Valvular Disease

Question 1

During what phase of the cardiac cycle are the pulmonary and aortic valves closed?

Answer 1

Diastole

Question 2

During what phase of the cardiac cycle are the tricuspid and mitral valves closed?

Answer 2

Systole

Question 3

Passive structures that respond to pressure

Answer 3

Valves

Question 4

under what conditions do heart valves open?

Answer 4

When contraction increases pressure within a given chamber greater than downstream pressure

Question 5

under what conditions so the heart valves close?

Answer 5

when contraction ends and pressure decreases below downstream pressure

Question 6

What prevent inversion of valves during ventricular systole and can become damaged from MI causing back flow “regurgitation”?

Answer 6

Chordae tendinae and papillary msucles

Question 7

Which valves are named after their half-moon morphology, have 3 leaflets each, have no papillary muscles or chordae tendonae, and do not lie back against the walls of the aorta or pulmonary artery

Answer 7

Semilunar valves

aortic and pulmonic

Question 8

You are more likely to experience symptoms with valvular disease on which side of the heart?

Answer 8

Left

Question 9

Which valvular disorder is most common in older adults?

Answer 9

Aortic stenosis

Question 10

Mitral stenosis

Answer 10

• primarily occurs in females
• main cause is rheumatic heart disease
• parachute mitral valve
• valve leaflets don’t open easily
• decrease area and increases resistance to flow between A-V
• stretch of LA causes arrhythmias
• at risk for thrombus due to pooling in LA and increased turbulence
• may advance to right HF
• Medical mngmt: anti-coagulants, antiarrhythmics, surgery

Question 11

What would you expect to see in a pt with mitral stenosis?

Answer 11

• LA hypertrophy
• Limited LV filling (A-fib, pulm congestion &HTN)
• dyspnea upon exertion
• opening snap, diastolic rumble

Question 12

Mitral regurgitation

Answer 12

• mitral valve does not close completely during systole
• creates back flow
• increases SV to compensate
• upstream chamber (LA) dilates out
• eccentric hypertrophy to accommodate increased volume

Question 13

SXS of mitral regurgitation

Answer 13

• anxiety and palpitations w/ exercise

- symptomatic pts take beta blockers for exercise

Question 14

Mitral Valve prolapse

Answer 14

-extreme regurgitation/incompetence

Question 15

Aortic stenosis

Answer 15

• Usually, calcific aortic and congenital bicuspid aortic valve stenosis
• mild thickening, calcification, or both of a tri-leaflet aortic valve without restricted leaflet motion
• 25% of population is older than 65 years

Question 16

What would you expect to see in a pt with aortic stenosis?

Answer 16

Volume overload
-LV dilates out
-LVH
Dyspnea upon exertion
diastolic murmur "blowing"

Question 17

What would you expect to see in a pt with mitral valve prolapse?

Answer 17

• Volume overload
  
  • LA dilates, A-fib, thrombus formation, pulmonary congestion
• LVH for forward flow
• Dyspnea upon exertion
• holosystolic murmur (regurgitation into LA)

Question 18

What are the possible causes of aortic regurgitation/incompetence?

Answer 18

Congenital, rheumatic, endocarditis, deterioration with age as well as long standing HTN
Rarer conditions: marfans syndrome, ankylosing spondylitis, certain STDs

Question 19

What would you expect to see in aortic regurgitation/incompetence?

Answer 19

volume overload
-LV dilates out
-LVH
Dyspnea upon exertion
diastolic murmur "blowing"
-no pulmonary symptoms until very advanced stages

Question 20

What are the exercise considerations for Valvular stenosis?

Answer 20

• close monitoring of RPE
• low muscle perfusion may limit exercise
• suppressed BP response to exercise; possible exaggerated HR
• Low cardiac output
• Asymptomatic: low intensity and gradually progressed
• Angina may be a symptom

Question 21

Considerations for Mechanical valve replacements

Answer 21

• lasts a lifetime but require anticoagulant meds
• higher risk for infection, thrombus, and emboli
• younger pts would be better candidate due to limited life of biological valve

Question 22

What are the pros and cons of minimally invasive valve replacements?

Answer 22

PROS:
reduced postoperative mortality and morbidity
shorter hospital stay
better cosmetics
CONS:
limited by longer cross-clamp and cardiopulmonary bypass times

Question 23

Under what conditions would you use Trans-cutaneous valve repairs?

Answer 23

Patient at high risk for open heart surgery

older patients or those with significant compromise

Question 24

Outermost layer of pericardium, firmly bound to the central tendon of the diaphragm, sternum, and mediastinal pleura.

Answer 24

Fibrous pericardium

Question 25

Lines the inner surface of the fibrous pericardium and is reflected onto the heart as the visceral layer forms a closed sac.

Answer 25

serous pericardium

Question 26

potential space formed by the sac filled with fluid that lubricates the heart and reduces friction during movement

Answer 26

pericardial space

Question 27

Outer later of connective tissue that covers the heart, contains variable amounts of adipose tissue that tends to aggregate along vessels and in the grooves on the surface of the heart

Answer 27

Epicardium

Question 28

Common causes of pericarditis

Answer 28

viral infections
bacterial infections (less common)
fungal infections (rare)
heart attack
radiation therapy
post open heart surgery

Question 29

SXS of pericarditis

Answer 29

sharp retrosternal pain with radiation to the back (lasting hours)
fever
pain worsens with deep breathing or coughing or lying flat
pain is improved while sitting up and leaning forward (different than MI)
Friction rub on ausultation

Question 30

Pericardial effusion (define, causes, sxs)

Answer 30

-accumulation of fluid in the pericardial sac which causes compression against the heart
Causes: similar to pericarditis (viral infections, bacterial, infections, fungal infections, heart attack, radiation therapy
post open heart surgery)
SXS: pressure in chest, dysphagia, dyspnea, muffled heart sounds, possible JVD

Question 31

Where is Erb’s point?

Answer 31

Left 3rd intercostal space aka left lower sternal border

Question 32

S1: the first heart sound

Answer 32

“Lub”

• closure of the AV valves (tricuspid/mitral)
• occurs with ventricular contraction
• marks the approximate beginning of systole

Question 33

S2: the second heart sound

Answer 33

“Dub”

• closure of the semilunar valves (aortic/pulmonic)
• marls the beginning of ventricular relaxation and end of systole
• shorter duration and higher frequency than the first heart sounds

Question 34

When does S3 occur and what does it mean?

Answer 34

• beginning of diastole after S2 and is lower in pitch than S1 or S2 as it is not of valvular origin
• indicates ventricular/heart failure

Question 35

When does S4 occur and what does it mean?

Answer 35

• occurs prior to S1, produced by the sound of blood being forced into a stiff hypertrophic ventricle
• indicative of LVH or HCOM

Question 36

Definition of heart murmur

Answer 36

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

Question 37

What characteristics should murmurs be assessed on?

Answer 37

Shape (crescendo, decrescendo, plateau)
location- where the murmur originates
timing-murmurs are longer than heart sounds
intensity-(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)
pitch- high, medium, low