Valve Disease - Part 1 Flashcards
Which valves have 3 leaflets?
Which valves have 2 leaflets?
3: tricuspid, pulmonic, aortic
2: mitral
What are the basic types of pathologic mechanisms seen with valve disease?
Stenosis
Regurgitation
Prolapse
Right Sided Heart Failure - what physical changes do we see with this?
Increased RV pressure Increased RA pressure Increased CVP Increased JVD Hepatomegaly Ascites Edema
Left Sided Heart Failure - what physical changes do we see with this?
Increased LV pressure Increased LA pressure Increased PA pressure Shortness of breath CHF Decreased EF Decreases systemic perfusion
What tests can help you diagnose valve disease?
History and physical EKG CXR Echo - TTE, TEE, 3D Cardiac cath Swan ganz cath CT scan/Gated MRA
What are the basic options for tx of valve disease?
Observation Medical Percutaneous --balloon valvulopasty --TAVR (Transcatheter aortic valve replacement) Surgery --repair --replacement
What are the causes of tricuspid stensosis?
Rheumatic
Carcinoid
Congenital
Tricuspid Stenosis - Rheumatic cause
- Seen in combo with …
- Usually what type of disease
- Hallmark is …
- What changes are seen?
- Calcification?
- Seen in combo with mitral rheumatic disease
- Usually regurg with variable stenosis
- -rare causes may be pure stenosis
- Hallmark is commissural fusion
- Chordal thickening and mild fusion
- Calcification absent
Tricuspid Stenosis - Carcinoid cause
- Secondary to …
- Deformity?
- Leaflets?
- What changes are seen?
- Seen secondary to serotonin production
- Seen with carcinoid syndrome
- Cicatricial deformity in TV and PV
- Fibrous plaques form on leaflets
- Commissure fusion, leaflets thicken and shorten, chordae become thick and fused
- Combined stenosis and regurg
Symptoms of tricuspid stenosis
Excessive fatigue
Dyspnea (can be from associated left sided lesions)
What kind of failures are seen with tricuspid stenosis?
Both forward and backwards failure
Forwards
- decreased LV preload
- decreased SV
- salt and water retention via RAA system
Backwards
-hepatic congestion and peripheral edema
What kind of murmur is heard with tricuspid stenosis?
Mid-diastolic murmur over left lower sternal border
Murmur increases on inspiration
What findings does a CXR show with tricuspid stenosis?
EKG?
Echo?
CXR!!!! Pathognomonic
- increased RA
- lack of pulmonary artery enlargement
- clear lung fields
EKG - prominent P waves (unless a fib)
Echo
- RA enlargement
- leaflet thickening
- measure gradient
- look for associated lesions
What are the causes of tricuspid regurgitation?
- Rheumatic
- Endocarditis
- Trauma
- Carcinoid
- Myxoma
- Diffuse collagen disorders
- Fibroelastosis
- Functional (majority due to MV disease mainly)
- Congenital: Ebstein’s Anomaly
What is ebstein’s anomaly?
Ventricularization of tricuspid valve
What findings might you see with tricuspid regurgitation?
- PANSYSTOLIC murmur maximal over lower sternal border
- murmur increases with inspiration
- enlarged liver - systolic pulsitations, tender
- JVD
- Hepatojugular reflex present
- Edema
- Ascites
- Anasarca
What other finding will you see in a majority of patients that have tricuspid regurgitation?
Atrial fib
What are the tx options for tricuspid valve disease?
Observation
–a majority of lesions fall into this category
Medical
- -tx left sided valve lesions for function disease
- -diuretics for possible after load reduction
Tricuspid valve ring valvuloplasty/repair
Commissurotomy
–mostly for congenital disease
Tricuspid valve replacement
Pulmonary valve lesion are mainly …
congenital lesions
e.g. tetralogy of fallout, pulmonary atresia
What is a Ross procedure?
Remove pulmonary valve to use as an autograph to replace Aortic valve
- –valve can grow with child as child grows
- –can be done in adults occassionally
What are the important anatomical components of the mitral valve?
- Leaflets - two - anterior and posterior
- Annulus - hinge on which leaflets are attached
- Chordae tendineae - from papillary mm to actual leaflet
- Papillary mm
Mitral Stenosis
- flow
- CO
- Size
- Consequences
- Decreased flow to LV
- Decreased CO (b/c dec SV) - fatigue, mm wasting, weakness
- LA hypertrophy (LV normal or small)
- Pulmonary HTN
- Increased pulmonary vascular resistance
- pulmonary edema (if mean LA pressure exceeds oncotic pressure of plasma)
Mitral stenosis symptoms
Pulmonary congestions Cough Hemoptysis Orthopnea PND (paroxysmal nocturnal dyspnea) Pulmonary edema Dyspnea on exertion Cardiac cachexia
What auscultory triad is seen with mitral stenosis?
Apical diastolic rumble
Increased 1st heart sound
Opening snap
What findings are seen on CXR with mitral stenosis?
Increased LA
Normal cardiac size
Straight left heart border
Often MV is calcified - this can be seen on CXR, echo, cath
What are Kerley’s Lines?
Seen with severe mitral stenosis
Engorged pulmonary lymphatics
What is nearly the exclusive cause of mitral stenosis?
Rheumatic disease
except for rare congenital lesions, extra-valvular causes like myxoma, and severe senile calcific disease
Progress mitral stenosis eventually results in …
fibrosis of leaflets, commissures, subvalvular apparatus, and calcifies
What are the findings on ECHO with mitral stenosis?
LA enlargement Leaflet thickness Vegetations Changes in valve area and EF Associated lesions Thrombus Calcification
Leaflet “doming” secondary to restrictive opening of the stenotic valve
Mitral Stenosis Tx
Observation/medical
- centered on following echo exams on asymptomatic patients
- medical tx of a fib and HR control
Percutaneous balloon commissurotomy
- in symptomatic patients with MVA less than/equal to 1.5
- in pts with minimal calcium and favorable anatomy in the absence of LA thrombus and mod-severe MR
Commissurotomy or replacement
Repair for rheumatic disease
