Valve disorders Flashcards
When you hear harsh/rumbling sounds, think
stenosis (pressure overload)
When you hear a blowing sound, think
regurgitation
What’s unique about the MVP murmur?
click - delayed (which also decreasing venous return increases this murmur)
AR MS PT: diastolic murmurs
aortic regurg and mitral stenosis, tricuspid stenosis, pulmonic regurg
Where does mitral regurg radiate to?
axilla
Where do aortic and pulmonic stenosis radiate to?
carotid
What are some general symptoms someone with aortic stenosis may present with?
exertional dyspnea, fatigue, angina, syncopal episodes
What puts someone at risk for aortic stenosis?
metabolic syndrome, obesity, HTN, smoking, renal failure, hyperlipidemia, males, oxidate stress, age
What is a severe aortic valve area indicating aortic stenosis?
<1 (this is a trend)
At what age does degenerative/calcific aortic stenosis occur?
60s-70s, RARE in <50
nodular calcification of all 3 flaps
At what age does congenital aortic stenosis present?
around 50, with bicuspid or unicuspid aortic valve
How do you know an aortic stenosis is from rheumatic fever?
History, 3 cusp valve, mild calcification, + fissured commissures
What does calcium do to the aortic valve and how does this present on an EKG?
obstructs ventricular flow –> increased afterload –> LVH!
this can ultimately lower CO and cause hypoperfusion :(
What does this murmur indicate:
systolic ejection murmur with a crescendo-decrescendo late peaking, low pitched, HARSH, heard over right sternal border and radiates to the carotid arteries?
aortic stenosis
How can you increase an aortic stenosis murmur?
sit forward, increase venous return, expiration
Are there extra heart sounds with aortic stenosis?
yes
What’s the gold standard for aortic stenosis Dx (actually for all valve disorders)?
TTE
What would you see on a CXR of aortic stenosis?
cardiomegaly, calcification, root dilation
What is another indicator of aortic stenosis (think phys)?
ejection fraction
What’s the only effective treatment for aortic stenosis?
aortic valve replacement
What’s your recommendation for type of prosthesis for <60 years for aortic stenosis?
mechanical prosthesis MUST BE PUT ON ANTICOAGULANTS
What’s your recommendation for type of prosthesis for >60 years for aortic stenosis?
porcine or bovine, last 10-15 years and avoid need for anticoagulation!
What are some symptoms that could indicate aortic insufficiency/regurg?
acute - sudden, severe SOB, fast HF, CP, aortic dissection
chronic - asymptomatic until exertional fatigue, paroxysmal nocturnal dyspnea and pulmonary edema, and sudden death
Is acute aortic insufficiency an emergency?
yes
What could acute aortic regurg be caused by?
aortic dissection or endocarditis
maybe trauma
In who is aortic regurg more prevalent?
african americans, men, and older
What else can cause aortic regurg?
congenital BICUSPID aortic valve, rheumatic fever, dilation of aortic root
What does this murmur indicate:
diastolic decrescendo murmur, high pitched blowing sound (loudest at left sternal border/Erb’s point)?
aortic regurgitation
how can you make aortic regurgitation louder?
leaning forward, expiration, increased venous return
What other murmur may you hear in aortic regurg?
austin-flint murmur
What else on aortic regurg PE could indicate the dx?
- bounding pulses
- WIDE pulse pressure
- Becker - visible pulsations of retinal arterioles
- Corrigan - “water-hammer” pulse
- Hill - popliteal s>40 brachial s
- Quincke - visible pulsations on fingernail bed w/ light compression
How do you treat aortic regurgitation?
aortic valve replacement, same as aortic stenosis
afterload management
What are common findings in mitral stenosis?
exertional dyspnea, hemoptysis, palpitations, thromboembolism, pulmonary HTN –> RHF with ascites, edema, hepatomegaly
When is the onset of mitral stenosis?
30s and 40s
What is the MCC of mitral stenosis?
rheumatic fever 20 years post episode
In who is mitral stenosis most common?
females
What else can mitral stenosis be caused by?
congenital issues, infective endocardidits, many other diseases…
What does this murmur describe:
low pitched mid-diastolic rumbling murmur after prominent/loud opening snap, at apex?
mitral stenosis
How do you make mitral stenosis louder?
left lateral decubitus, expiration, increased venous return
What on an EKG could indicate mitral stenosis?
atrial fibrillation, LAE, pulmonary HTN (RVH, RAD)
What valve area means severe mitral stenosis?
<1. Yup
What prophylaxis must be given in mitral stenosis for high risk patients?
endocarditis
What prophylaxis is essential for all patients to prevent mitral stenosis?
benzathine penicillin
If rhythm is normal sinus in mitral stenosis, tx =
diuretics, BBs, CCbs
If rhythm is afib in mitral stenosis, tx =
ventricular rate control w/ BBs, CCBs, digitalis + anticoagulations
If a patient has mitral stenosis and is unstable, tx =
direct current cardioversion
If there’s a fib, chances are you need
anticoagulation
What’s your INR target (MS)
2-3
IF there are signs of pulmonary HTN, intervention is needed!
Treatments for mitral stenosis =
1) percutaneous mitral balloon valvuloplasty
2) valve replacement surgery if 1st isn’t good or high PA pressure
In who is mitral regurg most seen?
women 15-30 years with familial history
What are some symptoms of mitral regurg?
acute - pulmonary edema, dyspnea, CP
chronic - fatigue, orthopnea, SOB, DOE
What are two ways to get mitral regurg?
primary like from MVP affecting valve, or secondary such as disease like CAD
acute - no LA/LV enlargement
chronic - enlargement
What’s the most common form of valvular disease and isolated MR in north america?
MVP
What murmur is this:
mid or late systolic “click” with high pitched mid-late systolic crescendo-decrescendo “whooping” or “honking” at apex?
MVP
How do you increase MVP murmur?
decrease venous return like standing up
Whats this murmur:
high pitched blowing apical pansystolic murmur at apex that radiates to axilla?
mitral regurg
How do you increase mitral regurg murmur?
LLD, increased venous return
With advanced mitral regurg, what could you see on PE?
RV failure with ascites, hepatomegaly, DOE
What could you see on a mitral regurg EKG?
LAE, LVH, a fib (Chronic)
mitral stenosis was RVH!
If atrial fibrillation with mitral regurg, tx =
anticoag therapy w/ INR goal 2-3
How do you treat mitral regurg first line?
treat HF, HTN, and reduce afterload with diuretics, BBs, ACE-Is, digitalis
IF a patient has acute ischemic mitral regurg AND endocarditis, tx =
surgery
If a patient has chronic nonischemic severe MR, surgery is recommended if =
symptomatic from CHF
new onset AF
pulmonary HTN
EF<60%
replace valve! mitral clip! TAVI
What valve disorder is often masked by mitral stenosis symptoms such as like pulmonary congestion and fatigue with severe displaying hepatomegaly, ascites, edema, and potentially cirrhosis?
tricuspid stenosis
What murmur is only seen with mitral stenosis and is rarely seen alone if at all that is from carcinoids or prosthetic failure in developed or rheumatic fever in developing countries?
tricuspid stenosis
What murmur is a mid-diastolic rumble w/ presystolic accentuation best heard along left sternal border + over xiphoid process?
tricuspid stenosis
What increases a tricuspid stenosis murmur?
inspiration, increased venous return
What do these diagnostics indicate:
- RAE
- prominence of RA + SVC on CXR w/o enlargement
- echo = valve is thickened + domes in diastole, area<1, RA + IVC are enlarged
tricuspid stenosis
How do you treat tricuspid stenosis?
diuretics to relieve fluid congestion
What could tricuspid regurgitation present as?
fatigue, DOE, cervical pulsations, abdominal fullness, diminished appetite, muscle wasting
What could cause tricuspid regurgitation?
secondary to dilation of annulus from RVE due to pulmonary artery HTN - NOT primary ==
-pacemaker lead placement
-late stages of rheumatic fever or CAd
-cardiomyopathies
-infarction of papillary muscles
-TVP
-carcinoid heart disease
-infective endocarditis
-leaflet trauma
What does this PE indicate:
- right sided HF, distended neck veins, marked hepatomegaly, ascites, pleural effusion, edema?
tricuspid regurgitation
What murmur is: blowing high pitched holosystolic murmur along left sternal margin?
tricuspid regurgitation
What increases a tricuspid regurg murmur?
inspiration – Carvallo’s sign (which can distinguish from mitral regurg!), increased venous return
What do these diagnostics indicate:
EKG - atrial fibrillation
CXR- RA+RV enlargement, pleural effusion
echo - RA dilation, RV volume overload w/ abnormal interventricular wall movement + prolapsed leaflet
tricuspid regurgitation
What’s the treatment for tricuspid regurgitation?
diuretics for RHF + treatment of pulmonary HTN
What are the indications for treatment for tricuspid regurgitation?
-triscupid regurg
1) clinical decision (improvement)
2) moderate to severe TR or any structural TR
3) RV volume overload
4) RHF
5) repair vs replacement
endocarditis
1) severe TR
2) persistent sepsis
3) recurrent PE
4) excision vs replacement vs repair
In who is pulmonary stenosis most common?
pediatric patients, with female>male
How does pulmonary stenosis present?
> 1 year = murmur only
2nd, 3rd, 4th decade of life = CRHF, DOE
How do you cause pulmonary stenosis?
congenital the majority of the time OR acquired from endocarditis or rheumatic fever, secondary to previous procedures
“teratology of Fallot”
What is this murmur: loud, harsh systolic murmur w/ ejection click radiating towards left shoulder?
pulmonary stenosis
Does pulmonary stenosis decrease or increase with inspiration?
Rinspiration
What diagnostics do these indicate -
EKG - RVH, RAE, RAD?
pulmonary stenosis
How do you treat pulmonary stenosis?
must always monitor!!
diuretics for symptoms + signs of CHF
percutaneous balloon valvuloplasty = initial intervention w/ congenital valvar PS
What dominates pulmonic regurgitation and its symptoms?
pulmonary artery HTN – right heart volume overload + RHF symptoms – hepatic congestion (fullness + bloating), ascites, JVD, edema
What causes pulmonic regurgitation?
secondary due to pulmonary HTN and issues from left heart or congenital
What is this murmur: high pitched, decrescendo diastolic blowing murmur along left sternal border “Graham steel”
pulmonic regurgitation
What increases the pulmonic regurg murmur?
inspiration, increased venous return
How do you treat pulmonic regurg?
focus on underlying cause – reduce PA vascular resistance + pulmonary HTN
SAD is for
aortic stenosis
syncope
angina
dyspnea
Low CO, perfusion
“Pulsus tardus”
aortic stenosis
Low CO -> low BP
Increased backflow = increased preload → increased SV → high BP and WIDE pulse pressure
aortic regurg
