S7C58 - Valvular Emergencies

Question 1

Murmurs that don’t nee further work up

Answer 1

-mid-systolic

Question 2

Mitral stenosis

Answer 2

• prevents normal diastolic filling of LV
• most common cause is rheum heart dz
• LA enlargement, pulmonary HTN, a fib due to atrial enlargement
• sx: PND, pulm edema, hemoptysis (ruptured pulmonary vein), orthopnea, PAC
• may have signs of R heart failure
• dx: ECG, RAD, notched P wave, CXR may have loss of pulmonary window and pulm edema, echo
• mrm: mid-diastolic rumble that crescendos into S1, loud snapping S1

-tx: diuretics for pulm edema, AC for a fib, baloon valvotomy, MVR

Question 3

Mitral Regurgitation

Answer 3

• etiology: MI, LV dilatation, rheum heart dz, collagen-vascular dz
• LA enlargement
• acute MR causes acute pulm edema, decreased forward stroke volume and CO resulting in cardiogenic shock
• S4 gallop, harsh apical systolic mrm loudest early in systole
• chronic MR: exertional dyspnea, a. fib, high pitched holosystolic mrm radiates to axilla, s3

-tx: if acute MR, may require emergency surgery, O2, nitrates, diuretics, intubation for resp failure, nitroprusside if normotensive
>if hypotensive give dobuatime (5-20mcg/kg/min in addition to nitroprusside) or Ao baloon
>treat a fib with BB or CCB, AC

Question 4

Mitral Valve Prolapse

Answer 4

• can occur with or without regurge
• common in connective tissue d/o - marfan
• sx: often asymptomatic but can have palpitations, fatigue, anxiety, dyspnea
• mid-systolic click
• dx: normal ECG/CXR, reaures echo
• tx: usually initiated by cardiologist, BB, avoid EtOH/smoking/caffeine

Question 5

Aortic Stenosis

Answer 5

• cause: calcific Ao stenosis or bicuspid valve, rheumatic heart dz (RHD)
• similar risk factors to atherosclerosis
• critical AS = valve area

Question 6

Aortic Regurgitation

Answer 6

-cause: calcific degeneration, bicuspid valve, HTN, myxomatous degeneartion, RHD, marfan, syphilis, ank spon, Ehlers Danlos, Reiter
-slow course
-increased LV end diastolic volume leads to dilatation, wide pulse pressure
-exercise improves it whereas isometric exercise or stress increase afterload and therefore worsen symptoms
-leads to heart failure
-acute AR = infective endocarditis, Ao dissection, trauma
Sx:
-dyspnea, pulm edema
-high-pitched blowing diastolic mrm
-tachycardia, tachypnea and rales
-chronic = exertional dyspnea, fatigue, c/p, palpitations
-1/4 are asymptomatic and experience insidious LV failrue and sudden death

Dx:
-echo
-CXR if acute AR- plum edema w/o cardiomegally
-look for signs of dissection
-chronic AR CXR: cardiomegaly, Ao dilatation, CHF
Tx:
-acute AR = immediate surgical intervention
-nitroprusside plus inotrope (dobutamine) to agument forward flow and reduce LV end diastolic pressure
-avoid BB b/c they block compensatory tachycardia
-Abx if endocarditis
-chronic AR: ACEi, nifedipine, AVR

Question 7

Right sided valvular heart dz

Answer 7

• tricuspid dz - usually IVDU (endocarditis), staph aureus
• other causes of TR: COPD, PE, LV failure, MV dz, Ao stenosis
• pulmonic stenosis - usually assoc with TOF (rheumativ fever and carcinoid syndrome may cause acquired pulmonic stenosis)
• pulmonic regurg is seen in pulm HTN or after repair of PS

Sx:
-RH failure picutre: JVD, peripheral edema, hepatosplenomegaly, ascites, exeritonal dyspnea
-TR: soft, blowing, holosystolic
-TS: rumbling cresc-decresc diastolic mrm
-PS: harsh systolic mrm, loud ejection click before mrm, exeritonal dyspnea, syncope, c/p, RH failure
-PR: high pitched and blowing diastolic mrm (Graham steell), increases with inspiration, S3
Dx:
-echo
-CXR - RA and RV enlargement, dilatation of L pulm artery if PS
-ECG: RA enlargement, RVH
Tx:
-endocarditis - Abx
-diuretics for heart failure
-balloon valvotomy
-valve replacement

Question 8

Warfarin reversal

Answer 8

• if no bleeding and INR 5-10 can just hold warfarin or give vit K 1-2.5mg PO
• if severe bleeding then give FFP and octaplex and 10mg vit K IV