Valvular Disease Flashcards
1
Q
heart structure that is part of endocardium; composed of CT and nearly transparent
A
Heart valves
2
Q
Name of aortic valve cusps
A
Right coronary cusp
Left coronary cusp
Non-coronary cusp
3
Q
How do aortic valve cusps help coronary artery blood flow?
A
During closure, the brief diastolic flow into the cusps supplies the coronary arteries
4
Q
Mitral valve anatomy
A
Two leaflets (anterior and posterior) Two papillary muscles with chordae tendinae
5
Q
Size of normal mitral valve orifice
A
4-6 cm2
6
Q
Each mitral valve leaflet is divided into…
A
3 segments and anterior/posterior commissures
7
Q
Part of a mitral valve leaflet that marks the joining of the two leaflets
A
Commissure
8
Q
Names of tricuspid valves
A
Anterior
Posterior
Septal
9
Q
Mnemonic for pattern of listening for heart sounds on the chest
A
All (Aortic)
Physicians (Pulmonary)
Take (Tricuspid)
Money (Mitral)
10
Q
Why does inspiration cause physiologic splitting of S2?
A
During inspiration, there is an increase in venous return and therefore RV filling is increased. It takes longer for blood to leave the RV, prolonging closure and therefore P2 is delayed compared to A2.
11
Q
Which is normal to hear in children, S3 or S4?
A
S3
12
Q
auscultation finding of turbulent flow; can be from stenosis or regurgitation
A
Murmur
13
Q
scratchy, “squeaky leather” sound of the pericardial layers
A
Rub
14
Q
High-pitched sound of the semi-lunar valves opening or mitral valve closing; occur after S1
A
Click
15
Q
Short, high frequency sound after S2 (diastole) due to sudden arrest of the opening of AV valves
A
Snap
16
Q
Systolic murmurs
(mitral vs. aortic)
(stenosis vs. regurgitation)
A
Mitral regurgitation
Aortic stenosis
17
Q
Diastolic murmurs
(mitral vs. aortic)
(stenosis vs. regurgitation)
A
Mitral stenosis
Aortic regurgitation
18
Q
Congenital fusion of 2 of the 3 cusps in the aortic valve; usually the LCC and RCC; can have calcification with age; associated with coarctation, turner syndrome and dilated ascending aorta (can rupture)
A
Bicuspid Aortic Valve
19
Q
Autosomal dominant; weakened leaflet stretches and balloons back into left atrium; associated with CT diseases (Marfan’s) or endocarditis; myxomatous degeneration (pale extracellular matrix)
A
Mitral Valve Prolapse
20
Q
Mitral valve prolapse is typically (repaired/replaced)
A
Repaired
21
Q
Most common form of valvular heart disease worldwide (especially developing countries); GAS pathogens stimulate Ab that cross react with heart tissue; resulting fibrosis makes valves stiff (typically left-sided valves: mitral and aortic)
A
Chronic rheumatic heart disease
22
Q
Diagnosis of Acute Rheumatic Fever needs GAS infection and 2 major criteria. What are they?
A
Carditis Polyarthritis Sydneham chorea (involuntary movements) Erythema marginatum (skin rash with clear center) Subcutaneous nodules
23
Q
Gross and microscopic anatomy of acute rheumatic fever
A
Gross: valves swollen with vegetations
Microscopic: Aschoff granulomas and Anischkow cells (macrophages)
24
Q
Macrophages with owl eye/ caterpillar nuclei; seen in acute rheumatic fever
A
Anischkow cells
25
Which valves are most affected in Chronic Rheumatic Heart Disease?
Mitral and Aortic
26
Infection of the endocardium; typically involves left-sided valves (mitral and aortic); can be acute or subacute
Infective Endocarditis
27
Bacterial endocarditis that involves virulent organisms (Staph. aureus); can affect normal valves; rapid progression; IV drug abusers can innoculate skin flora
(Acute vs. Subacute)
Acute Bacterial Endocarditis
28
How can acute bacterial endocarditis affect the tricuspid (right heart) valve, when infective endocarditis usually affects left heart valves?
Intravenous drug abusers innoculate bacteria into systemic circulation
29
Bacterial endocarditis that involves less virulent organisms (Strep. viridans); requires an abnormal valve (RHD, prosthetic); slow progression
(Acute vs. Subacute)
Subacute Bacterial Endocarditis
30
Complications of bacterial endocarditis
Thrombus/embolus formation, damaging CNS, kidneys, spleen, skin, eyes, etc.
31
Typical pathogens for infective endocarditis
Staphylococci (aureus, coag. negative staph)
Streptococci (viridans, enterococci, bovis)
HACEK
32
"Culture Negative" pathogens (HACEK)
```
Haemophilus
Aggregatibacter
Cardiobacterium
Eikenella
Kingella
```
33
Treatment for Infective Endocarditis
Prolonged IV and oral antibiotics
| Surgery to remove vegetations or replace valves
34
Most common cause of valvular disease in the developed world; thickened, calcified valves; typically affects left-sided valves; can be seen with congenital bicuspid aortic valve
Calcific Valvular Disease
35
Treatment for Calcific Valvular Disease
Only effective treatment is valve replacement
36
also known as "marantic" endocarditis; occurs in patients with "wasting diseases"; sterile fibrin vegetations on left-sided valves; possibly caused by increased coagulability or immune response
Nonbacterial Thrombotic Endocarditis (NBTE)
37
malignancy of neuroendocrine cells (lung, GI, etc.) that produce high levels of serotonin, inducing valve fibrosis in right-sided valves; can lead to tricuspid regurgitation or pulmonic stenosis
Carcinoid tumor
38
Chronic inflammatory disease in men affecting the spine and sacroiliac joints (associated with HLA-B27)
Ankylosing Spondylisis
39
Most common valvular disease in developing vs. industrialized countries
Developing: Rheumatic Fever
Industrialized: Calcific Valvular Disease
40
Aortic valve stenosis can retard what curve on the Wiggers Diagram
The aortic pressure doesn't rise much with ventricular systole (blood flow across valve is impeded)
41
How does the heart compensate with aortic stenosis?
LVH (concentric), but ends up reducing compliance of LV and elevating diastolic pressure causes LAH also
42
Symptoms of aortic stenosis
```
Angina
Exertional Syncope
Dyspnea (Heart Failure)
Murmur (Cres.-Decres. systolic murmur; loudest at base)
Weak/delayed carotid pulse
```
43
How does aortic stenosis cause angina?
More muscle mass/stress
| Less coronary perfusion because of elevated diastolic pressure
44
How does aortic stenosis cause exertional syncope?
Stenotic orifice prevents increased CO, and vasodilation leads to decreased cerebral perfusion
45
How does aortic stenosis cause dyspnea?
LVH---> contractile dysfunction---> inc. LA and pulmonary pressure---> pulmonary congestion
46
When is aortic valve replacement indicated?
Development of symptoms
Evidence of progressive LV dysfunction
Valve area <1cm2
47
Treatment for aortic stenosis
Only effective treatment is replacement (or balloon valvuloplasty)
48
Aortic stenosis treatment; not very effective (50% patients develop restenosis)
Percutaneous balloon valvuloplasty
49
Failure of the aortic valve to close tightly, causing back flow into the left ventricle; can be caused by valve abnormalities (bicuspid, endocarditis, etc.) or root issues (aneurysm, dissection, syphilis)
Aortic regurgitation
50
Why does chronic aortic regurgitation cause widened pulse pressure?
Volume overload---> chronic eccentric dilation---> inc. compliance---> diastolic pressure drops while systolic rises (higher volume)
51
Physical exam findings for wide pulse pressures in aortic regurgitation
De Musset sign: head bobbing with each systole
Quincke sign: capillary flushing and draining at nail bed
Traube sign: "pistol shot" heard over femoral artery during systole
52
Wiggers Diagram abnormality that indicated aortic regurgitation
After aortic valve "closes", the aortic pressure decreases at a faster rate
53
Symptoms of Aortic Regurgitation
Widened pulse pressure
Murmur (decres. heard at V2, best heard leading forward after exhaling)
Angina
Heart Failure (inc. size, edema)
54
How might aortic regurgitation cause angina?
Dec. aortic diastolic pressure causes decreased coronary perfusion pressure. This reduction of oxygen supply with inc. LV size causes angina
55
How might aortic regurgitation cause heart failure?
Progressive remodeling of the LV (eccentric hypertrophy) results in systolic dysfunction, increasing LA and pulmonary pressures.
56
Treatment for asymptomatic/symptomatic patients with aortic regurgitation
Asymptomatic: vasodilators if HTN
Symptomatic: valve replacement (otherwise death within 4 years)
57
Impaired filling of the LV across a narrowed/stiff mitral valve; reduces cardiac output; significant when valve area is <2cm2; can be caused by calcification, rheumatic fever or endocarditis
Mitral stenosis
58
Symptoms of mitral stenosis
```
Loud S1 (still open in systole)
Opening snap
Dyspnea
Hemoptysis
Right-sided HF
A-Fib
Stroke
```
59
Why might mitral stenosis cause dyspnea and hemoptysis?
Higher LA pressure---> Higher pulmonary pressures---> fluid into the lungs (and potential rupture)---> dyspnea and hemoptysis
60
Two distinct forms of pulmonary HTN in mitral stenosis
Passive: backward pressure because of fluid
Reactive: vessel hypertrophy in response to increased pressure (helps prevent edema, but increases resistance)
61
How might mitral stenosis cause Right-sided HF?
Elevation of pulmonary pressure---> Elevation of Right-sided heart pressure---> Right ventricular hypertrophy and dilatation---> Right HF
62
How might mitral stenosis result in a-fib?
Pressure overload---> LA enlargement---> stretch of atrial conduction fibers---> A-fib
63
How might mitral stenosis result in stroke?
Stagnation of blood in LA (along with a-fib)---> thrombus formation---> emboli in peripheral organs---> stroke
64
Wiggers Diagram abnormality with mitral stenosis
After mitral valve "opens", atrial and ventricular pressures should be same. But atrial pressure is higher and only slowly decreases (slow flow of blood into ventricle)
Treatment for mitral
65
Treatment for mitral stenosis
```
Diuretics (congestion)
Beta/calcium blockers (A-fib)
Valvuloplasty
Commissurotomy
Valve replacement
```
66
portion of LV stroke volume is ejected back into LA; elevated LA volume, reduced CO and volume stress on LV; can be causes by primary (valve issues like prolapse) or secondary (muscle issues like cavity dilatation)
Mitral regurgitation
67
How does the heart compensate for mitral regurgitation
LV stroke volume rises to meet circulatory needs
68
Regurgitant Fraction equation
Volume of MR/Total LV stroke volume
69
Symptoms of mitral regurgitation
```
Murmur (blowing sound best heart at apex left-laterally)
Pulmonary edema
Low CO
LV contractile dysfunction
Right-sided heart failure
```
70
Wiggers Diagram abnormality with mitral regurgitation
After ventricular systole, atrial pressure rises tremendously (instead of staying low)
71
Treatment for mitral regurgitation
Diuretics (edema)
Vasodilators (inc. CO) (less helpful for chronic)
Intra-aortic balloon pump
Valve repair/replacement
72
Valves that are rarely involved with stenosis or regurgitation
Tricuspid and Pulmonic (usually either congenital, rheumatic or RV enlargement)
73
Layers of the pericardium
Parietal (outer, thick)
| Visceral (inner, thin)
74
Space between the pericardial layers
Pericardial cavity (potential space)
75
Normal volume of (serous) fluid in pericardial space
15-50 mL
76
Serous fluid is produced by the...
epithelial cells
77
Purposes of the pericardial sac
Fixes heart w/i mediastinum
Limits spread of infection from lungs
Limits cardiac extension from increased intracardiac volume
78
Thin watery fluid which contains proteins and other dissolved molecules; found in pericardial sac
Serous fluid
79
Most common pericardial disease; inflammation of pericardium; more common in adult males; mostly caused by idiopathy, viral infections, uremia and post-surgery,
Acute pericarditis
80
Acute pericarditis is most commonly caused by what class of pathogen
Viral
81
Viruses associated with acute pericarditis
Echovirus
Coxsackievirus
Less common (varicella, mumps, HBV, EBV, HIV)
82
Non-viral pathogens associated with acute pericarditis
Tuberculous (immunosuppressed)
Pneumococcus
Staph
83
occurs within few days after MI; inflammation of epicardial surface of injured myocardium; <5% of patients because we now treat MI patients so aggressively
Post-MI Pericarditis
84
occurs weeks to months after an MI; inflammation due to autoimmune activity against antigens from necrotic myocardial cells
Dressler's Syndrome
85
Pathogenesis of acute pericarditis
Inc. serous fluid---> Inflammatory vasodilation with plasma protein leakage (fibrinogen) into pericardial space---> PMN or macrophage accumulation
86
Stage in acute pericarditis with increased serous fluid production by mesothelium
Serous stage
87
Stage in acute pericarditis with inflammatory vasodilation with leakage of plasma proteins (fibrinogen)
Firbrinous stage (Bread and Butter)
88
Stage in Acute Pericarditis with either the accumulation of PMNs (bacterial) or granulomas/macrophages (mycobacteria)
```
Purulent stage (bacterial)
Tuberculous stage (mycobacterial)
```
89
Most cases of acute pericarditis...
Heal and regain normal anatomy/function (few cases have fibrosis)
90
Severe fibrosis after a case of acute pericarditis can result in...
Constrictive pericarditis (an egg shell around the heart, restricting movement)
91
heart is covered in a thick, white layer composed of large quantities of fibrous (scar) tissue replacing normal pericardium and pericardial space
Constrictive pericarditis
92
Symptoms of acute pericarditis
```
Fever, malaise, myalgia
Retrosternal chest pain (may radiate to trapezius ridge)
Pleuritic
Worse in supine, better when sitting up
Non-productive cough
Dyspnea
```
93
Physical exam finding suggestive of acute pericarditis
Friction Rub (scratchy sound, like rubbing a balloon)
94
Stages of ECG evolution for acute pericarditis
1. DIFFUSE Concave ST elevation and PR depression (onset)
2. PR depression (early)
3. T-wave inversion (late)
4. T-waves return
95
Why might acute pericarditis result in low-voltage readings on ECG
Fluid dampening (effusion)
96
When do you want to hospitalize someone with acute pericarditis?
Uncertain etiology
Concern for effusion/tamponade
High risk (fever, leukocytosis, immunosuppression, elevated Troponin)
97
Treatment for acute pericarditis
NSAIDS (Ibuprofen 300-800 mg every 6-8 hours)
Aspirin
Colchicine (added to NSAID)
Corticosteroids (last ditch effort)
98
How does constrictive pericarditis effect ventricular filling?
Inhibits transmission of thoracic pressure
Limits expansion of ventricles
Compresses heart mid-to-late diastole
99
Effects of constrictive pericarditis on left vs. right heart chambers
Inc. RV volume due to dec. LV filling and septal shift
100
Physical exam findings of Constrictive Pericarditis
```
All similar to right-sided HF:
Peripheral edema
Ascites
Fatigue
JVP
Hepatomegaly
Pericardial knock
```
101
Kussmaul's sign
Increased JVP
102
Jugular venous pulsation that is suggestive of constrictive pericarditis
prominent y descent (right ventricular filling)
103
Treatment for constrictive pericarditis
Pericardiectomy (pericardial stripping) (significant morbidity/mortality)
104
extreme form of pericardial constraint due to accumulation of pericardial fluid; present throughout the cardiac cycle
Cardiac tamponade
105
Causes of cardiac tamponade
Acute: trauma, rupture or invasive procedure
Subacute: neoplastic, uremic, viral or idiopathic
106
How does cardiac tamponade cause shock?
Inspiration---> inc. venous return---> impaired RV filling due to tamponade---> septum bulges into LV---> impaired LV filling---> impaired cardiac output (shock)
107
Physical exam findings suggestive of cardiac tamponade
```
Hypotension
Sinus Tach (inc. stroke volume)
Pulsus Paradoxus
Electrical alternans
Cool extremities (shunt blood to core)
Muffled heart sounds
Elevated JVP
```
108
Beck's Triad for cardiac tamponade
Elevated JVP
Muffled Heart Sounds
Hypotension
109
Jugular venous pulsation that is suggestive of cardiac tamponade
Blunted y-descent (impaired RV filling)
110
seen in cardiac tamponade; exaggerated decrease in systolic BP (>10 mmHg) seen with inspiration
Pulsus paradoxus
111
What causes pulsus paradoxus in cardiac tamponade
Due to bulging of RV septum into LV during inspiration (limits LV filling and hence CO)
112
How to measure for pulsus paradoxus
Inflate cuff to above SBP
Slowly deflate until 1st sound only during expiration
Continue until sound heard at both expiration and inspiration
Difference between the measurements
113
Treatment for cardiac tamponade
```
Catheter pericardiocentesis (1st line)
Surgical drainage (if hemorrhagic or recurrent)
```
114
symptoms that are associated with acute rheumatic fever
FEVERSS (Fever, Erythema marginatum, Valvular damage, increased Erythrocyte sedimentation rate, Red-hot joints, Subcutaneous nodules, Sydenham chorea).
