Valvular Disease Flashcards
When does a valve open?
When contraction increases pressure within a given chamber greater than the downstream pressure,
When does a valve close?
When contraction ends and pressure decreases below downstream pressure
What valve is on the left side?
Bicuspid/mitral
What valve is on the right side?
Tricuspid
Chordae tendinae and Papillary muscles functions
- Prevent inversion of valves during ventricular systole.
* Can become damaged from MI causing back flow “regurgitation”.
What are the semilunar valves?
- Aortic and Pulmonic
- Three leaflets on each
- No papillary muscles or chordae tendonae
- Do not lie back against the walls of the aorta or pulmonary artery
General symptoms of Cardiac valvular disease
- Easy Fatigue
- Dyspnea
- Palpitations
- Murmur
- Chest Pain
- Pitting Edema
- Orthopnea
- Dizziness
Congenital valvular disease causes
- genetic
- maternal exposure
Acquired valvular disease causes
- rheumatic fever
- endocarditis
- gradual fibrosis
Main cause of mitral stenosis
rheumatic heart disease
Mitral stenosis
- Primarily occurs in females (66%)
- Valve Leaflets don’t opening easily or completely
- Decreases area and increases resistance to flow between A-V
- Hypertrophy occurs in chamber upstream from stenosis, concentric type
- Stretch of L Atrium creates multiple foci causing arrhythmias
What to expect upon pressure overload with mitral stenosis?
PRESSURE OVERLOAD
- LA hypertrophy
- limited LV filling
- LA thrombus breeding ground
- A-fib
- Pulmonary congestion and HTN
EXERTION
- dyspnea
AUSCULTATION
- opening snap, diastolic rumble
Why is mitral stenosis at risk for thrombus?
Pooling in left atrium and increased turbulence
Why may a patient not present with mitral stenosis symptoms?
The body compensates
What may mitral stenosis advance to?
right heart failure
medical management of mitral stenosis
- anti-coagulants
- antiarrhythmics
- surgery
what happens when the mitral valve does not close completely during systole (incompetence)
- Creates back flow (Regurgitation)
- Increase SV to compensate for back flow
- Upstream chamber (L Atrium) dilates out
- Eccentric hypertrophy to accommodate increased volume
What are the signs and symptoms of mitral regurgitation/incompetence?
anxiety and palpitations with exercise
- asymptomatic are fine to exercise
- symptomatic patients: use beta blockers
Mitral valve prolapse
- valve snaps open during systole
- 2-6% of the population
- mostly asymptomatic, cause unknown
What to expect upon volume overload during mitral prolapse
VOLUME OVERLOAD LA dilates - Afib - thrombus formation - pulmonary congestion LVH for forward flow
EXERTION
- dyspnea
AUSCULTATION
- holosystolic murmur: regurgitation into LA
Causes of aortic regurgitation/incompetence
Congenital, rheumatic, endocarditis, deterioration with age as well as long standing HTN
Rarer conditions of aortic regurgitation/incompetence
Marfanvsyndrome, ankylosing spondylitis and certain STDs
What to expect with aortic regurgitation/incompetence
VOLUME OVERLOAD
- LV dilates out
- LVH
UPON EXERTION
-dyspnea
AUSCULTATION
- diastolic murmur “blowing”
Signs of aortic regurgitation/incompetence
- Eccentric hypertrophy
- Late stages maybe LA concentric hypertrophy?
- No pulmonary symptoms until very advanced stages
Exercise considerations for valvular stenosis
- Close monitoring with RPE
- Low muscle perfusion may limit exercise
- Suppressed BP response to exercise, possibly exaggerated HR
- Low cardiac output
- Patients with symptomatic aortic stenosis clients are typically not candidates for exercise programs!
- Asymptomatic aortic stenosis: intensity should be low and progressed gradually
- Angina may be a symptom
Mechanical Valves
- last a lifetime but require anticoagulant meds
- young pts are better candidates
- higher risk for infection, thrombus and emboli
Biologic valves
- made of human, pig or cow tissue (xenografts)
- pig valves can be stents or stentless
Da-Vinci Robot
- minimally invasive option
- becoming more common
- reduced postop mortality and morbidity, shorter hospital stay and better cosmetics
- limited by the longer cross- clamp and coardiopulmonary bypass times
Transcutaneous Aortic Valve Repair/Implantation
- Typically reserved for patients at high risk for open heart surgery
- Usually Older patients, or those with significant compromise
- Promising early results comparing 4yr clinical outcomes to open heart
Pericardium: fibrous layer
outermost layer, firmly bound to the central tendon of the diaphragm; sternum (sternopericardial ligaments) and mediastinal pleura
Pericardium: Serous layer
Lines the inner surface of the fibrous pericardium (Parietal) and is reflected onto the heart as the visceral layer (Epidcardium), forms a closed sac
Pericardium: Pericardial space
Potential space formed by the sac, filled with fluid that lubricates the heart and reduces friction during movement
Epicardium
Outer layer of connective tissue that covers heart, contains variable amounts of adipose tissue that tends to aggregate along vessels and in the grooves on the surface of the heart.
Pericarditis
swelling and irritation of the pericardium
Pericarditis common causes
- viral infections
- bacterial infections (less common)
- fungal infections (rare)
- may occur due to a heart attack, radiation therapy and post open heart surgery
Pericarditis signs and symptoms
- Sharp retrosternal pain with radiation to the back (lasting hours), fever,
- Pain worsens with deep breathing or coughing and when laying flat.
- Pain is mprovedwhile sitting up and leaning forward
- Friction rub on auscultation
Pericardial effusion
- accumulation of fluid in the pericardial sac
- may progress to a cardiac tamponade
Pericardial effusion causes
similar to those of pericarditis
Pericardial effusion symptoms
pressure pain in chest, dysphagia, dyspnea
Pericardial effusion signs
muffled heart sounds, possible JVD
Auscultation
- Auscultation should include the 4 primary auscultation areas of the heart using the diaphragm, staring with the patient in the supine or seated position.
- Start by finding the angle of Louis (sternal angle aka manubriosternal junction) located at the 2nd rib, which is easily felt as a small protuberance along the sternum.
- Auscultate each point starting with the Aortic region using the following Mnemonic
- All –Physicians –Take –Money
Auscultation regions
- Aortic Region: Right 2nd intercostal space, parasternal
- Pulmonic Region: Left 2nd intercostal space, parasternal
- Erb’s point: Left 3rd intercostal space aka Left Lower Sternal Border
- Triscupid Region: Left 4th intercostal space, parasternal 5. Mitral Region: Left 5th intercostal space, mid- clavicular
Normal S1 sound
- lub
•Closure of the AV valves
•(Tricuspid and Mitral)
•Occurs with ventricular contraction
•Marks the approximate beginning of systole.Normal S2 Sound
-dub
•Closure of the Semilunar valves
•(Aortic and Pulmonic).
•Marks the beginning of ventricular relaxation and end of systole.
•The second heart sound is of shorter duration and higher frequency than the first heart sound.
Extra Heart Sounds (Gallops)
•S3 occurs at the beginning of diastole after S2 and is lower in pitch than S1 or S2 as it is not of valvular origin.
•Indicative of ventricular/heart failure.
•S4 Occurs prior to S1, produced by the sound of blood being forced into a stiff or hypertrophic ventricle
.•Indicative of LVH or HCOM
Murmurs definition
- Extra sounds during the cardiac cycle, such as whooshing or swishing made by turbulent blood flow often due to a faulty valve or structural changes in the myocardium.
- Onomatopoeia
Murmur shape
•Crescendo (grows louder), decrescendo, crescendo-decrescendo, plateau
Murmur location
- Determined by the site where the murmur originates
* A, P, T, M listening areas
Murmur timing
- Murmurs are longer than heart sounds
* Systolic, diastolic, continuous
Murmur intensity
- Graded on a 6 point scale
- Grade 1 = very faint
- Grade 2 = quiet but heard immediately
- Grade 3 = moderately loud
- Grade 4 = loud*
- Grade 5 = heard with stethoscope partly off the chest*
- Grade 6 = no stethoscope needed*
Murmur pitch
high, medium, low
Systolic murmurs
- Aortic stenosis -ejection type
- Mitral regurgitation -holosystolic
- Mitral valve prolapse -late systole
- HCOM-ejection type
- Ventral Septal Defect-holosystolic
Diastolic murmur
- Aortic regurgitation -early diastole
2. Mitral stenosis -mid to late diastole
