Valvular disease Flashcards
heart sounds: S1, S2, S3, S4
-S1: AV valves closure at the beginning of systole
-“lub”
-S2: semilunar valve closure at the end of ventricular systole and the beginning of diastole
-“dub”
-S3: Occurs at the beginning of diastole following the S2
-Lower in pitch
-Benign in youth
-New can indicate volume overload
-S4: Occurs after atrial contraction at the end of diastole before S1
-Blood being forced into a stiff ventricle
dx of valvular disease
-Transthoracic echocardiogram*: dx!
-Visualization of the valve measuring valve areas and gradients
-Main modality to diagnose valvular disease
-Transesophageal echocardiogram:
-Best modality to further assess severity mitral valve disease (endocarditis, severe path)
-Distinguish between moderate and severe
-Cardiac catheterization
-aortic valve
-make sure valve issue isnt from blood not getting to that wall
aortic stenosis
-Narrowing of the aortic valve opening increasing afterload
-Leads to LV failure
-LV hypertrophy
-finger over hose
-listen over right 2nd intercostal space
-Most common valvular disease in the US*
-Causes:
-Congenital defects- Bicuspid valve (only two flaps)
-Rheumatic heart disease
-Endocarditis- Most commonly bacterial
-Connective tissue disorder
-Degenerative disease
aortic stenosis signs and symptoms
Dyspnea*
Orthopnea
PND
Fatigue
Chest pain*
Dizziness
Pre-syncope
Syncope*
-Left sided heart failure:
-Rales
-Decreased breath sounds at bases
-Hypoxia
-Auscultation:
-Harsh cresendo-decrescendo systolic murmur**
-2nd Right intercostal space*
-Radiation to the carotids*
-lub pshhHHHHhhh dub
-Soft s2 or loss of s2
-Parvus et tardus: diminish carotid pulse
-Pericordial thrill- severe
aortic stenosis tx
-Medical therapy:
-HF tx: diuretics and vasodilators
-Caution with beta-blockers -> risk for overloaded LV as pts are preload dependent
-Surgical therapy:
-Aortic valve replacement -> For symptomatic pt with valve area that is 1.0 cm2 or less
-Open (SAVR) vs. Transcatheter (TAVR)*
-Bio-prosthetic vs. Mechanical:
-Mechanical valves require anticoagulation
-Coumadin only FDA approved anticoagulation
-INR 2.5-3.5
bio-prosthetic valves
-MC
-types:
-Bovine = cow
-Porcine = pigs
-Equine = horse
-TAVR is only bio-prosthetic valves
mechanical vales
-Types:
-Bileaflet,
-Ball cage valve
-Favored if patient is <50 years
-Requires life-long anticoagulation with Coumadin*
transcatheter aortic valve replacement (TAVR)
-Low to high-risk patients
-Approach
-Femoral: Most common
-Apical
-Subclavian
aortic regurgitation
-inadequate closure of the aortic leaflets leading to LV volume overload
-Also known as aortic insufficiency
-Inability to remain closed during diastole resulting in backward flow from aorta to the left ventricle
-Causes:
-Rheumatic fever
-Endocarditis
-Bicuspid aortic valve
-Marfan’s syndrome
-SLE
-Ehlers-Danlos Syndrome
-Aortic dissection or dilation
-Hypertension
-Syphilis
-Acute MI
aortic regurgitation symptoms and signs
-Dyspnea
-Orthopnea
-PND
-Palpitations
-Angina
-Dizziness
-Syncope
-Paroxysmal nocturnal dyspnea
-Left sided heart failure
-Auscultation:
-Diastolic decresendo murmur best heard at LLSB
-Murmur increases with hand gripping, sitting and leaning forward
-Corrigan’s pulse- Bounding pulse due to increased stroke volume
-Austin-flint murmur:
-low pitch rumbling murmur
-Heard at the apex- Severe AR
aortic regurgitation tx
-Medical management
-Heart failure management
-Afterload reduction
-ACE inhibitor (Ramipril, Lisinopril)
-ARB (Valsartan, Losartan)
-Surgical management
-Definitive treatment with aortic valve replacement
-For acute of symptomatic AR
-Asymptomatic AR with LV decompensation
mitral stenosis
-narrowing of the mitral valve affecting blood flow between the left atrium and ventricle
-Cause increase left atrial pressure and volume overload
-Most common cause is rheumatic heart disease*- streptococcal antigens lead to scaring & narrowing
-Causes:
-Infective endocarditis
-Congenital
-Systemic lupus
-Rheumatoid arthritis
-Amyloidosis
-Degenerative disease
-Left atrial myxoma
mitral stenosis signs and symptoms
-Dyspnea*
-Orthopnea
-Cough
-Palpitations
-Angina
-Dizziness
-Syncope
-Hemoptysis !!
-Left sided heart failure AND right sided heart failure
-Atrial fibrillation- warfarin
-Auscultation:
-Opening snap with low pitched DIASTOLIC murmur
-Best heard at apex in left lateral decubitus position
-lub dub pshhh
mitral stenosis: tx
-Medical management
-Heart failure management
-Anticoagulation in patient with atrial fibrillation -> Require warfarin
-Surgical management
-For symptomatic patients with severe mitral stenosis with a valve area of 1.0cm2 or less
-Surgical mitral valve replacement
-Transcatheter mitral valve replacement -> Approved for valve-in-valve procedures
acronym sounds
mr as- systolic
ms ar- diastolic
mitral regurgitation
-inadequate closure of the mitral leaflets causing retrograde flow from left ventricle into left atrium
-Causing left atrial dilation and increase pulmonary pressure
-MC cause in US is mitral valve prolapse -> MC in developing countries is rheumatic fever
-Causes:
-Endocarditis
-Papillary muscle dysfunction
-Chordae tendinae rupture
-Rheumatic fever
-Marfan’s syndrome
-Degenerative disease
mitral regurgitation: signs and symptoms
-Dyspnea
-Orthopnea
-PND
-Angina
-Dizziness
-Syncope
-Palpitations
-Left heart failure
-Auscultation:
-Blowing holosystolic (throughout whole systole) murmur
-Best heard at the apex
-Radiation to the axilla
-lub whoooosh dub
mitral regurgitation tx
-Medical management
-Heart failure management
-Afterload reduction with ACE/ARBs
-Surgical management
-Surgical mitral valve replacement vs. mitral valve repair
-Mitral valve repair preferred over replacement
-Benefits of repair:
-repair if you can
-Preserved LV function
-Lower risk of endocarditis
-Less thrombotic events
-Transcatheter MitralClip
-High risk patient
mitral valve prolapse
-misplacement of mitral leaflets into the left atrium
-MC cause of mitral regurgitation in US
-Causes:
-Degeneration of mitral valve
-Marfans syndrome, Ehlers-Danlos syndrome
-Rheumatic fever
-Papillary muscle rupture
mitral valve prolapse symptoms and signs
-Most are asymptomatic
-Palpitations *
-Chest pain
-Dyspnea
-Dizziness
-Syncope
-Fatigue
-Left sided heart failure- When significant mitral regurgitation with MVP
-Auscultation:
-Mid-systolic ejection click
-Best heard at the apex
tricuspid stenosis
-narrowing of the tricuspid valve causing volume overload of the right atrium -> Can lead to right sided HF
-Causes:
-Infective endocarditis
-Rheumatic fever
-Carcinoid syndrome
-Radiation therapy
-Congenital
-Ebstein anomaly
-Symptoms:
-Fatigue
-Abdominal distention
-Palpitations
-Signs:
-Right sided heart failure
-Mid-diastolic murmur at LLSB
-Increases with inspiration
tricuspid regurgitation
-inadequate closure of the tricuspid leaflets causing backflow of blood into the right atrium during systole
-causes:
-pulmonary HTN
-COPD
-rheumatic fever
-endocarditis
-IV drug use!!!*- staph
-PE
-congential
-PPM/ICD wires
-symptoms:
-fatigue
-weakness
-SOB
-palpitations
-signs:
-right sided HF
-diuertic therapy
-auscultations:
-holosystolic murmur
-best hear at left lower sternal border
-increases with inspiration
-radiated to the xiphoid
pulmonic stenosis
-narrowing of the pulmonic vale causing right ventricular obstruction
-decreased blood flow between right ventricle and pulmonary artery
-causes:
-almost always congenital
-tetraolgy (4) of fallot=cyanotic lesion
-1. overriding aorta
-2. ventricular septal defect
-3. right ventricular outflow obstruction
-4. right ventricular hypertrophy
-symptoms:
-fatigue
-dyspnea
-syncope
-chest pain
-signs:
-right sided HF
-auscultation:
-mid systolic murmur
-best heard at 2-3rd left intercostal space
-radiated to the left shoulder
-increases with inspiration
pulmonic regurgitation
-inadequate closure of the tricuspid leaflets causing backflow of blood into the right ventricle
-Causes:
-Congenital*
-Pulmonary hypertension*
-Endocarditis (not really)
-Rhematic fever (not really)
-Symptoms:
-Usually asymptotic until right sided heart failure
-Signs:
-Right sided heart failure
-Graham-Steel murmur: high pitched decrescendo early diastolic murmur at LUSB
-Murmur increases with inspiration
septal defects: atrial septal defect (ASD)
-Failed closure between the right and left atrium
-Most commonly asymptomatic until adulthood
-Auscultation: systolic ejection murmur at 2nd LICS*
septal defect: ventricular septal defect (VSD)
-Failed closure between the right and left ventricle
-Auscultation: systolic murmur at LLSB*
-Symptoms depend of size
-Asymptomatic to failure to thrive
septal defects: patent foramen ovale
-Failed closure of foramen ovale
-Can be asymptomatic
-Embolic CVA known as paradoxical embolism
murmurs chart
murmurs sound chart
dental prophylaxis
-Guidelines for dental prophylaxis against endocarditis:
-1. History of endocarditis
-2. Prosthetic cardiac valve repair
-3. Congenital heart disease:
-Unrepaired cyanotic disease
-Completely repaired congenital with prosthetic material in the first 6 months
-Repaired cyanotic heart disease with residual defect
-Antibiotics:
-First-line: Amoxicillin - 2 grams 30-60 min prior to procedure
-Allergic to penicillin:
-Cephlaxin 2 grams
-Clindamycin 600 mg
-Azithromycin 500 mg
reversal agents
-med -> reversal agent
-beta blocker -> glucagon
-heparin -> protamine
-coumadin (warfarin) -> vitamin K, FFP
-dabigatran (pradaxa) -> idarucizumab (pradabind) (dont need to know)
-digoxin -> digoxin immune Fab (digibind)
-apixaban (eliquis) -> andexanet alfa (andexxa) (dont need to know)
