SM 141a/142a - Valvular Heart Disease Flashcards
Which valvular disease causes more LV hypertrophy:
Aortic regurgitation
Mitral regurgitation
Aortic regurgitation
A patient with mitral stenosis has NHYA Class III symptoms.
What treatment do you recommend?
Surgical mitral valve commissurotomy or replacement
(Recommended for NHYA Class III-IV, or if severe pulmonary HTN is present)
List the common etiologies of mitral regurgitation
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
Describe the symtpoms of mitral regurgitation
May be asymptomatic for decades due to compensatory mechanisms
Decompensation leads to…
- Dyspnea
- Angina
- Fatigue
- Palpitations
Widened pulse pressure due to increased systolic and decreased diastolic blood pressure is present in which valvular disease?
Aortic regurgitation
What is the difference between primary and secondary causes of mitral regurgitation?
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)
What are the available treatments for aortic stenosis?
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
What is (by far) the most common etiology of mitral stenosis?
Rheumatic fever
A patient with mitral stenosis has NHYA Class I and severe pulmonary HTN.
What treatment do you recommend?
Surgical mitral valve commissurotomy or replacement
(Recommended for NHYA Class III-IV, or if severe pulmonary HTN is present)
What are the recommended medical treatments for mitral stenosis?
- Diuretics
- Decrease pulmonary congestion
- Betablockers
- Prevent tachycardia
- Digoxin +/- beta blokers if atrial fibrillation
- Control ventricular rate
- Anticoagulations if atrial fibrillation
- Prevent emboli
What physical exam findings are associated with wide pulse pressure?
- 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
Describe the pathophysiology of mitral regurgitation
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
What are the common etiologies of aortic regurgitation?
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
What are the indications for surgical intervention in aortic stenosis?
- Any symptoms
- LV systolic dysfunction
- Very severe aortic stenosis (<0.6 cm2)
What are the 3 pathophysiologic manifestations of mitral stenosis?
What are the effect?
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
LV hypertrophy is consistent with which valvular pathologies?
Aortic Stenosis
Aortic regurgitation
Severe mitral regurgitation
What are the recommended medical treatments for aortic regurgitation?
No medical therapy except HTN treatment
Surgery is required if there are any symptoms, or aysmptomatic aortic dilation, LV dilation, or LV systolic dysfunction
What are the typical symptoms of aortic regurgitation
Patients may be asymptomatic for decades
Usually, symptoms only arise when decompensation occurs -> Angina, dyspnea
Describe the pathophysiology of aortic stenosis
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)
- Increased LA pressure (if severe)
- LV enlargement (if severe)
- LV systolic dysfunction
- Increased LV diastolic pressure
- Myocardial ischemia
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?
Aortic stenosis
How does mitral stenosis increase risk of stroke?
- Mitral stenosis -> Increasd LA pressure
- LA dilation
- Atrial fibrillation
- Blood clot
- Systemic arterial embolization
- Stroke
- Systemic arterial embolization
- Blood clot
- Atrial fibrillation
- LA dilation
Displaced LV impulse, brisk carotid upstrokes, holosystolic apical murmur, apical S3, and apical diastolic rumble are physical exam findings consistent with which valvular disease?
Mitral regurgitation
Also mid-systolic click if caused by prolapse, and apical diastolic rumbe if MR is severe
What are the typical symptoms of mitral stenosis?
-
Dyspnea
- Due to pulm. congestion
-
Fatigue
- Due to low CO
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?
Mitral stenosis
What is the leading cause of heart disease worldwide?
Rheumatic fever
More prevalent in areas where diagnosis and treatment of strep is not as readily available
Describe the pathophysiology of aortic regurgitation
- 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
Why is it important to differentiate between bicuspid (congenital defect) and tricuspid (normal) aortic valves in patients with Aortic Regurgitation?
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
A patient with mitral stenosis has NHYA class I symptoms and recurrent emboli despite anticoagulation.
What treatment do you recommend?
Percutaneous balloon mitral valvotomy (PBMV)
Recommended for anyone with NYHA Class II symptoms, Recurrent emboli despire anticoagulation, and mild-moderate pulmonary HTN)
A patient with mitral stenosis has NHYA class II symptoms and mild pulmonary HTN.
What treatment do you recommend?
Percutaneous balloon mitral valvotomy (PBMV)
Recommended for anyone with NYHA Class II symptoms, Recurrent emboli despire anticoagulation, and mild-moderate pulmonary HTN)
Compare the bioprosthetic heart valves with mechanical prosthetic heart valves
- Bioprosthetic
- Better tolerated by the body
- Less durable
- Mechanical
- Requires anticoagulants forever
- More durable
What are the typical symptoms of aortic stenosis?
Dyspnea
Angina
Syncope/presyncope
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?
Aortic regurgitation
What are the most common etiologies of aortic stenosis?
- 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
Left atrial enlargement and right ventricle hypertrophy are consistent with which valvular pathology?
Mitral stenosis
In general, how are the indications for surgery different in obstructive vs. regurgitative valvular disease?
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)
What are the indications for surgical intervetion in aortic stenosis?
- Any symptoms
- Aortic dilation
- LV dilation
- LV systolic dysfunction
When in the cardiac cycle can you hear aortic regurgitation?
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
Which valvular diseases result in increased left ventricular preload?
-
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
What is the recommended medical treatmet for mitral regurgitation?
There is no effetive medical treatment
Surgery is recommended if there are any symptoms, or asymptomatic LV systolic dysfuction, pulmonary HTN, or atrial fibrillation
Rheumatic fever can cause any valvular disease, but it is most commonly associated with….
Mitral stenosis
(Aortic stenosis is second most common)
Why is afterload increased in aortic regurgitation?
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)
What are the recommended medical treatments for aortic stenosis?
There are none!
Sugery is required if the patient becomes symptomatic
What are the indications for surgical intervention in mitral regurgitation?
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
What are the indications for surgical intervention in mitral stenosis?
- 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
