Valvular Disease Flashcards
location of the valves from
anterior
posterior
& number of cusps
quick anatomy
pulmonic valve: most anterior (three leaflets)
tricuspid valve: most to the right (three leaflets)
mitral valve: most to the left (two leaflets)
aortic valve: in the middle (three leaflets)
each valve has a “skeleton” a annulus in which it sits
- the valves are open and closed by chordae tendineae, attached posteriorly to papillare muscles which all the “parachute” effect when then open because on increased pressure
Aortic Stenosis
- aortic valve anatomy
- etiology
- pathology
aortic valve: trileafet valve which right above the valves are the cornary osstum – feeding into the cornary vessels
Etiology
- congential: born with a Bicuspid valve (or unicuspid)
- acquired: chronic accumulation of calcification the most common cause of aortic stenosis
- acquired: rhumatic disease (in developing worlds)
- acquired: fabry disease (connective tissue disorder)
- survival is great when asymptomatic– but once symptoms arise –> survival becomes POOR
Pathology
- increased afterload: the calcification of the valve makes it HARDER to push the blood out and over the valve
- leads to left ventricular outflow tract obstruction
- leads to more blood leftover after you pump: increased end diastolic pressure
- leads to an increase in myocardial oxygen consumption (takes more O2 to work for the cells since theres so much pressure against them)
- distension and ischemia of the ventricle because it acn never relax— HEART FAILURE
Aortic Stenosis
- clinical signs
- diagnosis
- treatment
Clinical Signs
- asymptomatic period 10-20 years
- age 50-70 symptoms appear if congenital, 70+ if calcified
- SAD: Syncope, angina, dyspnea
- heart failure: orthopnea, pulmonary edema
- non cardiac: GI bleeding and cerebreal emboli
mid-systolic ejection murmur in right second intercostal space – radiates to neck
- caroitid upstroke: puluse parvus et tardus (late, faint carotid pulse)
- edema and fuid overload
- murmur so strong it radiates to apex
Diagnosis
- gold standard: TEE TTE if non symptoms
- aortic valve repair is needed
Asymptomatic pts. get surgery if…
- EF < 50%
- already getting surgery
- abnormal exercise test
- velocit peak > 5m/sec with preussre > 60
- annual progression of peak velocity growing .3/year
Aortic Insufficiency (regurg)
- etiology
- pathology
congenital
-turners, marfans, EDS
bicuspid or uni valve
acquired:
-strucutral (problem wiht leafelets or the root of the aorta) dilated root of aorta can cause improper closing of the valve
- rheumatic (underdeveloped) or autoimmune,
- infection,
- aortic dissection (tear so close it hurts valve)
Pathology (acute and chronic)
Acute
- backflow into the left ventricle quickly causes a SHARP increase in end-diastolic volume –> increase atrial pressure and thenrefore increases pulmonary pressure –> ARDS
- essentially: this happens so quick that the LV doesnt have time to adjust– so it all backflows
Chronic
- remodeling of the ventricle due to hypertrophy of myocytes –> initially the cells can dialte and accomidate then increase in backflow
- but after some time, they can’t compensate with the stress; so they become fiberotic and theres a decrease in LV compliance
Causes
Acute
- infective endocarditis
- aortic dissection
- prosthetic valve dysfunction
Chronic
- rhumatic fever (developing worlds)
- congenital abnormalities
- age related dialtion of the aorta – think HTN
Aortic Insufficiency
- clinical signs
- Diagnosis
- treatment
acute clinical signs
- dyspnea, cough, palpationas DOE
- rapid onset cardiogenic shock
chronic clinical signs
- orthopena, palpations, syncope, chest pain (after somet time)
soft, high-pitched early diastolic decrescendo murmur at 3rd left intercostal space @ end expiration
- murmur accenuated by increased afterload (increase pressure, more force against resistance)
austin flint murmur: the regurg causes premature closing of the mitral valve– rumbling presystolic
- widened pulse pressure
- pulsus bisferiens: biphasic pulse with two peaks in systole
- waterhammers pulse: bouding peripheral pulses
Diagnosis
- TEE gold standard
Treatment
- surgery if symptomatic
- not if EF < 35% (too sick)
Mitral Stenosis
- etiology
- patho
- clincial signs
- diagnosis
- treatment
Etiology
- most common cause: rhumatic fever calcification of the leaflets
- can be infective endocarditis, rhumatoloigc disorder, maligant carcinoid syndrome
Pathology
- stenosis causes an increase in atrial pressure becaus its not all flowing through into ventricle –> therefore a decrease in left ventricle end diastolic volume
- leads to atrial hypertrophy & afib
- loss of atrial kick
Clinical Signs
- happening 20 years after rhumatic fever
- mid-diastolic rumbling murmur best hear at apex in left-lateral position
- hear an opening snap because the mitral valve is forcing open again due to increased pressure in atrium
- pt. presents with RIGHT sided herat fialure: side the pressure increase in the atrium –> backs up to lungs
- JVP, hepatomegaly, pulm HTN
- a fib. possible too
diagnosis
- TEE is gold standard
treatment
- mitral valve replacement surgery
Mitral Regurgitation
- etiology
- pathology
backflow from LV to LA
Etiology
Primary
- degerative, congenital, infectious or rhumatic
- structural disease
- papillary muscle rupture, mitral valve prolaspe, leaflet perforation
Secondary
- functional or ischemic
- not a problem of the valves itsels – but due to ischemia or displacement of the papillary muscles
Patho
- flow from left ventricle to atrium
- leads to increase left ventricle volume (takes the amount that regurged back on the next pump)
- leads to remodeling of the ventricle, increasing ejection fraction
- volume overload so severe that the wall dialtes and decreased contractility as a result
Mitral Regurgitaion
- clinical signs
- diagnosis
- treament
Clinical
mitral valve regurg: holosystolic murmur at the cardiac apex
- decline in cardiac output: results can be cardiogenic shock
- cough with clear, pink frothy sputum
- dyspena at rest
- syncope, cyanosis, clubbing
Diagnosis
- TEE
Treatment
- surgery
- if valve damage due to chordal or papilarry muscle damage = MR surgery
- if damage ** due to ischemia or functional issue = CABG**
Mitral Valve Prolapse
- leading cause of mitral regurgitation
- early systolic murmur with a mid-systolic click
- EDS, marfans, etc. myxomatous degeneration; present in younger patients
- leads to mitral insufficency
heard louder/earlier click with standing/valsalva (decreased venous return)
heard quiter/later when squatting with increased venous return
Tricuspid Stenosis
- etiology
- patho
- clinical signs
- treatment
Etiology
Acquired
- most commonly rheumatic fever
- can also be due to drugs causing fiberosis and thickening of the leaflets
Congenital
- ebstein’s anomaly & other congeital disorder
Iatrogenic
- post ICD: after implanted device –> fibrosis and stensosis of the Tricuspid can occur
Patho
- stenosis of the tricuspid: leads to less blood flowign through into the RV –> increased pressure in the RA and reight sided congestion of the heart accompanies
- therefore –> failure to adjust to increased pressure –> poor flow to the lungs –> decreased cardiac output
- can lead to right sided hear failure & signs and symptoms
Clinical Signs
- mid-diastolic rumble murmur at 4th intercostal space – can have a preceeding opening snap
- will be softer than mitral stenosis
- valsalva manuvers will increase its intensity
Treatment
- valve surgery
Tricuspid Regurgitation
- etiology
- pathology
- clinical signs
- treatment
Etiology
- two etiology: priamry and secondary
- most commonly: secondary (aka strucutral) causes are the reason for tricuspid regurg.
- specifically: left sided heart issues valves, cardiomypathies, pulm. HTN) – left-sided valve disease causes right sided valve disease!!!
Patho
- increased right atrial pressure due to backflow of the blood causes right atrial congestion & right heart congestion
- results in an increased gradient between atria and ventricle during diastole
Clinical Signs : sounds just like a mitral regurg– but different location
blowing, holosystolic murmur best heard at the left sternal boarder– radiates to the right boarder
(mitral will be best heard at the apex)
- pt. will have signs of right ventricualr dilation and dysfunction
Treatment
- surgery: if theyre going for left-sided valve surgery– do the right side too
- surgeyr: if they ahve evidence of right sided HF
Pulmonic Stenosis
- etiology
- patho
- clincail signs
- treatment
etiology
- typically benign problems
- a result commonly due to congential disorders: (Tetralogy of Fallot)
Patho
- remodeling of the pulmonary valve –> remodels the right ventricle
- results in right ventricular dysfunction and heart failure & backing up to the portal system!
- decreased oxygenation to since less is getting out to the lungs to get O2
Clinical
- upper left sternal boarder: systolic ejection murmur that radiates to the back!!! hear a split S2 too
- most pts. are asymptomatic
- symptoms: DOE, fatigue and RHF
Treatment
-TEE
- surgery to fix
Pulmonic Insufficiency
- etiology
- patho
- clincial
- treatment
etiology
Valvular disease: congential, endocarditis, drugs & Post-Ross proceudre: replaced with a prostetic valve
Annular enlargement: the structure of the valve it too big: think Marfans, pulmonary HTN
Patho
- normally, the pressure in the RV gets high during systole –> forcing the blood to push through the pulmonic valvaes into the lungs
- but due to the above issues –> there is backflow of the blood (because the pressure is too high in teh artery (HTN) and thus not all the blood makes it out, and it comes back to the ventricle
- leads to ventrcualre remodeling, dilattion and reduced compliance
Clincial
- decrescendo early diastolic murmur because you hear the blood rushing back after its forced through the valve in systole
- sigsn of RHF: cyanosis, JVP, palpations, swelling, DOE
Treatment (TEE)
- treatment of the underlying cause is better than surgery
- surgery: if they have reduced function, elevated pressure or inability to exercsie
