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CV II Exam 3 > Valvular disease > Flashcards

Valvular disease Flashcards

1
Q

history of rheumatic heart disease. She presents with fever, fatigue and neck throbbing. She complains of abdominal fullness. Examination shows peripheral edema and ascites. Tricuspid regurg with tricuspid stenosis. Both murmurs are increased with inspiration. A split first heart sound is present.
This patient would also be expected to exhibit which abnormality in the jugular venous tracing?

A

Giant A wave and blunted Y wave

Hard to fill ventricle and atria, atria contracts very hard building up extra pressure

**Tricuspid stenosis is prominent problem

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2
Q

What also causes cannon A wave

A

Complete heart block

Ventricle won’t relax and hard to fill

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3
Q

Tricuspid regurgitation murmur

A

Systolic blowing murmur at the lower left sternal border

Increases with inspiration

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4
Q

Tricuspid stenosis

A

Diastolic rumble

Increases with inspiration

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5
Q

What valve gradient is considered significant?

A

Gradient >5 mmHg

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6
Q

Most common cause of tricuspid regurgitation and stenosis?

A

Carcinoid

Rarely rheumatic

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7
Q

Increased murmur intensity with inspiration

A

Carvallo sign
Seen with right sided murmurs
Applies to tricuspid and pulmonic valve only

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8
Q

Where does carcinoid tend to distribute?

A 
*Tricuspid valve
Pulmonary valve
Septum
Right ventricle
Pulmonary artery
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9
Q

Treatment for tricuspid stenosis

A

Diuretics - torsemide and spironolactone for ascites

Balloon valvotomy, open commissurotomy, or bioprosthetic valve

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10
Q

Why torsemide for tri stenosis?

A

Symptom of edema inhibits absorption - torsemide is better absorbed in gut

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11
Q

Why bioprosthetic valve?

A

Mechanical valves tend to clot with low flow velocity

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12
Q

A 55 y/o female with history of a prior right ventricular MI presents with fatigue and abdominal fullness. Examination shows peripheral edema and ascites. There is a 3/6 systolic blowing murmur at the lower left sternal border with an audible S3. The murmur is increased with inspiration.

A

Tricuspid regurgitation

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13
Q

Tricuspid regurgitation jugular venous tracing

A

Prominent cV wave

Atria doesn’t ever fully empty and fills up while ventricle is contracting

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14
Q

Cause of tricuspid regurgitation

A

Any RV dilation - pulmonary hypertension, pulmonic regurgitation, or LV failure where PA or RV systolic pressure is above 40 mmHG
Rarely an inherent valvular problem - Ebstein’s anomaly, pacemaker catheter injury, endocarditis, MI, sarcoid, RV dysplasia, or even fenfluramine/phenteramine (“FenPhen”) which causes low pressure TR

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15
Q

Tricuspid regurgitation treatment

A

Treat the primary issue - LV failure or pulmonary hypertension.
If a true valvular defect replace valve

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16
Q

A 55 y/o male with COPD and pulmonary hypertension presents with a split P2 and a diastolic 2/6 murmur at the left 2nd intercostal space that increases with a deep breath.

A

Pulmonic regurgitation

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17
Q

Pulmonic regurgitation murmur

A

Graham steell murmur

Can be from pulmonary HTN or secondary to mitral stenosis

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18
Q

High pressure pulmonic insufficiency

A

Prolonged RV systole with split S2 - pulmonary hypertension or from mitral stenosis

COPD (lung problem,) left heart problem

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19
Q

Low pressure pulmonic insufficiency

A

Very little murmur

Trauma with a dilated pulmonary annulus, carcinoid plaque, bicuspid valve, repaired tetralogy

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20
Q

High pressure PI treatment

A

Treat pulmonary HTN

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21
Q

Low pressure PI treament

A

Watchful expectancy

Treat the primary cause

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22
Q

Exertional dyspnea, orthopnea and paroxysmal nocturnal dyspnea. Auscultation with the patient in the left lateral decubitus position reveals a loud M1 and an early diastolic sound at the mitral area. Hockey stick effect seen on Echo. Straight edge of heart on xray.

A

Mitral stenosis

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23
Q

Hockey stick effect

A

Doming of anterior mitral valve leaflet during diastole

Thickening of leaflet

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24
Q

Straight edge of heart

A

LA enlargement

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25
Q

Heart sounds of mitral stenosis

A

Loud M1
Opening snap - earlier after S2 with worsening LA pressure.
Rumbling diastolic murmur
Presystolic accentuation of diastolic rumble

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26
Q

What heart sounds change with calcification in mitral stenosis?

A

Loud M1

Opening snap

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27
Q

What are the two syndromes associated with this disease and how do they present clinically?

A

Mild to moderate (valve surface area of 1.5 cm2) with early pulmonary edema

Severe (< 1 cm2 ) with pulmonary HTN (secondary pulmonary vasculature stenosis) and right sided CHF, AF and low CO

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28
Q

What is a Graham Steell murmur?

A

Murmur at left sternal border from relative PI

Can be secondary to mitral stenosis (back up pressure)

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29
Q

Typical EKG findings with mitral stenosis

A

Neg P wave in V1

RAD

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30
Q

How does atrial contraction effect mitral stenosis murmur

A

Accentuates murmur

No atrial contraction -> no accentuation of murmur

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31
Q

Treatment of mitral stenosis

A

Based on ECHO evaluation with a scoring system which grades various mitral parameters to decide time for intervention with mitral valvuloplasty

Score of 8 or less try valvuloplasty
> 8-10 needs mechanical (INR 2.5 - 3.0) or bioprosthetic valve (last 10-15 years)

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32
Q

Why do you use mechanical valve in young patient

A

They last much longer

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33
Q

A 55 y/o male with long standing mitral regurgitation presents with new onset palpitations, orthopnea and PND. There is a high pitched pan systolic murmur with an S3 at the apex. The patient is on a beta blocker and an ACE inhibitor.

A

Mitral regurgitation

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34
Q

What heart sound is a marker for severe mitral regurgitation

A

S3

Pan-systolic murmur also present

35
Q

What do you see with echo/xray/EKG with mitral regurgitation?

A

Straightening of heart edge –> LV also enlarged
LA and LV enlargement seen on EKG
See blood leaking on Echo

36
Q

What structural change can lead to mitral regurgitation?

A

Defective papillary muscles (dilated cardiomyopathy, MI)
Chordae (too long, too short or ruptured as in MVP, Marfan)
Leaflets (redundant, perforation in endocarditis)
Annulus (calcified or cardiomyopathy)

37
Q

What happens to fluid dynamics with mitral regurgitation?

A

Increased preload and decreased afterload
Increased preload = enlarged LV = increased EF
Eventually the LV fails and EF drops with increased end systolic volume

38
Q

What lab test reveals CHF?

A

Increased BNP

Indicates LV dysfunction

39
Q

What is the effect of handgrip and squatting on mitral regurgitation murmur?

A

Increase intensity

40
Q

What causes decreased intensity of mitral regurgitation murmur?

A

Amyl nitrate and valsalva

41
Q

What EKG changes are seen with mitral regurgitation?

A

LVH, LAH, or AF

42
Q

Acute mitral regurgitation

A

High LA pressure -> pulmonary edema

IHD with papillary muscle dysfunction, MVP with ruptured chordae, or infective endocarditis with valve perforation = pulmonary edema, tall cV wave in LA and low CO

43
Q

Chronic mitral regurgitation

A

Dilated LA with normal pressure

LA and LV enlargement as seen on chest Xray

44
Q

Increased LA pressure reads as

A

Increased wedge pressure

45
Q

Initial treatment of MR?

A

Afterload reduction - beta blocker

46
Q

When to suggest surgery for MR

A

EF < 60%

End systolic dimension > 40 mm

47
Q

Asymptomatic patient with severe MR

A

ERO > 40 mm2

May show as exercise inducible pulmonary hypertension on ECHO

48
Q

Repair vs replacement for MR

A

Better to replace if no calcification, ERO < 40, and chordae can be maintained

49
Q

An anxious 32 y/o female presents with complaints of chest pain and palpitations. Exam reveals a mid systolic click with a late systolic murmur which shortens with lying down, handgrip and squatting. The patient has joint laxity and skin changes as shown.

A

Mitral valve prolapse

Classic presentation

50
Q

Mitral valve prolapse on echo

A

Dilated LA and LV in diastole

Valve moving out in opposite direction

51
Q

What maneuvers increase mitral prolapse murmur?

A

Standing, valsalva and amyl nitrate

52
Q

What maneuvers decrease mitral prolapse murmur?

A

Squatting

53
Q

How does squatting change afterload and venous return?

A

Increase afterload and venous return

54
Q

How does increased blood in heart effect mitral prolapse?

A

Increase blood in ventricle allows approximation of the leaflets and reduces murmur

55
Q

Mitral valve prolapse

A

Associated with aortic root disease
Maybe part of a hyperadrenergic syndrome in young females
Myxomatous degeneration of the mitral valve – Marfans, Ehlers Danlos syndrome (associated with aortic regurgitation)

56
Q

Mitral prolapse heart sounds

A

Mid-systolic clicks with late systolic murmurs which worsen with a smaller ventricle

57
Q

Mitral prolapse and arrhythmias

A

Both atrial and ventricular

58
Q

Mitral prolapse treatment

A

Beta blockers
Mitral valve repair
Mitral replacement

59
Q

A 45 y/o male presents with syncope. History is positive for a “murmur” since childhood. He reports recent onset of PND and exertional dyspnea and chest pain. There is an ejection sound with a diamond shaped harsh systolic murmur at the base and a high pitched systolic murmur at the apex. The former murmur increases after an ectopic beat and decreases with squatting.

A

Aortic stenosis

60
Q

Gallaverdin phenomenon

A

Sound of aortic stenosis refers to the apex

61
Q

What type of aortic problem is present with aortic stenosis?

A

Biscuspid valve or degenerative problem (calcific - atherosclerosis)

62
Q

Syncope and aortic stenosis

A

Peripheral vasodilation from high ventricular pressures stimulating baroreceptors in the LV -> reduced afterload calls for increased stroke volume which can’t occur due to the aortic stenosis -> BP falls and the patient faints

Aorta dilates, patient can’t fill it, they pass out

63
Q

What is a patient’s pulse like with aortic stenosis?

A

Carotid palpitation reveals a “parvus et tardus”

Pulse is weak, small, and late

64
Q

EKG with aortic stenosis

A

LVH and LAH

65
Q

How is the pressure gradient across the aortic valve measured in this patient?

A

Peak doppler gradient = measurement of the flow velocity through the valve orifice squared x 4. Thus a 4 m/s flow = 64 mm Hg peak gradient. (42 x 4).
LV failure, angina or syncope occur when the peak valvular gradient reaches 64 mmHg (mean gradient of 40 mmHg).

66
Q

What is the critical valve area?

A

Valve area < 1 cm2

67
Q

What are the dangers in heart catheterization and the treatment of AS?

A

Crossing the aortic valve at heart cath for CAD can induce cardiogenic shock, pulmonary edema, stroke or death. Nitrates are also dangerous.

68
Q

Critical aortic stenosis

A

Mean gradient > 50 mmHg, valve area < 0.75 cm2, severe calcification density, pulmonary hypertension > 50 mmHg, and elevated C-terminal BNP

69
Q

How is it possible for a patient with severe aortic stenosis to present with a valve gradient of < 30 mmHg?

A

This is called low gradient, low flow aortic stenosis with reduced EF (there is a paradoxical normal EF). The patient either has failure as a result of the increased afterload or another cardiac contractility problem as from ischemic heart disease, MI, fibrosis or some other cardiomyopathy.

70
Q

How to diagnose low gradient, low flow aortic stenosis with reduced EF

A

Diagnose with a dobutamine ECHO: < 20% increase in SV = no muscle reserve

71
Q

Poor prognosis for aortic stenosis

A

Poor LV function

BNP greater than 550 regardless of dobutamine result

72
Q

Bicuspid aortic valve is prone to

A

Stenosis, regurgitation or both

Also associated with dilation and coarctation

73
Q

Treatment for aortic stenosis

Depends on age

A

Often needs CABG as well.

Young: percutaneous valvuloplasty.
Elderly: bovine valve.
Middle age : mechanical plus anticoagulation (INR 2.0-2.5).
May need aortic root replacement, especially with bicuspid valve, and aortic root diameter > 50 mm.

Trancutaneous Aortic Valve Replacement (TAVR) is in vogue for comorbid patients, but is associated with strokes.

74
Q

A 50 y/o male with history of a biscuspid aortic valve and hypertension presents with new onset PND (paroxysmal nocturnal dyspnea). Upon exam he has a 2/6 systolic murmur at the base with a 3/6 descrendo diastolic murmur at the base and a 1/6 late diastolic low pitched murmur at the apex.

A

Aortic insufficiency

75
Q

What will be the response of the basal diastolic murmur to squatting and handgrip with aortic insufficiency?

A

Increased

Decreased with standing or valsalva

76
Q

What is characteristic of the patient’s pulse with aortic insufficiency?

A

Large bounding pulses

Wide pulse pressure (140/50) with Corrigan’s and Quincke’s (nailbed) pulse, and De Musset’s sign

77
Q

What also causes large bounding pulses?

A

Atherosclerosis, AV fistula, thyrotoxicosis, anemia, fever, heart block

78
Q

Corrigan’s pulse

A

Large carotid pulse

79
Q

Quincke’s pulse

A

Blanching or reddening of nail bed with pressure

80
Q

De Musset’s sign

A

Nodding of head with heart beat

81
Q

The patient subsequently
becomes more dyspneic and orthopneic with increased basilar crackles.
Further evaluation reveals an absent M1 (see above) with a only a grade 1/6 diastolic murmur and disappearance of the wide pulse pressure.

A

Worsening of aortic insufficiency

82
Q

When would you do surgery for aortic insufficiency?

A

Symptoms of exertional dyspnea, orthopnea and PND
or
LV dysfunction with contractility failure (EF < 55%, end systolic LV dimension > 50 mm) (AR = 55/50)
or
BNP > 130 pg/mL = progression to surgery

83
Q

What other type of acute aortic insufficiency might present with an absent M1, Austin Flint murmur, 1/6 aortic diastolic murmur and acute CHF?

A

Aortic dissection (marfan’s, Ehlers Danlos), endocarditis, hypertension, inflammatory disease (syphilis, giant cell arteritis, Takayasu’s), seronegative spondyloarthropathies.

84
Q

Treatment of aortic insufficiency

A

Afterload reduction:
Beta blockade
ARBs - reduce aortic stiffness by blocking TGF beta
These are not to be used in the absence of hypertension

BNP evaluation as surgical indication
Root replacement with valve replacement

CV II Exam 3 (13 decks)

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