Valvular disease

Question 1

What is aortic stenosis? What are the main causes?

Answer 1

Inability of the aortic valve to open properly

Thickening/calcification, rheumatic heart disease, or congenital (bicuspid)

Question 2

What is a Wigger’s diagram?

Answer 2

Shows you pressures, volume, EKG, and heart souds

Question 3

What happens to aortic pressure relative to LV pressure in aortic stenosis– in Wigger’s diagram?

Answer 3

Higher P in LV due to inability of valve to open AND delays upstroke of aortic pressure bc it can’t open

Question 4

What compensation and decompensation happens in aortic stenosis?

Answer 4

(1) Compensation: wall thickness increases to allow LV pressure to increase
(2) Decompensation: hypertrophic heart –> decreased LV compliance

Question 5

What are the symptoms of aortic stenosis?

Answer 5

Angina: increased muscle mass –> increased O2 demand

Syncope: failure to augment CO during exercise

Dyspnea: hypertrophy –> decreased LV compliance –> increased LVDP –> increased PCWP

Question 6

What’s the physical diagnosis of aortic stenosis?

Answer 6

Carotid upstroke delayed & reduced in amplitude

S4

Harsh systolic ejection murmur R 2nd intercostal space

Reduced A2

Paradoxical splitting of S2

Question 7

What’s the prognosis of aortic stenosis?

Answer 7

Long latent period (benign)

Once you get symptoms, you decline much more rapidly

Question 8

What’s the treatment for aortic stenosis?

Answer 8

Surgical aortic valve replacement

Transcatheter valve replacemtn

Question 9

What is aortic regurgitation? Causes?

Answer 9

Leaking of aortic valve due to

(1) Primary abnormality of aortic valve leaflet
(2) Dilitation of aortic root

Many causes– congenital (bicuspid), endocarditis, rheumatic, aortic dissection, Marfan’s, hypertension

Question 10

What are metrics for the size of regurgitation?

Answer 10

Regurgitant volume

Regurgitant fraction

Effective regurgitant orifice

Question 11

What’s the difference between acute and chronic aortic regurgitation?

Answer 11

Acute: normal LV size/compliance so increase LV diastolic V and P –> increase in PCWP & pulm congestion = shock, resp failure= emergency!

• *Chronic**: compensation allows it to be better tolerated – heart can accept a larger volume w/less increase in diastolic pressure
• widened pulse pressure bc increase in SV leads to increase in aortic systolic BP & large regurg volume leads to decrease in diastolic pressure
• Normal CO is maintained
• Dyspnea, fatigue, decreased exercise tolerance, angina (rare)

Question 12

What are the physical findings of chronic aortic regurgitation?

Answer 12

Decrescendo diastolic murmur (diminishes) at LLSB

Similar metrics of severity of aortic stenosis

Question 13

How do you treat aortic regurg?

Answer 13

Surgical aortic valve replacement

Question 14

What is aortic dissection?

Answer 14

Blood can escape through a tear in aorta –> enters aortic wall & goes through media of the aorta

Caused by htn, connective tissue disorders (Marfan)

Question 15

What is mitral stenosis? Causes?

Answer 15

Mostly rheumatic also calcif, congential, endocarditis

Valve can’t open properly –> abnormal diastolic gradient across stenotic mitral valve (normall, P’s are =)

Question 16

What’s the pathophysiology/symptoms of mitral stenosis?

Answer 16

LA P/V overlad –> backup in PA –> pulmonary alveolar edema & RV pressure overload

Can lead to atrial dilitation due to P/V overload –> predisposed to A-Fib, tachycardia, and stangnant flow (risk of LA clot formation)

Dyspnea, Pulm alveolar edema

Question 17

What do you find on the physical exam of aortic stenosis?

Answer 17

Loud S1 due to mitral valve closure

Opening snap in diastole

Diastolic rumble

**Earlier snap/longer rumble =more severe disease

Question 18

What’s the progression of MS? Treatment?

Answer 18

Long latent period, 10 year survival after symptom onset 50% wherease asymptomatic patient >80% live 10 years

Treat with valvuloplasty, surgical mitral valve replacemetn
+ diuretics, rate/rhythm control, aticoag’s for AFib

Question 19

What’s mitral regurgitation? Causes?

Answer 19

During systole, portion of LV stroke volume ejected back into low pressure LA

Mitral valve leaks –> back flow into LA during systole –> increased LA, V+P, decreased CO, volume stress on LV due to return of regurg volume to LV in addition to normal pulmonary venous return

Rheumatic, degenerative, endocarditis, rupture chords/ pap muscles

Question 20

What’s the difference between acute and chronic MR?

Answer 20

Acute: noncompliant LA –> increase LAP/PCWP –> acute pulm edema –> RV failure
Also CO decreases
**Emergency!

Chronic: LA enlargement –> accomodation of regurg volume
**shift of LV diastolic P-V relationship, normal CO maintained, eccentric hypertroph due to volume overload
- fatigue, weakness on exertion, dyspnea, Afib

Question 21

What do you see on physical exam of MR?

Answer 21

Holosystolic murmur at apex radiating to axilla; worsens with fist clench bc increased afterload

Apex can be displaced/diffuse

S3 audible/palpable

Treat: diuretics, afterload reduction, if functional MR, treat underlying dysfunction, mitral repair/replacement

Question 22

AS, AR, MS, MR: PV loops

Answer 22