Valves Flashcards
Splitting of S2
Physiological
Parodoxical
during inspiration, A2 before P2, increased venous return delays P2, decreased return to the L quickens A2
during expiration, delayed closure of the aortic valve (AS, HOCM, LBBB)
Persistent S2 splitting
splitting throughout the respiratory cycle, increased during inspiration
early A2 or delayed P2 (severe MR/VSD or RBBB, pulm htn, pulmonic stenosis)
Fixed S2 splitting
always split, not increased in inspiration
delayed P2 only (increased flow across valve)- ASD
mitral stenosis in American elderly
senile calcific MS
calcification of mitral annulus and leaflets-> narrow annulus, rigid leaflets, no commissural fusion
no role for percutaneous mitral balloon or surgical commissurotomy
delay intervention until symptoms are severely limiting
treat with diuresis and HR control
causes of MS
rheumatic heart disease
senile calcific MS
congenital disease (parachute mitral valve, mitral chordae attached to a single or dominant papillary muscle-> a component of the Shone complex: supramitral rings, valvular or subvalvular AS, and aortic coarctation)
tumors, obstruction
treatment of acute severe MR
surgery
temporize with diuresis and afterload reduction (vasodilator->nitroprusside, ACEI/ARB/ARNI/nifedipine, IABP)
Do not use vasoconstrictors
prominent v waves
TR
brief, high-pitched sound after S2 followed by a low-pitched rumble, best heard at the apex at held expiration.
opening snap with MS
Percutaneous balloon mitral commissurotomy vs surgical
preferred as long as the valve is mobile, relatively thin, and free of calcium and there is no left atrial clot or more than mild mitral regurgitation (MR)
TEE before to eval MR and r/o clot
surgery if perc is CI+ low-intermediate risk for surgery+ severe MS
exercise testing with doppler or invasive hemodynamics in MS when
discrepancy between resting Doppler echocardiographic findings and clinical symptoms or signs.
Percutaneous mitral balloon commissurotomy indicated in
symptomatic severe MS or asymptomatic with pulmonary hypertension, moderate or severe stenosis and favorable valve morphology in the absence of left atrial thrombus or moderate to severe mitral regurgitation.
meds are preferred if preggo
high gradient+ small EOA
functional-> patient prosthesis mismatch
pathologic (thrombus/pannus)
prosthetic valve obstruction
indexed EOA <0.65, acceleration time < 100ms, DVI>0.25
acceleration time > 100 ms
flushing, diarrhea, hypervolemia, elevated 5-HIAA
carcinoid heart
carcinoid
TR, hepatic vein flow reversal if severe TR
Causes of primary TR
Ebstein’s (apical displacement of leaflets >8 in comparison to mitral leaflets)
endocarditis
implanted devices (eccentric, restricted septal leaflet)
carcinoid (thickened leaflets)
radiation
rheumatic heart disease
Systolic notching of the pulmonic valve
pulm htn
Pulmonary vein flow reversal
severe MR
severe MS
MVA <1.5, T1/2> 150ms
warfarin preg
if <5 mg, can continue
switch to UFH for delivery
if >5, discontinue in first trimester for any heparin
medical mgmt of MS
diuretic, beta blocker
apex is HYPERDYNAMIC, grade 2/6 systolic murmur and grade 2/4 diastolic murmur along the left sternal border
m-mode
AR
fluttering of anterior mitral leaflet, early closure of mitral valve due to increased LV pressure in diastole
chronic vs acute AR
wide pulse pressure
treatment of severe AR
surgery
DO NOT USE IABP OR BETA BLOCKERS (tachycardia is appropriate) OR phenylephrine (increases afterload)
valve choice in bleeders
bioprosthetic (reasonable in 50-70 yo) over mechanical
consider bioprosthetic in anyone at increased risk of bleeding even just from high risk activities such as motorcycling
early surgery in IE indications
heart failure, perivalvular extension, and embolic events
repair preferred
AS treatment
replace if severe and symptomatic / asymptomatic+severe+reduced EF/
very severe but asymptomatic/
rapid progression/
at time of other cardiac surgery
early systolic click+ crescendo-decrescendo systolic murmur + decrescendo diastolic murmur
bicuspid aortic valve with AR
high pitched sound after S1
pulmonary ejection sound
ejection click due to dilated aorta or pulmonary artery or bicuspid or flexible stenotic aortic or pulmonary valve
decreases with inspiration
AS vs MR
HCM murmur
handgrip (increases afterload): decreases vs increases
valsalva/abrupt standing (decreases VR): increases due to decreased size of LVOT and increased gradient
squatting (increases VR)
Periop bridging for patients with mechanical valve if
atrial fibrillation, mitral valve position, previous thromboembolism, hypercoagulable condition, older-generation mechanical valves [ball-cage or tilting disc], left ventricular systolic dysfunction, or >1 mechanical valve
don’t even hold if low bleeding risk- cataract surgery
severe AR
replace
vena contracta > 0.6/ holodiastolic aortic flow reversal/ RVol> 60/ RF>50%/ ERO> 0.3
severe symptomatic AR or (asympt + EF <50%/ LVS diameter > 50mm/ diastolic > 65)
TEE in IE
change in clinical signs or symptoms (e.g., new murmur, embolism, persistent fever, heart failure [HF], abscess, or atrioventricular heart block) and in patients at a high risk of complications (e.g., extensive infected tissue/large vegetation on initial echocardiogram or staphylococcal, enterococcal, fungal infections).
Abnormal conduction in aortic valve IE
valve ring between the right and noncoronary cusp; this anatomic site overlies the intraventricular septum that contains the proximal ventricular conduction system.
Mechanical mitral valve antithrombotic
bioprosthetic valve
aspirin (CI if active bleeding/intolerant) + warfarin (INR 2.5-3.5), higher if thrombotic event on AC
any mechanical valve= aspirin+ warfarin
low dose aspirin, can add warfarin in 90 days after TAVR and 180 days after surgery if not at increased risk for bleeding, can do plavix+asa for 6 months after TAVR if unable to AC
Antibiotic prophylaxis for endocarditis prior to dental procedures that involve manipulation of the gingival tissues, the periapical region of the teeth, or perforation of oral mucosa indications
prosthetic material
prior history of infective endocarditis
cardiac transplant recipients with valvulopathy, completely repaired congenital heart disease (CHD) in the previous 6 months
repaired CHD with residual shunts or defects unrepaired cyanotic CHD
Meds for IE prophylaxis
can’t take PO
allergic to -cillins
amoxicillin
cefazolin/ ampicillin/ ceftriaxone
cephalexin/ clinda/ azithro
LFLG AS
management
due to reduced EF or low stroke volume with preserved EF
AVR if there is contractile reserve-> find out and confirm AS on dobutamine stress
Measure of MR severity in late systolic, asymptomatic MR
Holosystolic MR
Regurgitant volume (discrepancy between EROA and Rvol) other measures such as PISA, vena contracta, jet area
worsening AS murmur
the ejection sound and the intensity of A2 diminish; the murmur peaks later in systole. The AS murmur increases after a premature ventricular contraction.
AS= single S2 due to delayed closure of aortic valve, louder after PVC/brady/pause
Dilated aortic root or ascending aorta
Evaluate for AR or bicuspid valve with TTE
Cath if large enough to warrant repair (>5.5)
STS score for TAVR
> 8%
Gallavardin phenomenon
vs MR
AS, a harsh murmur at the base with a musical murmur at the apex
vs holosystolic
Increased pulmonary artery (PA) oxygen saturation
due to L-R shunt like VSD
secondary MR
treatment
due to adverse LV remodeling
improve ventricular function and volume status (DO NOT REPLACE/REPAIR.)
rheumatic heart disease secondary prevention abx
residual valvular disease
no residual disease
fever without carditis
oral penicillin V twice daily, monthly benzathine penicillin G intramuscular injection, or daily sulfadiazine
penicillin prophylaxis for 10 years from the last episode of acute rheumatic fever or until the age of 40
10 years or age 21 (whichever is longer)
5 years or age 21
severe asymptomatic surveillance
6 months to 1 year if velocity is >4
1-2 years if velocity is 3.0-3.9 m/sec
3-5 years if velocity is 2.0-2.9 m/sec
severe asymptomatic AS surveillance
6 months to 1 year if velocity is >4
1-2 years if velocity is 3.0-3.9 m/sec
3-5 years if velocity is 2.0-2.9 m/sec
single S2
pulmonic stenosis, severe aortic stenosis, congenital absence of the pulmonic valve, transposition of the great arteries, or pulmonary htn
Types of MR
I: normal leaflet motion (primary)
II: excessive leaflet motion (flail, prolapse, primary)
IIIa: restricted leaflet motion (MAC/ rheumatic disease, primary)
IIIb: restricted due to LV dysfunction (secondary, lateral wall hypokinesis, tethered pap muscle)
Post valve implant care
TTE 6 weeks-3 months after
then annual exam
in bioprosthetics, routine TTE starting at 10 years (no routine TTE for mechanical)
BAV and an ascending aortic aneurysm >4.5 cm surveillance
annual imaging
also if increase >0.5cm/year or family history of aortic dissection
HTN in chronic AR treatment
dihydropyridine calcium channel blockers or ACEI/ARB
inferior wall MI pap muscle rupture
posteromedial
asymptomatic primary severe MR + (LVEF of 30-60% or LVESD of 40 mm)
repair
new HF+ h/o valve replacement
evaluate for valve dysfunction
BAV+ aortopathy surgery
> 5.5 cm, >0.5 cm/year, or family history of dissection
asymptomatic severe AS
normally wouldn’t intervene BUT exercise test if not highly active. Intervene if SBP does not rise by 20 or symptoms develop
