Valvular disease Flashcards
Closure of mitral valve
S1
Closure of aortic valve
S2
Ventricular gallop
S3
What is S3 most commonly associated w/?
Left ventricular failure/overload
Atrial gallop
S4
What is S4 most commonly associated w/?
Left ventricular hypertrophy
Right sided murmurs increase w/ what?
Inspiration
Ventricular Septal Defect (VSD)
- Harsh
- Systolic
- Best at LSB but heard throughout precordium
Why do you feel pulse while you listen to murmurs?
Helps identify:
- Systolic vs diastolic
- S1 vs S2
Signs & sx of left HF
- Dyspnea (exertional, postural, nocturnal paroxysmal)
- Rales/crackles
- Pleural effusion (diminished breath sounds)
- Pallor or cyanosis
- Fatigue
- Tachycardia
When is an echo indicated?
- systolic murmur > II
- diastolic murmur (any grade)
What does an echo do?
- Assess chamber size/fxn & other valve disease
- Identifies culprit lesion(s)
- Severity, pressure gradients, magnitude of regurgitant flow
Cardiac cath (right & left)
Direct measurement of pressure gradients if valves are stenotic
- intrachamber pressures
- identifies concomitant CAD
What is the most common cause of aortic stenosis?
A calcified valve
- Also due to congenital bicuspid AOV, rheumatic fever,
What is the initial response of aortic stenosis?
Compensatory LVH
Sx of AS
- Long asymptomatic period
- Classic triad*:
˚ Angina
˚ Syncope
˚ HF
In aortic stenosis, what do you see on PE?
- Delayed carotid upstroke
- Sustained apical impulse (non-displaced, diffuse)
- Split S2, S3 if HF, & S4 due to stiff LV
- Systolic ejection crescendo-decrescendo murmur @ RUSB radiating to neck
Surgical intervention for AS
Replacement = #1 choice
- w/ mechanical or tissue valve
What indicates that someone should undergo surgery for AS?
- Severe w/ sx
- LV dysfunction
- Moderate when the patient needs CABG
What options are available for those not candidates for surgery?
- TAVR
- Balloon valvuloplasty
Features of a bioprosthetic valve
- 10-15 yr lifespan
- Usually used in elderly
Features of a mechanical valve
- lasts longterm
- Usually used in younger population
- Requires anticoagulation w/ warfarin
What are the biggest complications w/ TAVR?
- CVA
- Complete heart block
- Paravalvular leak
What are causes of aortic regurgitation?
- Disease of leaflets or abnormalities of aortic root or ascending aorta
- Chronic (over 10 yrs for LV dysfunction to develop): Bicuspid AOV, valve disease, root dilation, rheumatic fever, endocarditis, collagen vascular diseases
- Acute: Aortic dissection*, endocarditis, post valve replacement or valvoplasty
Sx of AR
Usually asymptomatic for a long time
- Dyspnea
- Sx of left HF
What is the workup for AR?
- EKG: LVH, LAD, left atrial abnormalities
- CXR: cardiomegaly, dilated aortic knob, pulmonary edema
- Echo: overall severity, root size, LV size/fxn
When is surgery indicated for AR?
- Symptomatic regardless of LVEF
- If Asx, but undergoing other heart surgery
- AVR & LV dysfunction or LV dilation
- Aortic root dilation over 5cm
What is the most common cause of MR?
Mitral valve prolapse
What causes mitral valve prolapse?
Myxomatous degeneration of mitral valve
What are the primary causes of chronic mitral regurgitation
- Mitral valve prolapse
- Myxomatous degeneration
- Rheumatic (leaflet fibrosis)
What are the secondary causes of chronic mitral regurgitation?
- Ischemic
- Endocarditis
- Annular dilation/ dilated cardiomyopathy
Sx of mitral regurgitation
Usually Asx for yrs
- Dyspnea
- Exercise intolerance
- Fatigue
- Sx of left HF
- AF
Medical tx of MR
- Vasodilators, diuretics, warfarin (if AF)
However, will not prevent progression
Surgical indications of MR
- Based on severity, sx, cardiomyopathy
- Repair is always favored over replacement
Acute mitral regurgitation patho
- Papillary muscle infarct
- Chordae tendinae rupture (related to myxomatous degeneration)
What are causes of mitral valve stenosis?
- Rheumatic fever
- Congenital (rare)
- Systemic diseases (rare)
What is the recommended therapy for mitral stenosis according to severity? (Mild vs mild w/ sx vs AF)
- Mild (MVA > 1.5): No tx
- Mild sx of dyspnea: Diuretics & salt restriction, beta blockers
- AF: Anticoagulant w/ Warfarin ONLY
What are surgical options for mitral stenosis?
- Percutaneous balloon valvuloplasty
- Full replacement (if open repair required)
Fxn of cardiac valves
- Prevent back flow
- Ensure blood moves in 1 direction
What 2 valves are considered the “AV Valves”? How many cusps do they each have?
- Mitral: has smaller posterior cusp & larger anterior cusp
- Tricuspid: has anterior & posterior cusps, along w/ a septal cusp
What 2 valves are considered the semilunar valves? Where are they located?
- Aortic: btwn left ventricle & aorta
- Pulmonary: btwn right ventricle & pulmonary artery
Anatomy of mitral & tricuspid valves
- Made up of fibrous ring & leaflets/cusps
- Attached to chordae tendinae
What can stenotic lesions lead to?
Pressure overload
What do regurgitant lesions lead to?
Volume overload & dilation of chambers
Define: Preload (What can cause it to increase?)
Amt of blood in ventricle at the end of diastole
- Increases w/ exercise, sympathetic tone, & blood volume
What has a direct relationship w/ CO?
Preload
Preload is determined by what 2 factors?
- Amt of venous return
- Blood left after systole
Afterload
Resistance or impedance to ejection of blood from LV
- Load the muscle must move after it starts to contract
What has an inverse relationship to CO?
Afterload
- Ex. Low aortic pressure/decreased afterload = quicker contraction (& vice versa!)
Diastolic dysfunction
- LV inability to relax
- Decreased LV wall compliance
- Limits filling of ventricle –> reliance of LA
- Pressure rises in LA –> pulmonary edema, enlargement of atria (predisposing to atrial arrhythmias)
Causes of LV diastolic dysfunction
- HTN
- Ventricular hypertrophy
- Fibrosis
- Infiltrative cardiomyopathy
- Pericardial constriction
Causes of RV diastolic dysfunction (rare)
- Constrictive pericarditis
- Restrictive cardiomyopathy
Sx of valvular heart disease
- SOB (constant or w/ exertion)
- Chest pain
- Palpitations
- Syncope
- Edema
- Weakness
- Fatigue
Sx of right HF
- Fatigue
- Tachy
- Weight gain
- Ascites, peripheral edema
- Hepatojugular reflex
- Jugular venous distension
Murmur grades/intensity
- I: heard in quiet room
- II: heard by most
- III: loud w/out thrill
- IV: loud w/ thrill
- V: very loud thrill, audible w/ stethoscope pressed to chest
- VI: very loud thrill, audible w/ stethoscope away from chest
What does AR look like on PE?
- Widened pulse pressure
- Water Hammer pulse (rapid upstroke, quick collapse)
- Blowing diastole decrescendo murmur @ LUSB
- Austin Flint murmur (mid-late diastolic rumble heard at apex)
- Signs of left HF
Acute aortic regurgitation (what dx should you not miss?)
- Aortic dissection
- Do-not-miss dx
- Endocarditis
What does acute AR cause?
Hemodynamic emergency bc LV has no time to develop compensatory mechanisms
- Results in cardiovascular decompensation
Sx of acute AR
- Sudden hemodynamic deterioration (weakness, change in mental status, dyspnea, syncope) –> collapse
- *Chest pain - aortic dissection
What does acute AR look like on PE?
- Signs of hemodynamic compromise
- Soft diastolic murmur
- Pulse is weak, thready, & rapid
- Soft or absent S1
What is the workup for acute AR?
- EKG: ST/T changes, sinus tach
- CXR: widened mediastinum
- TEE & blood cultures (if endocarditis suspected)
- Echo
Tx for acute AR?
- Surgical emergency
- hemodynamic stabilization (vasodilators, IV inotrops)
- Beta blockers (if acute aortic dissection)
