors of heart are rare (0.002-0.3 % of autopsy series) * Most primary cardiac tumors benign (90%) & resectable * With possible exception of lymphoma, most malignant primary (10%) and metastatic lesions are resistant to chemo & XRT & have poor prognosis

Answer 57

* **Myxoma** * Rhabdomyoma * **Papillary fibroelastoma (most common tumor of cardiac valves, 75%)** * Fibroma * Lipoma * Teratoma

Answer 58

* Sarcomas: Rhabdomyosarcoma and Angiosarcoma * Lymphoma * Teratoma

Answer 59

* Carcinoma lung, breast * Sarcoma * Melanoma * Renal Cell, Lymphoma,

Answer 60

* Most common type of primary cardiac tumor in all age groups * Most commonly found in the left atrium, 75%

Answer 61

* Fever, Weight loss * Anemia * Signs of systemic embolization * Presyncope or Syncope

Answer 62

Most commonly presents with sudden onset of symptoms that are typically positional in nature (ie occurs when changing position such as rolling over in bed or when bending over to tie his shoes) due to the effect that gravity has on the tumor.

Answer 63

may reveal characteristic early diastolic sound or “tumor flop”

Answer 64

* Most benign lesions are resectable & curable * Surgery for cardiac sarcomas & metastatic lesions usually for diagnostic purposes or palliative resection; long term survival for malignant cardiac tumors poor