valve disease awr p.551-p.556 Flashcards
AS, AR, MS, MR, ASD
WHAT PE+ CAN BE SEEN WITH AS?
+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
PRESENTING SX OF AS?
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
1MC VALVE DISEASE IN ADULTS?
AS
MOST IMPORTANT SINGS SECIFIC TO AS ON EXAM?
+DELAYED AND SLOW CAROTID UPSTROKE AND PULSE
+SYSTOLIC CRE-DECRE MURMUR AT RSB AND/OR RADIATING TO THE CAROTIDS
SIGNS OF SEVERE AS?
+S4
+PARADOXICAL SPLIT S2(REVERESE SPLIT S2)
+LATE PEAKING SYSTOLIC MURMUR
+ECHO WITH GRADIENT >40, VALVE<1SQ CM ON ECHO
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?
NEXT DO DOBUTAMINE ECHO
BECAUSE DISCORDANT FINDINGS:
PE-MID PEAKING SM -MODERATE AS
ECHO-
**+VALVE <1SQCM-SEVERE AS
** +GRADIENT 20MM-MILD AS
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?
**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
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?
**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
PT PRESENT WITH EXERTIONAL DYSPNEA AND NEAR SYNCOPE
PE:
+SOFT S2,
+LATE PEAKING SM @RSB
ECHO:
EF 65%
VALVE 1.6SQ CM
NEXT STEP?
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.
PT WITH
-SX
+AS
ECHO
+VALVE>1
+GRAD <20
SEVERITY OF AS?
MNGMT?
SEVERITY IS :
MILD AS(>1SQ CM, GRAD<20MM)
MNGMT:REPEAT ECHO Q3-5 YEARS
PT WITH
-SX
ECHO:
VALVE>1SQ CM
GRAD-20-39MM
SEVERITY OF AS?
MNGMT?
SEVERITY- MODERATE AS(VALVE>1, GRAD 20-39)
MNGMT:
REPEAT ECHO Q1-2 YEARS
PT WITH
-SX
ECHO:
+VALVE<1SQ CM
+ GRAD>40
EF>51%
SEVERITY OF AS?
MNGMT?
SEVEREITY:
SEVERE AS(VALVE<1, GRAD>40)
EF>51- NORMAL
REPEAT ECHO Q6-12 MONTHS
PT WITH
-SX
ECHO:
+VALVE<1SQ CM
+ GRAD>40
EF<50%
SEVERITY OF AS?
MNGMT?
SEVEREITY:
SEVERE AS(VALVE<1, GRAD>40)
EF<50- NOT NORMAL
MNGMT?
AORTIC VALVE REPLACEMENT
75 YO PT
AS GRAD>80 ON ECHO AND+ SX OF SYNCOPE
HAS HIP # AFTER FALL
NEXT STEP?
MUST REPLAVE THE AORTIC VALVE FIRST BEFORE SENDING TO SURGERY TO FIX HIP!
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?
TAVR
TRANSCATHETER AORTIC VALVE REPLACEMENT
PT WITH AS GOING FOR SURGICAL AV REPLACEMENT
WHAT ELSE NEEDS TO BE DONE PRIOR TO AV REPLACEMENT?
CORONARY ANGIOGRAM TO EVALUATE CORONARY ANATOMY FOR STENOSIS
IF ++STEONISIS CAN DO CABG AND AVR REPLACEMENT AT THE SAME TIME.
WHAT ELSE IS SEEN ON ECHO IN PT WITH AS?
LVH
PT WITH AV MALFORMATION WITH GI BLEED. WHAT IS THIS PATIENTS CONDITION RELATED TO?
AS
AR FINDINGS
*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)
AR PRESENTING SX?
MC MURMUR?
SEVERE AR MURMUR?
RX?
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!!!
SEVERE AR, WITH EF<55% AND +SX WHAT IS MNGMT?
NO NEED FOR LV DIMENSIONS- DO THE SURGERY!
PT WITH SEVERE AR
-SX
EF>55%
LV DIMENSIONS:
END SYSTOLIC DIMENTION(ESD)<40
AND
END DIASTOLIC DIMENTION (EDD)<60
NEXT BEST STEP?
ECHO IN 6-12 MONTHS
PT WITH SEVERE AR
-SX
EF>55%
LV DIMENSIONS:
END SYSTOLIC DIMENTION(ESD)>50
AND
END DIASTOLIC DIMENTION (EDD)>65
NEXT BEST STEP?
DO SURGERY
HOW DO YOU CHECK WHEN FOR AR ON PE?
with patient sitting up and leaning forward in full expiration –DM HEARD AT LSB
FEMALE PREGNANT WITH AR AND EF 60%
WHAT TYPE OF DELIVERY?
NORMAL VAGINAL DELIVERY
BEST CANDIDATE FOR USE OF SILDENAFIL IS?
PT WITH +AR AND PRESERVED LVEF
SPECIFIC FINDINGS FOR MS
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
COMPLICATIONS OF MS?
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.
WHY USE BB AND DILTIAZEM IN MS???
TO INCREASE DIASTOLIC FILLING TIME.
MR BUZZ WORDS
+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!!
MR TREATMENT
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.
