valve disease awr p.551-p.556

Question 1

WHAT PE+ CAN BE SEEN WITH AS?

Answer 1

+REVERSE SPLIT S2
+S4(SEVERE AS)
+SLOW RISING/DELAYED CAROTID UPSTROKE AND PULSE
+SM RADIATES TO CAROTIDS
+AS BEST HEARD AT RSB-2ND ICS AND RADIATES TO CAROTIDES
+MID SM OR CRE-DEC MURMUR IN SYSTOLE
+MILD AS- EARLY PEAKING SM GRADIENT ~20
+MOD AS- MID PEAKING SM GRADIENT~30
+SEVERE AS- LATE PEAKING SM GRADIENT>40, VALVE<1SQ CM
+AMYL NITRATE, POST PVC-AS MURMUR INCREASES
+VALSALVA/STANDING, HANDGRIP -AS MURMUR DECREASES
+AS BEST HEARD ON EXPIRATION
++CLOSEST DDX HOCM–VALSALVA DDX THESE TO HOCM VALSALVA WIOLL INCREASE AND AS WILL DECREASE

Question 2

PRESENTING SX OF AS?

Answer 2

1MC VALVE DZ IN ADULTS

+SYNCOPE
+CHEST PAIN
+++CHF**PRESENTING WITH THIS SYMPTOM(+S4) HAS THE WORST OUTCOME THAN IF WITH + SYNCOPE OR CP AS PRESENTING SYMPTOMS

Question 3

1MC VALVE DISEASE IN ADULTS?

Answer 3

AS

Question 4

MOST IMPORTANT SINGS SECIFIC TO AS ON EXAM?

Answer 4

+DELAYED AND SLOW CAROTID UPSTROKE AND PULSE
+SYSTOLIC CRE-DECRE MURMUR AT RSB AND/OR RADIATING TO THE CAROTIDS

Question 5

SIGNS OF SEVERE AS?

Answer 5

+S4
+PARADOXICAL SPLIT S2(REVERESE SPLIT S2)
+LATE PEAKING SYSTOLIC MURMUR
+ECHO WITH GRADIENT >40, VALVE<1SQ CM ON ECHO

Question 6

PT WITH PMHX OF MI 5 YEARS AGO
PRESENT WITH SOB
PE MID-PEAK SM AT RSB
ECHO VALVE 0.7SQ CM AND GRADIENT IS 20MMHG
NEXT STEP?

Answer 6

NEXT DO DOBUTAMINE ECHO
BECAUSE DISCORDANT FINDINGS:
PE-MID PEAKING SM -MODERATE AS
ECHO-
**+VALVE <1SQCM-SEVERE AS
** +GRADIENT 20MM-MILD AS

Question 7

PT WITH PMHX OF MI 5 YEARS AGO
PRESENT WITH SOB
PE MID-PEAK SM AT RSB
ECHO VALVE 0.7SQ CM AND GRADIENT IS 20MMHG
DOBUTAMINE ECHO DONE RESULTS SHOW
+ VALVE <1SQ CM
+GRADIENT >40MM
FINAL DIAGNOSIS?
RX?

Answer 7

**DX+ SEVERE AS
BECAUSE INITIAL PE AND ECHO:
MID PEAKING SM -MODERATE AS
**+VALVE <1SQCM-SEVERE AS
** +GRADIENT 20MM-MILD AS
WC ARE DISCORDANT FINDINGS SO HAD TO DO DOBUTAMINE ECHO TO GET THE REAL SEVERITY
DOBUTAMINE ECHO SHOWS
**VALVE <1SQ CM -SEVERE AS
***GRADIENT>40MM- SEVERE AS
SO FINAL SEVERITY IN DX - SEVERE AS
**RX AORTIC VALVE REPLACEMENT

Question 8

PT WITH PMHX OF MI 5 YEARS AGO
PRESENT WITH SOB
PE MID-PEAK SM AT RSB
ECHO VALVE 0.7SQ CM AND GRADIENT IS 20MM
DOBUTAMINE ECHO DONE RESULTS SHOW
+ VALVE >1SQ CM
+GRADIENT <20MM
FINAL DIAGNOSIS?

Answer 8

**DX+PSEUDO AORTIC STENOSIS
BECAUSE INITIAL PE AND ECHO:
MID PEAKING SM -MODERATE AS
**+VALVE <1SQCM-SEVERE AS
** +GRADIENT 20MM-MILD AS
WC ARE DISCORDANT FINDINGS SO HAD TO DO DOBUTAMINE ECHO TO GET THE REAL SEVERITY
DOBUTAMINE ECHO SHOWS
**VALVE >1SQ CM -MILD/MOD AS
***GRADIENT<20MM- MILD/MOD AS
SO FINAL SEVERITY IN DX - PSEUDO AORTIC STENOSIS
**RX NOTHING

Question 9

PT PRESENT WITH EXERTIONAL DYSPNEA AND NEAR SYNCOPE
PE:
+SOFT S2,
+LATE PEAKING SM @RSB
ECHO:
EF 65%
VALVE 1.6SQ CM
NEXT STEP?

Answer 9

NEXT STEP IS ANGIOGRAM BECAUSE
PE AND CLINICAL CC + SYNCOPE=+LATE PEAKING SM-+SEVERE AS
AND ECHO VALVE1.6(>1)+ NOT SEVERE AS
AND EF IS NORMAL
SO ANGIOGRAM NEEDS TO BE DONE TO CONFIRM THE PRESSURE GRADIENTS AND VALVE SIZE.

Question 10

PT WITH
-SX
+AS
ECHO
+VALVE>1
+GRAD <20
SEVERITY OF AS?
MNGMT?

Answer 10

SEVERITY IS :
MILD AS(>1SQ CM, GRAD<20MM)

MNGMT:REPEAT ECHO Q3-5 YEARS

Question 11

PT WITH
-SX
ECHO:
VALVE>1SQ CM
GRAD-20-39MM
SEVERITY OF AS?
MNGMT?

Answer 11

SEVERITY- MODERATE AS(VALVE>1, GRAD 20-39)

MNGMT:
REPEAT ECHO Q1-2 YEARS

Question 12

PT WITH
-SX
ECHO:
+VALVE<1SQ CM
+ GRAD>40
EF>51%
SEVERITY OF AS?
MNGMT?

Answer 12

SEVEREITY:
SEVERE AS(VALVE<1, GRAD>40)
EF>51- NORMAL

REPEAT ECHO Q6-12 MONTHS

Question 13

PT WITH
-SX
ECHO:
+VALVE<1SQ CM
+ GRAD>40
EF<50%
SEVERITY OF AS?
MNGMT?

Answer 13

SEVEREITY:
SEVERE AS(VALVE<1, GRAD>40)
EF<50- NOT NORMAL

MNGMT?
AORTIC VALVE REPLACEMENT

Question 14

75 YO PT
AS GRAD>80 ON ECHO AND+ SX OF SYNCOPE
HAS HIP # AFTER FALL

NEXT STEP?

Answer 14

MUST REPLAVE THE AORTIC VALVE FIRST BEFORE SENDING TO SURGERY TO FIX HIP!

Question 15

75 YO PT
AS GRAD>80 AND LVEF IS LOW ON ECHO AND+ SX OF SYNCOPE
AND HIGH SURGICAL RISK
HAS HIP # AFTER FALL

NEXT STEP?

Answer 15

TAVR
TRANSCATHETER AORTIC VALVE REPLACEMENT

Question 16

PT WITH AS GOING FOR SURGICAL AV REPLACEMENT
WHAT ELSE NEEDS TO BE DONE PRIOR TO AV REPLACEMENT?

Answer 16

CORONARY ANGIOGRAM TO EVALUATE CORONARY ANATOMY FOR STENOSIS

IF ++STEONISIS CAN DO CABG AND AVR REPLACEMENT AT THE SAME TIME.

Question 17

WHAT ELSE IS SEEN ON ECHO IN PT WITH AS?

Answer 17

LVH

Question 18

PT WITH AV MALFORMATION WITH GI BLEED. WHAT IS THIS PATIENTS CONDITION RELATED TO?

Answer 18

AS

Question 19

AR FINDINGS

Answer 19

*DM
*DM AT RSB
*DM @LSB
*FM@APEX-SEVERE AR
*PALPATION @ APEX WITH HYPERDYNAMIC IMPULSE-AR WITH NORMAL EF
*PALPATION AT APEX WITH LIFT/IMPULSE-AR WITH LOW EF
*TYPE OF MURMUR:
-EARLY DIASTOLIC MURMUR
OR - DECRECENDO DIASTOLIC MURMUR
* EARLY DM IS HEARD BEST AT THE LSB WHEN THE PATIENT IS SITTING UP, LEANING FORWARD WITH BREATH IN FULL EXPIRATION
* SEVERE AR- WITH +AUSTIN FLINT MURMUR– MID DIASTOLIC MURMUR IS HEARD AT APEX( EARLY SM FOLLOWED BY MID DIASTOLIC RUMBLE LIKE MS W/C IS ALSO IN APEX)

Question 20

AR PRESENTING SX?
MC MURMUR?
SEVERE AR MURMUR?
RX?

Answer 20

PRESENT WITH DYSPNEA( BACKED UP BLOOD AS IN CHF)

EARLY DM(DECRESCENDO DM) BEST HEAR AT LSB WHEN PATIENT IS SITTING UP, LEANING FORWARD AWITH BREATH IN FULL EXPIRATION

• SEVERE AR- WITH +AUSTIN FLINT MURMUR– MID DIASTOLIC MURMUR IS HEARD AT APEX( EARLY SM FOLLOWED BY MID DIASTOLIC RUMBLE LIKE MS W/C IS ALSO IN APEX)

RX–WITH SEVERE AS, -SX & EF >55% MNGMT DEPENDS ON LV DIMENSTIONS!!!

Question 21

SEVERE AR, WITH EF<55% AND +SX WHAT IS MNGMT?

Answer 21

NO NEED FOR LV DIMENSIONS- DO THE SURGERY!

Question 22

PT WITH SEVERE AR
-SX
EF>55%
LV DIMENSIONS:
END SYSTOLIC DIMENTION(ESD)<40
AND
END DIASTOLIC DIMENTION (EDD)<60

NEXT BEST STEP?

Answer 22

ECHO IN 6-12 MONTHS

Question 23

PT WITH SEVERE AR
-SX
EF>55%
LV DIMENSIONS:
END SYSTOLIC DIMENTION(ESD)>50
AND
END DIASTOLIC DIMENTION (EDD)>65

NEXT BEST STEP?

Answer 23

DO SURGERY

Question 24

HOW DO YOU CHECK WHEN FOR AR ON PE?

Answer 24

with patient sitting up and leaning forward in full expiration –DM HEARD AT LSB

Question 25

FEMALE PREGNANT WITH AR AND EF 60%
WHAT TYPE OF DELIVERY?

Answer 25

NORMAL VAGINAL DELIVERY

Question 26

BEST CANDIDATE FOR USE OF SILDENAFIL IS?

Answer 26

PT WITH +AR AND PRESERVED LVEF

Question 27

SPECIFIC FINDINGS FOR MS

Answer 27

SOB WITH
+OPENING SNAP**SPECIFIC

OR

SOB WITH MID-DIASTOLIC RUMBLE HEARD AT APEX*****SPECIFIC

OR

SOB AND
LOUDP2+,
PCWP ELEVATED, **
AND PAP ELEVATED ** TOGETHER -SPECIFIC

OR

SOB WITH HEMOPTYSIS AND
CXR+ FOR STRAITENING OF THE LEFT HEART BOARDER**SPECIFIC SINCE MEANS ENLARGEMENT OF THE LEFT ATRIUM

OR

SOB WITH HEMOPTYISIS AND ECG—SHOWS P WAVE LOOKS LIKE DUMBLE HUMP BOTH HUMPS POINTING UP…^^- MEANS M MITRALE AND LEFT ATRIAL ENLARGEMENT*****SPECIFIC OT BIPHSIC P WAVE- FIRST HUMP UP FOLLWED BY SECOND HUMP DOWN.^v

Question 28

COMPLICATIONS OF MS?

Answer 28

DIALATED LEFT ATRIUM—->ATRIAL FIBRILLATION—–> THROMBOEMBOLISM AND CHF

RX— IV VALVE<1.5SQ CM THEN DO VALVULOPLASTY– NOT REPLACEMENT– IT MEANS OPENING MV WITH A BALLOON.

Question 29

WHY USE BB AND DILTIAZEM IN MS???

Answer 29

TO INCREASE DIASTOLIC FILLING TIME.

Question 30

MR BUZZ WORDS

Answer 30

+HSM/PSM AT APEX
**RADIATES TO AXILLA

POSTMENOPAUSAL FEMALE -SX, PE NORMAL
DURING STRESS TEST- ECG+LATERAL LEADS WITH ST DEPRESSION AND +SM @APEX
5MIN AFTER STRESS TEST - MURMUR IS GONE—ISCHEMIC MR!!

Question 31

MR TREATMENT

Answer 31

DEPENDS ON LVEF REGARDLESS OF MR SEVERITY AND =/- SYMPTOMS

**IF LVEF<60% AND +MR—->PREFER SURGICAL MR REPAIR( NOT REPLACEMENT)

**IF LVEF<60% AND +MR AND POOR SURGICAL CANDIDATE—> THEN DO TRANSCATH MR REPAIR.

**IN GENERAL SURGICAL MR REPAIR IS PREFERRED OVER TRANSCATH MR REPAIR. ***

***+MR WITH EF>65% MNGMT WILL BE ECHO IN 6 MONTHS

**IF PATIENT HAS BOTH SEVERE MS and + MODERATE MR—>THEN DO MV REPAIR.

** IF PATIENT HAS SEVERE MS AND MILD MR THEN DO MV VALVULOPLASTY( NOT REPAIR AND NOT REPLACEMENT) PUT BALOON IN MV TO OPEN.