Murmurs and Valvular Disease

Question 1

Etiology of mitral stenosis

Answer 1

Most commonly rheumatic, although hx of acute rheumatic fever is now uncommon

[rare causes include congenital MS, calcification of the mitral annulus with extension onto leaflets]

Question 2

With mitral stenosis, sx most commonly begin in ____ decade, but MS causes severe disability at earlier ages in developing nations

Answer 2

4th

Question 3

Principle symptoms of mitral stenosis

Answer 3

Dyspnea and pulmonary edema precipitated by exertion, excitement, fever, anemia, tachycardia, pregnancy, sexual intercourse, etc.

Question 4

Complications of mitral stenosis

Answer 4

Hemoptysis, PE, pulmonary infxn, systemic embolization

Note that systemic endocarditis is uncommon in pure MS

Question 5

Lab ECG findings with mitral stenosis

Answer 5

Atrial fibrillation or left atrial enlargement when sinus rhythm is resent

Right axis deviation and RV hypertrophy in presence of pulmonary HTN

Question 6

CXR findings with mitral stenosis

Answer 6

LA and RV enlargement with Kerley B lines

Question 7

Echocardiogram is most useful noninvasive test for mitral stenosis. What are the typical findings?

Answer 7

Shows reduced separation, calcification, and thickening of valve leaflets and subvalvular apparatus, and LA enlargement

Doppler flow recordings provide estimation of transvalvular gradient, mitral valve area, and degree of pulmonary HTN

Question 8

Treatment for mitral stenosis

Answer 8

At-risk pts should receive prophylaxis for recurrent rheumatic fever (penicillin V 250-500 mg PO BID or benzathine penicillin G 1-2 M units IM monthly).

In the presence of dyspnea, sodium restriction and oral diuretic therapy; beta blockers, rate-limiting calcium channel blockers (i.e., verapamil or diltiazem), or digoxin to slow ventricular rate in afib. Warfarin (with target INR of 2-3) for pts with afib or hx of thromboembolism. For afib of recent onset, consider conversion (chemical or electrical) to sinus rhythm, ideally after > 3 weeks AC therapy.

Mitral valvotomy in the presence of symptoms and mitral orific < 1.5cm. In uncomplicated MS, percutaneous balloon valvuloplasty is the procedure of choice; if not feasible, then open surgical valvotomy.

Question 9

Etiology of mitral regurg

Answer 9

Mitral valve prolapse, rheumatic heart disease, ischemic heart disease with papillary muscle dysfunction, LV dilation of any cause, mitral annular calcification, hypertrophic cardiomyopathy, IE, congenital

Question 10

Echocardiogram findings with mitral regurg

Answer 10

Enlarged LA, hyperdynamic LV, identifies mechanism of MR; Doppler analysis helpful in dx and assessment of severity & degree of pulmonary HTN

Question 11

Treatment for mitral regurg

Answer 11

For severe/decompensated MR, treat as for heart failure. IV vasodilators (e.g., nitroprusside) are beneficial for acute, severe MR. AC is indicated in the presence of afib.

For chronic pulmonary MR, surgical tx — either valve repair or replacement — is appropriate if pt has symptoms or evidence of progressive LV dysfunction (e.g., LV ejection fraction [LVEF] < 60% or end-systolic LV diameter by echo > 40 mm). Operation should be carried out before development of chronic heart failure symptoms. Pts with functional ischemic MR may require coronary artery revascularization along with valve repair.

Functional nonischemic MR d/t LV enlargement with impaired contractile function should be treated with aggressive heart failure therapies and consideration of cardiac resynchronization therapy.

Question 12

Etiology of MVP

Answer 12

Most commonly idiopathic

May accompany Marfan or EDS

Question 13

Pathology associated with MVP

Answer 13

Redundant mitral valve tissue with myxedematous degeneration and elongated chordae tendinae

Question 14

Most imporant complication of MVP

Answer 14

Progressive MR; rarely, systemic emboli from platelet-fibrin deposits on valve

Sudden death is very rare outcome

Question 15

Treatment for MVP

Answer 15

Asymptomatic pts should be reassurd

Beta blockers may lessen chest discomfort and palpitations

Prophylaxis for infective endocarditis is indicated only if prior hx of endocarditis

Valve repair or replacement for pts with severe mitral regurg; ASA or AC therapy for pts with hx of TIA or embolization

Question 16

PE findings with mitral stenosis

Answer 16

Right ventricular lift; palpable S1; opening snap (OS) follows A2 by 0.06=0.12 seconds; OS-A2 interval inversely proportional to severity of obstruction

Diastolic rumbling murmur with presystolic accentuation when in sinus rhythm, best heard in left lateral decubitus position

Duration of murmur correlates with severity of obstruction

Other: may see malar rash or blue facies

Question 17

Clinical manifestations with mitral regurg (including sx and PE findings)

Answer 17

Sx: Fatigue, weakness, and exertional dyspnea

Physical exam:
Sharp low-volume upstroke of carotid arterial pulse, LV lift, S1 diminished: wide splitting of S2; S3 common; loud holosystolic murmur at apex (less than holosystolic in acute severe MR) and often a brief early-mid-diastolic murmur d/t increased transvalvular flow

Question 18

Clinical manifestations with mitral valve prolapse (including sx and PE findings)

Answer 18

More common in females; Most pts are asymptomatic and remain that way

Potential symptoms include vague chest pain and supraventricular and ventricular arrhythmias.

PE:
Mid or late systolic click(s) followed by late systolic murmur at apex; exaggeration by valvsalva maneuver, reduced by squatting and isometric exercise

Question 19

3 most common etiologies of aortic stenosis

Answer 19

Degeneration calcification of a congenitally bicuspid aortic valve

Chronic deterioration and calcification of a trileaflet valve

Rheumatic heart disease (almost always associated with rheumatic MITRAL dz)

Question 20

Symptoms associated with aortic stenosis

Answer 20

Exertional dyspnea, angina, and syncope are cardinal sx; they occur late, after years of obstruction and aortic valve area <1 cm

Question 21

PE findings with aortic stenosis

Answer 21

Weak and delayed (parvus et tardus) arterial pulses with carotid thrill

A2 soft or absent; S4 common. Crescendo-decrescendo systolic murmur, often with systolic thrill. Murmur is typically loudest at second right intercostal space, with radiation to carotids and sometimes at apex (Gallavardin effect)

Question 22

ECG and echo findings with aortic stenosis

Answer 22

ECG: often shows LV hypertrophy, but not useful for predicting gradient

Echo:
Shows LV hypertrophy, calcification and thickening of aortic valve cusps with reduced systolic opening. Dilation and reduced contraction of LV indicate poor prognosis. Doppler quantitates systolic gradient and allows calculation of valve area.

Question 23

Treatment for aortic stenosis

Answer 23

Avoid strenuous activity in severe AS, even in asymptomatic phase.

Treat heart failure in standard fashion, but use vasodilators with caution in pts with advanced disease.

Valve replacement is indicated in adults with symptoms resulting from AS and hemodynamic evidence of severe obstruction. Transcatheter aortic valve implantation (TAVI) is an alternative approach for pts at excessive or prohibitive surgical risk.

Question 24

2 major etiologies of aortic regurg

Answer 24

Valvular: rheumatic (especially if mitral disease is present), biscuspid valve, endocarditis

Dilated aortic root: dilation d/t cystic medial necrosis, aortic dissection, ankylosing spondyliitis, syphilis

Question 25

Clinical manifestations of aortic regurg

Answer 25

3/4 of pts are male

Exertional dyspnea and awareness of forceful heartbeat, angina pectoris, and signs of LV failure. Wide pulse pressure, “water hammer” pulse, capillary pulsations (Quincke’s sign), A2 soft or absent, S3 may be present.

Blowing, decrescendo diastolic murmur along left sternal border (along right sternal border when due to aortic dilation). In acute severe AR, the pulse pressure is typically not widened and the diastolic murmur is often short (i.e., occurring only in early diastole) and soft.

Question 26

Major finding on lab ECG and CXR with aortic regurg

Answer 26

LV enlargement

Question 27

Echo findings on pts with aortic regurg

Answer 27

LA enlargement, LV enlargement, high-frequency diastolic fluttering of mitral valve. Failure of coaptation of aortic valve leaflets may be present. Doppler studies useful in detection and quantification of AR. Cardiac magnetic resonance imaging helpful if echo is inadequate

Question 28

Treatment for pts with aortic regurg

Answer 28

Standard therapy for LV failure. Vasodilators (ACE inhibitor or long-acting nifedipine) are recommended if HTN present. Avoid beta blockers, which prolong diastolic filling. Surgical valve replacement should be carried out in pts with severe AR when symptoms develop or in asymptomatic pts with LV dysfunction (e.g., LVEF <50%, end-systolic diameter > 50 mm, or LV diastolic dimension > 65 mm) by imaging studies.

Question 29

Tx for tricuspid stenosis

Answer 29

In severe TS, surgical relief is indicated with valve repair or replacement

Question 30

Etiology of tricuspid regurg

Answer 30

Usually functional and secondary to marked RV dilation of any cause and often associated with pulmonary HTN

Question 31

Clinical manifestations of tricuspid regurg

Answer 31

Severe RV failure, with edema, hepatomegaly, and prominent v waves in jugular venous pulse with rapid y descent. Systolic murmur along lower left sternal edge is increased by inspiration. Doppler echocardiography confirms the diagnosis and estimates severity

Question 32

Tx for tricuspid regurg

Answer 32

Intensive diuretic therapy when right-sided heart failure signs are present. In severe cases (in absence of severe pulmonary HTN), surgical tx consists of tricuspid annuloplasty or valve replacement

Question 33

Which of the following presents with crescendo-decrescendo systolic murmur, often with systolic thrill, typically loudest at second right ICS?

A. Mitral stenosis
B. Mitral regurgitation
C. Mitral valve prolapse
D. Aortic stenosis
E. Aortic regurgitation
F. Tricuspid regurgitation

Answer 33

D. Aortic stenosis

Question 34

Which of the following presents with mid or late systolic click(s) followed by late systolic murmur at apex; exaggerated by valsalva maneuver and reduced by squatting?

A. Mitral stenosis
B. Mitral regurgitation
C. Mitral valve prolapse
D. Aortic stenosis
E. Aortic regurgitation
F. Tricuspid regurgitation

Answer 34

C. Mitral valve prolapse

Question 35

Which of the following presents with severe RV failure with edema, hepatomegaly, and prominent v waves in jugular venous pulse with rapid y descent, as well as a systolic murmur heard along lower left sternal edge that increases with inspiration?

A. Mitral stenosis
B. Mitral regurgitation
C. Mitral valve prolapse
D. Aortic stenosis
E. Aortic regurgitation
F. Tricuspid regurgitation

Answer 35

F. Tricuspid regurgitation

Question 36

Which of the following presents with fatigue, weakness, and exertional dyspnea as well as loud holosystolic murmur at apex, possibly with brief early-mid-diastolic murmur?

A. Mitral stenosis
B. Mitral regurgitation
C. Mitral valve prolapse
D. Aortic stenosis
E. Aortic regurgitation
F. Tricuspid regurgitation

Answer 36

B. Mitral regurgitation

Question 37

Which of the following presents with exertional dyspnea and awareness of forceful heartbeat, angina pectoris, and signs of LV failure with blowing decrescendo diastolic murmur along the left sternal border?

A. Mitral stenosis
B. Mitral regurgitation
C. Mitral valve prolapse
D. Aortic stenosis
E. Aortic regurgitation
F. Tricuspid regurgitation

Answer 37

E. Aortic regurgitation

Question 38

Which of the following presents with opening snap followed by diastolic rumbling murmur with presystolic accentuation when in sinus rhythm?

A. Mitral stenosis
B. Mitral regurgitation
C. Mitral valve prolapse
D. Aortic stenosis
E. Aortic regurgitation
F. Tricuspid regurgitation

Answer 38

A. Mitral stenosis

Question 39

Migratory polyarthritis of large joints, subcutaneous nodules, sydenham’s chorea, and erythema marginatum are major criteria for what condition?

Answer 39

Rheumatic heart dz

Question 40

Jones minor criteria used in RHD

Answer 40

Fever
Arthralgia
Increased ESR or CRP
Leukocytosis
Prolonged PR interval
Elevated ASO or anti-DNase B

Question 41

What is ortner syndrome and what valvular dz is it associated with?

Answer 41

Hoarseness d/t compression of left recurrent laryngeal n.; associated with mitral stenosis when left atrium enlarges and compresses on that nerve

Question 42

Acute ____ ____ can present with cardiogenic shock

Answer 42

Mitral regurgitation

Question 43

Papillary muscle dysfunction is common in _____ MI

Answer 43

Inferior wall