Left Valves Flashcards
Two common types of Aortic Valve Disease
- Aortic Stenosis
2. Aortic Regurgitation/Insufficiency
How can you get Aortic Stenosis?
- Acquired
2. Congenital
Which is the most common form of Aortic Stenosis?
Acquired
How does Aortic Stenosis occur in patients that ACQUIRE A.S.?
- Patients typically have a tricuspid aortic valve (normal) and there is degeneration and calcification of the aortic valve leaflets >50 years. (*Note: This inflammatory process is equivalent to artherosclerosis)
- Rheumatic (infectious disease)
Common risk factors for acquired AS?
- Age
- HTN
- Hypercholesterolemia
- Smoking
What type of aortic valve do patients with Congenital AS have?
Bicuspid
When is congenital AS typically found/symptomatic?
30-40 years old.
What is coarctation of the aorta?
Congenital condition whereby the aorta narrows in the area where the ductus arteriosus (ligamentum arteriosum after regression) inserts.
True or False:
Most patients with Aortic Stenosis have a rapid onset of symptoms.
False, most patients are often asymptomaic.
Progression of AS
- Acquired – 5th or 6th decade of life (40s and 50s)
2. Congenital – 30s and 40s
What are the Cardinal Symptoms of Aortic Stenosis?
ASC (Aortic Stenosis Complications)
A: Angina
S: Syncope
C: CHF
These symptoms present to stenotic limitation to flow. This can also be due to increased left ventricular wall mass (therefore an increased supply/demand mismatch)
When AS patients do get symptoms, does it stay latent and asymptomatic?
No, the onset is very severe and causes rapid decline in health.
Mortality based on symptoms:
CHF > Syncope > Angina
2 years > 3 years > 5 years
What are the physical findings of a patient presenting with AS?
- Crescendo-Descrescendo Systolic Murmur at the Right Upper Sternal Border radiating to the neck.
- Reappears over the apex (Gallivardin’s Phenomenon)
- Murmur will become softer and peak later as it gets more severe.
- Pulsus parvus et tardus
What is Pulsus parvus et tardus?
Carotid Upstrokes are diminished in amplitude (parvus = weak) and delayed in time (tardus)
What are additional tests to complete if suspecting AS?
- EKG !!!
- CXR
- Echo
- Cardiac Cath
What is the normal area for aortic valve?
3-4 cm^2
What is the area of the aortic valve for a patient with severe AS?
<1 cm^2
What is the area of the aortic valve for a patient with chronic AS?
<0.75 cm^2
What is the treatment for AS?
- Aortic Valve Replacement
- Blood pressure control and gentle diuresis
- Statins if calcific aortic stenosis
In a young patient with congenital AS, what is an alternative to Aortic Valve Replacement?
Balloon valvuloplasty
What are the potential causes of Aortic Insufficiency?
- Congenital Abnormality (Bicuspid Valve)
- Dilation of Aortic Root and Ascending Aorta
- Rheumatic (Infectious Disease)
Condition where there is a failure of aortic valve to close tightly causing back flow of blood into the left ventricle.
Aortic Insufficiency
What can cause Congenital Abnormalities of the Aorta that can lead to Aortic Insufficiency?
- Rheumatic Fever
- Endocarditis
- Trauma
- Bicuspid Aortic Valve
- Marfan’s Syndrome
- Fenfluramin-Phentermine
What can Aortic Root or Ascending Aorta abnormalities?
- Systemic HTN
- Aortitis (eg Syph)
- Trauma
- Dissecting Aneurysm
- Ehlers-Danlos Syndrome
Symptoms of AI
- May be asymptomatic
- Fatigue **
- Sense of pounding heart/head
- Atypical or anginal-like chest pain
- DOE, Orthopnea, PND if there is LV dysfunction
Aortic Insufficiency Physical Findings
- Wide Pulse Pressure (SBP - DBP)
- Rapid Rise and Fall of Arterial Pulses
- Other findings due to hyperdynamic pulse
What can cause a Wide Pulse Pressure?
- High Systolic Pressure due to Large Stroke Volume
2. Low Diastolic Pressure due to Rapid Runoff
What are the types of Hyperdynamic Pulse?
- Corrigan’s Pulse
- deMusset’s Sign
- Quincke’s Pulse
- Mueller’s Sign
- Rosenbach’s Sign
- Gerhard’s Sign
“Water-Hammer” Pulse
Rapid Rise and Fall
What is this called?
Corrigan’s Pulse
Capillary pulsations in the fingernails are called?
Quincke’s Pulse
Systolic Pulsations of the Liver are called?
Rosenbach’s Sign
Systolic Pulsations of the spleen are called?
Gerhard’s Sign
Systolic Pulsations of the Uvula are called?
Mueller’s Sign
Head bob occurring with each heart beat is called?
deMusset’s Sign
Where and when can you find a AI Murmur?
Lower Left Sternal Border during early diastole
How does an AI Murmur Sound?
Blowing – Sustained or decrescendo sound
What is the optimal position for hearing an AI Murmur?
With patient leaning forward and holding breath after exhalation.
A second low-pitches diastolic murmur/”rumble” that is heard at the apex. Indicative of AI murmur as well.
Austin Flint Murmur
True or False: Chronic AI is a surgical emergency
FALSE! Acute AI is a surgical emergency
This type of AI is progressive over time and allows for the left ventricle to compensate by dilation and hypertrophy.
Chronic
What makes Acute AI a surgical emergency?
- Left Ventricle has not had time to adapt
- Caused by Endocarditis, Aortic Root Dissection, Acute Dysfunction of Prosthetic Valve, and Trauma
- Large Regurgitant Volume causing acute pulmonary edema
- Many PhysEx findings are absent
Evaluation Techniques for AI
- EKG
- CXR
- Echo ** WILL help you identify the issue
How do you treat Chronic AI?
- Medical Therapy
- Serial Monitoring by Echo (checking LV dimension, LV function)
- Surgery (Valve replacement +/- aortic root replacement if pt is symptomatic. Has increasing LV size or decreasing LV function due to AI.
What is the medical management for Chronic AI?
- Vasodilators such as Calcium Channel Blockers or ACE inhibitors for afterload reduction
What are the three types of Mitral Valve Diseases?
- Mitral Stenosis
- Mitral Valve Prolapse
- Mitral Regurgitation
Causes of Mitral Stenosis?
- Rheumatic Cause
- Rare Causes of Congenital Abnormalities of Mitral Valve
- Valvulitis (SLE or amyloid) or Infiltrative Dz)
What does a rheumatic disease cause?
- Immobility and thickening of leaflets
- Fusion of commissures
- Mitral Stenosis is not part of the clinical presentation of the first episode of acute rheumatic fever
Pathophysio of Mitral Stenosis
Symptoms and Findings are related to increase in left atrial pressure from obstruction across the mitral valve.
– Increased left trial pressure leads to elevated pulmonary pressures, which can lead to symptoms of dyspnea, orthopnea, PND (CHF symptoms)
How will a patient with Mitral Stenosis present?
- Dyspnea (may last for decades, begins insidiously)
- Patients not aware of progressive limitations
- As LA pressure increases, so do symptoms of PND and Orthopnea
- Hemoptysis (inc. backfill capillary pressure in pulmonary vasculature leading to this)
- Atrial Fib may be the first sign!
Symptoms of Mitral Stenosis
1, Mean interval between acute rheumatic fever and symptoms is 15-20 years
2. Progression from mild to severe disability can take 8-9 years.
Physical Findings of Mitral Stenosis
- Loud first heart sound
- Opening Snap
- Diastolic rumbling murmur heard best at the apex in left lateral decubitus position
Evaluation Techniques for Mitral Stenosis
- EKG
- CXR
- Echo
- Cardiac Cath
Pharmacological Treatment of Mitral Stenosis
- Diuretics to treat congestive symptoms
- Maintenance of normal sinus rhythm (A. Fib with RVR can be devastating and cardioversion is usually warranted)
- Beta Blockers to Control Heart Rate
Is Mitrovalvuloplasty an applicable treatment?
Yes, but it is not a permanent fix.
What determines if mitral valvuloplasty will be effective for mitral stenosis?
Echo!!!
- Determines Sustainability
- Non-calcified, pliable leaflets
- No significant mitral regurg (if regurg you want replacement)
- No LA thrombus
What is the definitive treatment for Mitral Stenosis?
Mitral Valve Replacement
What causes Mitral Valve Prolapse?
Unclear, but may be due a manifestation of a connective tissue abnormality.
What is the most common cause of Mitral Regurg?
Mitral Valve Prolapse
Fun Facts of Mitral Valve Prolapse?
- Affects 2-4%
- More common in women
- Autosomal Dominant
- Can be found in otherwise normal individuals or people with systemic/connective tissue dx (Marfan’s, SLE)
How will someone with Mitral Valve Prolapse present?
Asymptomatic vs. Non-specific Complaints (CP, Palp, Dizziness, Anxiety)
Physical Exam Findings of MVP
Midystolic Click followed by Late Systolic Murmur due to MR
Evaluation used for MVP
ECHO!
Management of MVP
- No specific treatment for MVP by itself or with mild MR
- Beta Blockers may alleviate symptoms in patients
- Serial Echocardiograms to follow MR if significant
Causes of Chronic Mitral Regurgitation?
- Mitral Valve Prolapse **
- LV Dilation
- Posterior MI (scar)
- Rheumatic Dz
- Endocarditis
Causes of Acute Mitral Regurgitation?
- Posterior Wall/Papillary Muscle Ischemia**
- Rupture of Chordae tendinae
- Endocarditis
How will a patient with Chronic MR present?
- Prolonged Asymptomatic Period
- Fatigue/DOE
- A. Fib
- Left Heart Failure: DOE, Orthopnea, PND
- Can lead to Pulm HTN and Right heart failure
How will a patient with Acute MR present?
- Pulmonary Edema
2. Hypotension
Physical Findings of Chronic Mitral Regurg
- Blowing holosystolic murmur at apex radiating to the axilla and back *****
- Laterally displaced apical impulse (PMI)
Physical Findings of Chronic Mitral Regurg
- Systolic Murmur may be short, soft, or absent
2. S3
Evaluation Techniques for Mitral Regurg
- EKG
- Echo
- Cardiac Cath
Management of Chronic MR
- Often well tolerated
- Afterload reduction – ACE Inhibitors
- Maintain sinus rhythm if possible
- Decrease preload-diuretics and nitrates
- Serial Echos if moderate to severe MR (after EF falls, outcomes are worse)
- Sx for symptomatic pts
- Sx for asymptomatic but EF <55-60% and/or Increase LV end systolic dimension
Management of Acute MR
Life Threatening with hemodynamic instability and requires rapid evaluation and sx.
Treatment of Acute MR
- IV Vasodilators for Afterload Reduction (nitroprusside)
- Inotropes
- IABP
