Valvular Disease Flashcards
Stenotic valve
- Narrowed
- Not able to OPEN completely
- Blood has trouble moving forward
Regurgitant valve
- Fails to completely CLOSE
- Blood back flows
What is the MC indication for surgical valve replacement?
Aortic stenosis
What stage of VHD indicates symptomatic disease?
Stage D
What does aortic stenosis do to the heart and why?
- Myocardial hypertrophy in an effort to normalize wall stress
- From increased afterload
- LaPlace’s law
Define ischemia
Imbalance between O2 demand and availability
Describe the murmur of AS:
Systolic/midsystolic
Crescendo-decrescendo
Heard louder at aortic (2nd R ICS)
How does the isometric handgrip maneuver affect AS?
- DECREASES AS murmur intensity
- Increases afterload which increases TPR/BP
How do standing/valsalva maneuvers affect AS?
- DECREASES AS murmur
- Decreases ventricular filling
How does AS affect carotid pulse?
Small and slow rising (parvus tardus)
Heart sounds of AS?
- Paradoxical splitting of A2 during S1 (A2P2)
- Fourth heart sound (S4)
How is PMI affected by AS and why?
Prolonged impulse due to increased ejection time
What can sometimes be palpated with AS?
Precordial LV thrill
What is the preferred diagnostic test for AS?
Echo
How does echo assess AS?
- Hemodynamic measurements
- Anatomic integrity
- Aortic dilatation
- Co-existing aortic regurge
How often are echos ordered for stable AS patients for routine surveillance?
Every 3 years
*Once a year if mod-severe disease
Preferred tx of AS in symptomatic patients? What are these symptoms?
Surgery
*Syncope, angina, heart failure
What is the biggest drawback of mechanical valves?
Anticoagulation required after
What is the biggest drawback of bioprosthetic valves?
- Wear and tear
- Require abx prophylaxis for endocarditis
Percutaneous balloon valvuloplasty
Alternative surgical tx for AS patients who cannot tolerate open heart procedure
What is the biggest risk of percutaneous balloon valvuloplasty?
Restenosis
Types of aortic regurgitation
Valvular
Aortic root disease
In AR there is a _____ mechanism
Compensatory
Describe the compensatory mechanism of AR
- Regurge increases LV workload
- In response, SV is increased to maintain EF
- This leads to LV hypertrophy
Describe the murmur of AR
- Diastolic
- Decrescendo
- Heard best at 2-4 ICS on the R
How does AR affect carotid pulse?
Rapid rise and fall (Corrigan)
What is a Corrigan pulse and what causes it?
Rapid rise and fall
*Caused by AR
What is the de Musset’s sign and what does it indicate?
- Rhythmic bobbing/nodding of the head along with heart beat
- AR
What is Duroziez’s sign and what does it indicate?
- An audible diastolic murmur heard over a partially compressed femoral artery
- AR
What is Quincke’s pulse? Why does it happen? What does it indicate?
- Nailbed capillary pulsations
- Large SV
- Indicates AR
What indicates surgery for AR?
Abnormal LV function (EF
What is the MC cause of mitral stenosis? What population?
Rheumatic fever
-Developing countries, women (3x more common)
Pathophys of rheumatic MS:
Chronic inflammation leads to narrowing of valve
- Leaflets thicken
- Mitral commissures and chordae fuse/shorten
- Papillary muscles are abnormally close
- Valvular cusps become rigid
What is the hallmark of MS?
Decreased orifice area from 4-6 cm2 to 2cm2
What is considered severe MS?
Orifice
How does the heart compensate for MS?
High LA pressure in order to maintain CO
How does a mild-moderate MS patient present?
- Either asymp or symp only with extreme exertion
- Mitral valve area = 1 - 1.5 cm2
How does a severe MS patient present?
- Severe pulm HTN (decreased CO, RHF)
- Mitral valve area is
What is the MC pathology secondary to MS?
A-fib (occurs in 50-80% of MS pts)
How does A-fib affect MS?
- Does not allow for maximal diastolic filling in LV
- This further increases mitral valve pressure gradient
- To treat this, slow HR - allows for greater filling
Describer the murmur of MS and where it is best heard?
- Opening snap followed by diastolic low-pitched rumbling decrescendo
- Heard best at apex in L lateral decubitus position
What is the preferred method to diagnose MS?
Transmitted pressure gradient measured via echo w/doppler
When is valve replacement indicated with MS?
When stenosis and regurge are both present
Describe MR
- Back flow of LV SV into atrium
- Leads to LV and LA enlargement
- Leads to decreased EF as a result of persistent volume overload and decreased contractile function
What is Marfan’s syndrome associated with?
MR
What types of MR are there?
- Acute (acute MI, blunt trauma, rheumatic fever, etc)
- Chronic (Marfan’s, structural)
Describe the murmur of MR and where it is heard best?
- Pansystolic
- Heard best at apex
How does MR affect the carotid pulse?
Causes brisk upstroke
What heart sounds are a/w MR?
Prominent S3 (gallop)
Describe acute MR vs. chronic MR
- Acute: normal LA is subjected to extremely high regurge volume but has not undergone “remodeling” so LA pressure rises quickly
- Chronic: LA enlarges slowly but progressively, no or little rise in LA pressure
What is the treatment of MR?
Surgery for all symptomatic patients (esp with pulm HTN)
When is surgery indicated for asymp MR patients?
-EF 4.0 cm
Mitral valve prolapse is also called:
Floppy valve syndrome
Systolic click murmur syndrome
What is the cause of mitral valve prolapse?
Usually unknown but can be genetically linked (reduced Type III collagen)
Who is affected by MVP?
- Women more than men
- Thin patients w/musculoskeletal deformities
Describe the murmur of MVP
- Midsystolic clicks (due to multiple chordae or redundant valve tissue)
- Late systolic murmur
- With increased prolapsing = prolonged murmur = holosystolic
What is the treatment of MVP?
- Control arrhythmias with beta blockers
- Valve repair of chordae, redundant valve tissue
General description of tricuspid stenosis
- Less prevalent than MS but a/w MS
- Women > men
Pathophys of TS
- Diastolic pressure gradient
- Increased RA pressure which leads to systemic venous congestion
Describe the murmur of TS
- Diastolic rumble along left sternal border
- Increases with inspiration
Treatment of TS
- Diuretics (to decrease congestion)
- Replacement (treatment of choice) BIOPROSTHETIC valve NOT mechanical
What is unique regarding the surgical treatment of TS?
Both tricuspid and mitral are replaced at the same time since both are usually defective or may become defective
Describe TR
Back flow of blood from RV to RA
What usually causes TR?
- RV dilatation (80% of cases, NOT tricuspid disease)
- RV volume overload
- Pacemaker placement w/injury to valve (iatrogenic)
- Dilated cardiomyopathy
How does a patient with TR present?
Identical to R heart failure (increased JVP, ascites, edema of lower extremities, etc)
Describe the murmur of TR
- Blowing holosystolic murmur
- Along lower left sternal margin
- Intensifies with inspiration
- S3
Treatment of TR
- Valve replacement for severe TR
- Diuretics for edema
- Aldosterone antagonist for ascites
What causes pulmonary valve stenosis?
Congenital (essentially) - valve is domed and smooth with fusion of commissures
Pathophys of PS
Systolic pressure gradient between RV and PA
-RV hypertrophy develops
Murmur of PS
- Loud, harsh, crescendo-decrescendo
- Systolic ejection murmur in left upper sternal border
- Palpable thrill
- Increases with inspiration
Severity of PS is defined by:
-Mild
Treatment of PS
- Valve replacement in all symp patients
- Valve replacement in all with 60+ mm Hg regardless of symptoms
Types of PR
- High pressure (mostly due to pulm HTN)
- Low pressure (mostly due to valvular disease)
Describe the murmur of PR
- No murmur heard if low pressure PR
- Loud, decrescendo, diastolic murmur if high pressure PR
What is a Graham Steell murmur?
- A/w PR
- High pitched early diastolic
- Heard best at left sternal border, 2nd ICS in full inspiration
Heart sounds of PR
- S2 is split due to prolonged RV systole and associated delayed pulm valve closure (P2)
- Systolic click
