PMT, Johnston - Valvular Heart Disease Flashcards
What are the three most common VHD conditions found?
1) Degenerative - (progressive) senile calcification
2) Myxomatous degeneration - MVP
3) Congenital - bicuspid AV
Regurg v. stenosis
- Regurg - failure to close adequately (vol overload, dilation). AR, MR.
- Stenosis - failure to open fully. Impedes forward flow. AS MS.
RHD - cause and criteria
Group A strep
2 major criteria or 1 major/2minor - Jones Criteria
Jones Major criteria
Joint - migratory polyarthritis Carditis Nodules (subq) Erythemous Marginatum Syndham chorea (Minor: fever, arthralgia, CRP or sed rate, leukocytosis, prolonged PRi, elevated ASO)
MS - what is it?
Narrowing leading to pulm HTN and RVF
4th decade
DOE, cough, orthopnea, PND, pulm edema, hemoptysis, arterial emboli, Afib.
Ortner syndrome
MS Symptoms
What is Ortner syndrome?
As LA enlarges due to MS, compression of Left recurrent laryngeal nerve = HOARSENESS, indicative of MS.
See: Malar rash
Hear: increase S1, opening snap after S2. Rumbling, diastolic MURMUR, low pitch at apex - use bell.
MS PE
MS tx (esp if in afib)
Anticoagulation therapy if in afib!!
Balloon valvuloplasty MVReplacement
If a person has MS, why do they develop progressive symptoms, leading to RV-Failure?
pressure b/u in LA»_space; pulm edema»_space; r side involvement
MS looks like what on ECG? What other tests are indicative of MS?
afib
LAE - see straight left heart broder on chest xray
Indicative of MS due to RF
**Causes of Mitral Regurgitation (MR): Chronic and Acute
- Acute: rupture of chordal tendineae, rupture of papillary muscle, ischemic papillary muscle dysfunction, IE, valve perforation.
- Chronic: MVP (most common), Mitral Annular Calcification
Left straight heart border indicative what?
LAE (possibly due to MS)
MR s/s
Immediately apparent?
- Inc LA pressure abruptly.
- Pulmonary edema, LVF.
**ASYMPTOMATIC FOR YEARS»_space; fatigue, DOE. Then ACUTE onset of orthopnea, PND, RHF/LHF, volume overload.
MS v. MR murmur (murmur and s1)
- MS = DIASTOLIC rumbling murmur, low pitch at apex. Increased S1, opening snap after S2.
- MR = SYSTOLIC murmur at apex, radiating to left axilla (correlates with severity of disease). Decreased S1 w/ systolic click.
Tx of MR (3)
Vasodilator - afterload reduction
Decrease resistance to flow
ACEi - chronic MR
MVP - what sex predominant, what is it, what happens during it?
F>M 7:1
Associated with Marfans
Mitral leaflets prolapse into LA during systole to cause MR.
What are s/s of MVP?
Tx hyper-adrenergic state with what (i.e. if pt has MVP and thyroid disorder)?
- Asymptomatic to arrhythmias, chest pain, syncope
- Systolic murmur (may have systolic click)
- Tx with BB (for anxiety and palpitations)
Etiology of AS
Degenerative (calcific or senile)
Congenital bicuspid aortic valve
Rheumatic or post inflammatory scarring
AoV Area in normal aortic valve v. in AS
Normal is 4square cm.
Severe AS if AoV is less than 1square cm.
** exertional DYSPNEA, ANGINA, SYNCOPE, HF **
AS s/s
- Narrowed Pulse Pressure
- Delayed pulses - Parvis/Tardus
- Harsh systolic murmur, 2nd ICS RSB, radiates to supra sternal notch/carotids.
- Gallavardin phenomenon (murmur)
AS PE
Pulse pressure: AI v. AS
AI = wide pp AS = narrow pp
What is Gallavardin phenomenon and what is it associated with?
Associate with AS.
When the murmur radiates to the apex.
Tx of AS
percutanous balloon valvuloplasty - temporary AVReplaecemmt
Aortic Regurgitation (AR) is due to what and caused by what?
Due to leaf abnormalities (bicuspid AoV, IE)
Due to aortic root abnormalities (Marfans, aortic dissection, HTN, aging).
Caused by acute AR: IE, aortic dissection, BAV
Caused by chronic AR - syphilis, ankylosing spolylitis
What type of murmur can mimic MS?
Austin Flint murmur - the blood can hit the anterior leaflet of the MV and the MV won’t open as well as it should. Looks and sounds like MS.
PE of AR
Wide pulse pressure
- Quincke’s pulse - blanching, flushing of nailbed as blood flow goes in and out.
- De Musset sign - head bobbing
- Durozrey’s Sing - to and fro murmur over femoral artery
- Hill’s sign - BP higher in legs than arms
- Bisferious pulse - double notch to systolic flow (bifid pulse)
- See slide 83 for other signs
Hear: Diastolic, decrescendo murmur, 3rd ICS LSB. Soft systolic murmur may be present.
Tx of AR
ARB - decrease afterload to dec regurg volume
Surgery for AoV Regurg when symptomatic or EF less than 55%.
Tricuspid Stenosis (TS) is associated with what three things?
MS, TR, RHD
What indicates TS? (ECG and PE)
ECG: Prominent “A” wave in JVP ascites
PE: (Possible) Pulsatile hepatomegalia, Carvallo’s sign, Diastolic murmur LSB that increases with inspiration (Carvallo’s sign) and decreases with expiration.
Tricuspid Regurgitation (TR) is associated with what three things?
pulmonary HTN, inferior MI, RV infarction
What indicates TR? (ECG and PE)
ECG: Prominent “V” wave in JVP
PE: blowing systolic murmur LSB; increase with inspiration (Carvallo’s sign).
Pulmonary stenosis (PS) - PE
Systolic murmur with ejection click.
2nd-3rd ICS, LSB/radiates to left shoulder and increases on inspiration. RVH
Can cause angina and syncope.
Tx: if >50mmHg, then balloon commissurotomy
Pulmonary Regurgitation (PR or PI) - PE
Blowing diastolic murmur 2SB (Graham Steell).
Most cases are due to pulmonary HTN
What has systolic murmurs?
MR, TR
AS, PS (ejection click)
VSD
Aortopulmonary shints
What has diastolic murmurs?
AR, PR (blowing, Graham Steell)
MS, TS (LSB, Carvallo)
Atrial Myxoma
Continuous murmurs
PDA-machinery (neonatal)
AV fistula
ASD with high LA pressure
Coarctation
