Valve Disease - Part 2 Flashcards
Mitral Regurgitation Causes
- Rheumatic
- Dystrophic/Degnerative
- Ischemia - secondary to coronary disease
- Infective endocarditis - bacterial/fungal
- Cardiomyopathies
- CT disease - Marfans, etc
- Prolapse
- Myxomatous/Barlows disease
- Trauma
- Papillary mm rupture, dysfxn, displacement
- LV aneurysm
- Atrial myxoma
What is heart on heart exam of a patient with mitral regurgitation?
Loud pansystolic murmur transmitted to axilla
Mitral regurgitation
- pressures
- symptoms
- heart changes
Inc LA pressure/PCWP/Pulmonary vein pressure
Fatigue, dyspnea, dec exercise tolerance, palpitations/a fib
Increased LA size
What is the difference between gradual and acute mitral regurgitation onset in terms of functioning?
With gradual changes, can accommodate extra load w/o pressure rise till late and then will become symptomatic
With acute MR, normal or small LA cannot accommodate with resultant acute pulmonary edema and possible in extremis status
With MR, which way does the mitral annulus dilate?
Posteriorly
LV functioning in mitral regurg
LV fxn (in chronic forms of MR) usually remained adequate for a long period of time
But eventually decompensated with LV dilation and decreased EF
What changes with been seen on CXR with mitral regurg?
Enlarged LA
Eventually LV dilation
Various degrees of pulmonary congestion
–depending on where you are on spectrum of disease
MItral regurg tx
Observation
-follow with serial echo exams
Medical
- diuresis
- afterload reduction
- rhythm control
- beta blockers
Surgery - repair if at all possible
- MR repair
- MR annuloplasty
- MR replacement
If you have to do mitral valve replacement, what is an important step to take in the surgery?
Keep the posterior leaflet chords in tact to preserve LV geometry and function
Aortic stenosis causes
- degenerative/calcific disease aka senile calcific
- -most common
- -may affect conduction system
- congenital
- rheumatic
Aortic stenosis pathology
- increased after load with secondary impaired LV emptying in systole
- concentric LV hypertrophy
- LV less compliant
- LVH can lead to LV failure
- LV hypertrophy (inc mm mass, inc O2 demand)
- Microinfarcts
With decreasing LV complicance, how does the functioning of the heart change?
Have to rely on LA from maintaining LV filling and CO
Classic symptoms of aortic stenosis
Angina
Syncope
CHF (manifested as exertional dyspnea)
Aortic stenosis and sudden death
AS can result in sudden death - 20%
AS is the most common “fatal” valve lesion
Most pts die of CHF
Aortic stenosis - clinical course in terms of symptomatic apperance
Asymptomatic for years
Symptomatic can be a malignant diagnosis w/o treatment
Average survival post onset of:
- CHF – 2 years
- syncope – 3 years
- angina – 5 years
What findings are seen on exam of someone with aortic stenosis?
CXR?
EKG?
Exam - systolic ejection murmur in R 2nd ICS; diminished upstroke of carotid pulse
CXR - calcification of aortic valve/aorta, LVH, post-stenotic aorta enlargement
EKG - various changes can be seen, such as:
- -BBB
- -AV nodal block
- -a fib
Aortic stenosis treatment
Observation
Medical therapy
- control HTN (careful in end stage disease)
- control arrhythmias
- cautious use of diuretics (don’t want to lower preload)
Surgery (its rare to repair valve)
- aortic valve replacement
- TAVR (transcath aortic valve replacment)
Aortic regurgitation causes
- Usually mixed AS/AR
- Degenerative calcific AV disease
- rheumatic
- congenital
- annuloaortic ectasia
- marfans
- myxoid degeneration aortic leaflets
- aortic dissection
What is annuloaortic ectasia
Abnormal dilatation of annulus and aortic root
Pulls leaflets of aortic valve apart to the point where they can’t touch each other
Aortic regurgitation can be seen in association with
- bacterial endocarditis
- RA
- ankylosing spondylitis
- blunt/penetrating trauma
- VSD
- atrial myxomas
What functional changes are seen with aortic regurgitation?
- volume overload of LV
- increased LVEDP/LV diastolic volume/wall stress
- LV dilation and eventual failure
- eccentric hypertrophy of LV
- -inc chamber size and wall thickness
What is the difference between eccentric hypertrophy and concentric hypertrophy?
Eccentric
- with AR
- increased chamber size and wall thickness
Concentric
- with AS
- increased wall thickness
- no change in chamber size (until failure)
Symptoms of Aortic Regurgitation
- Angina (subendocardial ischemia)
- Dyspnea
- Orthopnea
- PND
- Syncope
With aortic regurg, what change in pulse pressure is seen?
Widened pulse pressure
-can’t hold diastolic pressure because blood is rushing back
What specially named symptoms, etc are seen with aortic regurg?
- Austin flint murmur
- Water hammer pulse
- -Corrigan’s
- -Watson’s
- De Musset’s sign
- Quincke’s pulse
- Duroziez’s sign
- Traube’s sign
Austin flint murmur
when regurgitant jet hits anterior leaflet of mitral valve it tends to close it causes murmur at apex
Water hammer pulse
Bounding and forceful peripheral pulse
- -corrigan’s - when in carotid
- -watson’s - when in limb
De musset’s sign
Bobbing of head with cardiac cycle
Quincke’s pulse
pulsating nail beds
Duroziez’s sign
systolic/diastolic murmur over femoral arteries
Traube’s sign
pistol shot sounds over large arteries
What is seen on a CXR of aortic regurg?
LV enlargement
Enlarged ascending aorta
Pulmonary edema
Inc LA
Treatment of aortic regurg
Observation
Medical
- afterload reduction
- diureticds
- tx HTN
Surgery
- usually repair
How long will various valve replacements last?
bioprosthetic valves
- 10-20 years
- no anti coagulation required
Mechanical vale
- lifetime
- but have to be anti coagulated
