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CVB by Minnie (Madeleine) > SM 141a/142a - Valvular Heart Disease > Flashcards

SM 141a/142a - Valvular Heart Disease Flashcards

1
Q

Which valvular disease causes more LV hypertrophy:

Aortic regurgitation

Mitral regurgitation

A

Aortic regurgitation

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2
Q

A patient with mitral stenosis has NHYA Class III symptoms.

What treatment do you recommend?

A

Surgical mitral valve commissurotomy or replacement

(Recommended for NHYA Class III-IV, or if severe pulmonary HTN is present)

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3
Q

List the common etiologies of mitral regurgitation

A

Many - Anything that causes the valve to function improperly

  • Primary causes
    • Mitral valve prolapse (most common cause of mitral regurgitation in the USA)
    • Rheumatic
    • Degenerative
    • Problems with papillary muscles, chordae tendineae
    • Congenital
  • Secondary causes: Due to faulty left ventricle
    • Ischemia
    • Cardiomyopathy
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4
Q

Describe the symtpoms of mitral regurgitation

A

May be asymptomatic for decades due to compensatory mechanisms

Decompensation leads to…

  • Dyspnea
  • Angina
  • Fatigue
  • Palpitations
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5
Q

Widened pulse pressure due to increased systolic and decreased diastolic blood pressure is present in which valvular disease?

A

Aortic regurgitation

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6
Q

What is the difference between primary and secondary causes of mitral regurgitation?

A

Primary = problem with the valve or things associated with the valve

Secondary = problem with the ventricle that causes problems with the valve (ex: ischemia, cardiomyopathy, may be due to MI)

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7
Q

What are the available treatments for aortic stenosis?

A

TAVR: Transcatheter Aortic Valve Replacement

SAVR: Surgical Aortic Valve Replacement

Note: it is usually safe to wait until symptoms arise before surgical intervention is required

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8
Q

What is (by far) the most common etiology of mitral stenosis?

A

Rheumatic fever

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9
Q

A patient with mitral stenosis has NHYA Class I and severe pulmonary HTN.

What treatment do you recommend?

A

Surgical mitral valve commissurotomy or replacement

(Recommended for NHYA Class III-IV, or if severe pulmonary HTN is present)

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10
Q

What are the recommended medical treatments for mitral stenosis?

A
  • Diuretics
    • Decrease pulmonary congestion
  • Betablockers
    • Prevent tachycardia
  • Digoxin +/- beta blokers if atrial fibrillation
    • Control ventricular rate
  • Anticoagulations if atrial fibrillation
    • Prevent emboli
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11
Q

What physical exam findings are associated with wide pulse pressure?

A
  • Quincke pulses
    • Increased pulses in capillaries of nail beds
  • Duroziez sign
    • Diastolic murmur in femoral artery
  • De Musset sign
    • Rhythmic nodding or bobbing of the head
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12
Q

Describe the pathophysiology of mitral regurgitation

A

Volume overload of the LV and LA

  • Increased LA pressure due to backflow from the LV
    • Pulmonary venous congestion
    • Pulmonary arterial HTN
    • RV dysfunction
    • Systemic venous congestion
  • LV dialtion to compensate for increased preload
    • Leads to LV systolic dysfunction
    • Increased LA pressure
    • Possible Atrial fibrillation
      • Systemic arterial embolism
      • Stroke
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13
Q

What are the common etiologies of aortic regurgitation?

A

Many!

Anything that damages the valve so it doesn’t close, or dilates the aorta so the valve no longer fits

  • Congenital
  • Degenerative (calcification)
  • Rheumatic
  • Endocarditis
  • Dissecting aortic aneurysm
  • Marfans
  • Syphilis
  • Ankylosin spondylitis
  • Trauma
  • Systemic HTN
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14
Q

What are the indications for surgical intervention in aortic stenosis?

A
  • Any symptoms
  • LV systolic dysfunction
  • Very severe aortic stenosis (<0.6 cm2)
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15
Q

What are the 3 pathophysiologic manifestations of mitral stenosis?

What are the effect?

A

Obstruction to LV inflow from the LA

  • Increased LA pressure
    • Pulmonary venous congestion
    • Pulmonary arterial HTN
    • RV dysfuntion
    • Systemic venous congestion -> Edema
  • Decreased cardiac output
  • LA dilation
    • Atrial fibrillation
    • Systemic arterial embolization
    • Stroke
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16
Q

LV hypertrophy is consistent with which valvular pathologies?

A

Aortic Stenosis

Aortic regurgitation

Severe mitral regurgitation

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17
Q

What are the recommended medical treatments for aortic regurgitation?

A

No medical therapy except HTN treatment

Surgery is required if there are any symptoms, or aysmptomatic aortic dilation, LV dilation, or LV systolic dysfunction

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18
Q

What are the typical symptoms of aortic regurgitation

A

Patients may be asymptomatic for decades

Usually, symptoms only arise when decompensation occurs -> Angina, dyspnea

19
Q

Describe the pathophysiology of aortic stenosis

A

Obstruction to LV outflow through the aorta

  • LV hypertrophy to compensate for initial increased pressure
    • Increased LV diastolic pressure
      • LV enlargement (if severe)
        • Increased LA pressure (if severe)
          • Pulmonary congestion (if severe)
    • LV systolic dysfunction
  • Myocardial ischemia
20
Q

Sustained LV impuslse, systolic thrill, delayed arotid upstrokes, soft S2, S4 heard at the apex, and midsystolic outflow murmur are physical exam findings consistent with which valvular pathology?

A

Aortic stenosis

21
Q

How does mitral stenosis increase risk of stroke?

A
  • Mitral stenosis -> Increasd LA pressure
    • LA dilation
      • Atrial fibrillation
        • Blood clot
          • Systemic arterial embolization
            • Stroke
22
Q

Displaced LV impulse, brisk carotid upstrokes, holosystolic apical murmur, apical S3, and apical diastolic rumble are physical exam findings consistent with which valvular disease?

A

Mitral regurgitation

Also mid-systolic click if caused by prolapse, and apical diastolic rumbe if MR is severe

23
Q

What are the typical symptoms of mitral stenosis?

A
  • Dyspnea
    • ​Due to pulm. congestion
  • Fatigue
    • ​Due to low CO
24
Q

Physical exam findings of increased RV impulse, loud S1, diastolic rumbe with presystolic accentuation, and a loud pulmonic omponent of the 2nd heart sound are consistent wtih which valvular pathology?

A

Mitral stenosis

25
Q

What is the leading cause of heart disease worldwide?

A

Rheumatic fever

More prevalent in areas where diagnosis and treatment of strep is not as readily available

26
Q

Describe the pathophysiology of aortic regurgitation

A
  • Increased LV preload -> LV dilation
  • Increased LV afterload -> LV hypertrophy
  • Widened pulse pressure
  • Eventrually, these may lead to
    • LV systolic dysfunction
    • Increased LV diastolic pressure
    • Pulmonary congestion
27
Q

Why is it important to differentiate between bicuspid (congenital defect) and tricuspid (normal) aortic valves in patients with Aortic Regurgitation?

A

Bicuspid valves age much more rapidly than normal trileaflet valves, and may decompensate more rapidly.

Therefore, treatment is often necessary sooner in bicuspid aortic valves

28
Q

A patient with mitral stenosis has NHYA class I symptoms and recurrent emboli despite anticoagulation.

What treatment do you recommend?

A

Percutaneous balloon mitral valvotomy (PBMV)

Recommended for anyone with NYHA Class II symptoms, Recurrent emboli despire anticoagulation, and mild-moderate pulmonary HTN)

29
Q

A patient with mitral stenosis has NHYA class II symptoms and mild pulmonary HTN.

What treatment do you recommend?

A

Percutaneous balloon mitral valvotomy (PBMV)

Recommended for anyone with NYHA Class II symptoms, Recurrent emboli despire anticoagulation, and mild-moderate pulmonary HTN)

30
Q

Compare the bioprosthetic heart valves with mechanical prosthetic heart valves

A
  • Bioprosthetic
    • Better tolerated by the body
    • Less durable
  • Mechanical
    • Requires anticoagulants forever
    • More durable
31
Q

What are the typical symptoms of aortic stenosis?

A

Dyspnea

Angina

Syncope/presyncope

32
Q

Dynamic, displaced LV impulse, brisk carotid upstrokes with rapid fall-off, apical S3, diastolic decrescendo blowing murmur, mid-systolic outflow murmur, and wide pulse pressure are physical exam findings consistent with which valvular disease?

A

Aortic regurgitation

33
Q

What are the most common etiologies of aortic stenosis?

A
  • Congential abnormality
  • Degenerative (due to aging)
  • Rheumatic

Note: Aortic stenosis due to congenital abnormalities or degenerative disease is usually calcific, while aortic stenosis due to rheumatic fever usually has a thickened/stiffened valve without calcifications

34
Q

Left atrial enlargement and right ventricle hypertrophy are consistent with which valvular pathology?

A

Mitral stenosis

35
Q

In general, how are the indications for surgery different in obstructive vs. regurgitative valvular disease?

A

Obstructive (stenosis): Safe to wait until symptoms arise before operating

Regurgitative: Should operate if there is any LV systolic dysfunction or sever LV dilation (even if the patient is asymptomatic)

36
Q

What are the indications for surgical intervetion in aortic stenosis?

A
  • Any symptoms
  • Aortic dilation
  • LV dilation
  • LV systolic dysfunction
37
Q

When in the cardiac cycle can you hear aortic regurgitation?

A

In both diastole and systole

Technically, aortic regurgitation is a diastolic murmur, but you can also heart it in systole because more volume needs to be pumped out of the LV

38
Q

Which valvular diseases result in increased left ventricular preload?

A
  • Mitral regurgitaiton
    • Blood flows back into the LA during systole
    • There is more blood in the LA at the beginning of diastole
    • Increased ventricular filling = increased preload
  • Aortic regurgitation
    • ​Blood flows back into the LV during diastole
    • This increase the amount of blood that is in the ventricle at the end of diastole
    • Increased ventricular filling = increased preload
39
Q

What is the recommended medical treatmet for mitral regurgitation?

A

There is no effetive medical treatment

Surgery is recommended if there are any symptoms, or asymptomatic LV systolic dysfuction, pulmonary HTN, or atrial fibrillation

40
Q

Rheumatic fever can cause any valvular disease, but it is most commonly associated with….

A

Mitral stenosis

(Aortic stenosis is second most common)

41
Q

Why is afterload increased in aortic regurgitation?

A

Aortic regurgitation causes increased preload

If the left ventricle begins to fail, blood will back up through LA, pulmonary circulation, and eventually systemic circulation

This will i_ncrease systolic blood pressure, therefore increasing afterload_

(This does not occur in mitral regurgitation, because MR gives the blood another “outlet” from the LV, thus preventing increases in afterload)

42
Q

What are the recommended medical treatments for aortic stenosis?

A

There are none!

Sugery is required if the patient becomes symptomatic

43
Q

What are the indications for surgical intervention in mitral regurgitation?

A

Surgery is recommended if any of the following are present in primary mitral regurgitation :

  • Symptoms
  • LV systolic dysfuction (even if asymptomatic)
  • Pulmonary HTN
  • Atrial fibrillatio

Note: The threshold for surgery is low if the valve can be repaired, rather than replaced, even if there are no symptoms or major indications in primary MR

There is lack of evidence to support repair in secondary MR: Treat the ventricle instead

44
Q

What are the indications for surgical intervention in mitral stenosis?

A
  • For percutaneous balloon mitral valvotomy (PBMV)
    • Mild symptoms (NYHA Class II)
    • Recurrent emboli despite anticoagulation
    • Pulmonary HTN
  • For Surgical Mitral Valve commissurotomy or replacement
    • Moderate-severe symptoms (NYHA Class III-IV)
    • Mild symptoms with severe pulmonary HTN

Note: Don’t need to operate until symptoms arise

CVB by Minnie (Madeleine) (43 decks)

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