Valvular disease-Lecture Flashcards
Which ausculation area is at the mid-clavicular line?
Mitral
The most common cause of aortic stenosis in adults is _
The most common cause of aortic stenosis in adults is age-related calcification
* Followed by rheumatic fever, congenital abnormality
Initially, the heart will compensate for aortic stenosis with _ ;
Next we can see _ occur as the result of elevated diastolic ventricular pressure
Initially, the heart will compensate for aortic stenosis with left ventricular concentric hypertrophy ;
Next we can see left atrial hypertrophy occur as the result of elevated diastolic ventricular pressure
Left ventricular hypertrophy
If you see a patient in 60s-70s with age-related valvular disease it is probably _
If you see a patient in 60s-70s with age-related valvular disease it is probably aortic stenosis
* It is the most common cause of acquired valvular disease in the developed world
Calcific aortic stenosis is thought to develop from wear and tear on the left side of the heart –> inflammation –> active calcification by _
Calcific aortic stenosis is thought to develop from wear and tear on the left side of the heart –> inflammation –> active calcification by osteoblast-like cell
Aortic stenosis
* Has thickened, rigid, calcified cusps
Three clinical manifestations of aortic stenosis:
Three clinical manifestations of aortic stenosis: makes people SAD
* Syncope exercise vasodilates –> drops SV
* Angina imbalance between oxygen supply and demand
* Dyspnea due to heart failure
What causes exertional syncope in patients with aortic stenosis?
- Inability to augment cardiac output (due to fixed stenotic orfice)
- Exercise causes vasodilation of the peripheral muscle beds
- These two things cause decreased cerebral perfusion pressure
Explain the pathogenesis of dyspnea in aortic stenosis
Progressive aortic stenosis –> LV develops contractile dysfunction over time (bc of high afterload) –> increased left ventricular diastolic volume and pressure –> elevated LA and pulmonary venous pressures –> pulmonary alveolar congestion
The average survival of a patient with aortic stenosis from the onset of angina is _ years
The average survival of a patient with aortic stenosis from the onset of angina is 5 years
The average survival of a patient with aortic stenosis from the onset of syncope is _ years
The average survival of a patient with aortic stenosis from the onset of syncope is 3 years
The average survival of a patient with aortic stenosis from the onset of dyspnea (heart failure) is _ years
The average survival of a patient with aortic stenosis from the onset of dyspnea (heart failure) is 2 years
The 5-3-2 survival predication is for patients with _
The 5-3-2 survival predication is for patients with aortic stenosis
Features of aortic stenosis murmur
Aortic stenosis:
* Crescendo decrescendo systolic murmur
* The worse the AS, the later the peak of the murmur
* Loudest at the base of the heart (aortic area)
* Carotid pulse is weak
* Parvus et tardus
The mitral valve has _ leaflets and _ papillary muscles
The mitral valve has two leaflets and two papillary muscles (mitral = bicuspid)
* We have an anterior and posterior commissure at the point where the leaflets join
* The coronary sinus and circumflex artery wrap around the mitral valve
Acute rheumatic fever is a condition that develops 2-3 weeks after infection with _
Acute rheumatic fever is a condition that develops 2-3 weeks after infection with group A strep (strep pharyngitis)
* Leads to a pancarditis (pericarditis, myocarditis, endocarditis)
* The valve problems do not resolve –> chronic rheumatic heart disease
After 10-30 years, chronic rheumatic heart disease can lead to valves that are _
After 10-30 years, chronic rheumatic heart disease can lead to valves that are thickened, fibrotic, stenotic, with leaflet fusion
The most common long term consequence of chronic rheumatic fever is _
The most common long term consequence of chronic rheumatic fever is mitral stenosis
* Mitral > aortic > others
* Recall that RF likes the high volume valves
Patients with severe mitral valve stenosis might present with _ or _
Patients with severe mitral valve stenosis might present with dyspnea or hemoptysis
* LA pressure high –> increased venous and capillary pressures –> fluid back up into lung interstitium and alveoli –> dyspnea
* Significant pulmonary venous pressure elevation –> rupture of bronchial vein into the lung parenchyma –> hemoptysis
Mitral stenosis causes CO to decrease due to _
Mitral stenosis causes CO to decrease due to reduced LVEDV –> reduced preload –> reduces stroke volume
Mitral stenosis may lead to (right/ left) heart failure
Mitral stenosis may lead to right heart failure
* The problem is that blood accumulates in the left atrium –> backs up into the pulmonary circulation –> this provides extra resistance to the right side of the heart –> RV hypertrophy –> Right heart failure –> JVP, hepatomegaly, ascites, peripheral edema
Another consequence of mitral stenosis is the development of _ (arrythmia)
Another consequence of mitral stenosis is the development of atrial fibrillation
* Back up of blood in LA –> dilation –> stretches atrial conduction fibers –> atrial fibrillation
Right ventricular hypertrophy can be identified on ECG by a large R wave in lead _
Right ventricular hypertrophy can be identified on ECG by a large R wave in lead V1
* Recall that a normal ECG shows more negative deflection in V1 meaning R wave is small and S wave is big
In individuals with mitral stenosis, whom we worry are at risk of a.fib/ stroke, we will give _ medication
In individuals with mitral stenosis, whom we worry are at risk of a.fib/ stroke, we will give warfarin
* Clinical studies show it is the best method of anticoagulation for these patients
What does the mitral stenosis murmur sound like?
Opening snap followed by a mid-diastolic rumbling
In patients who have mitral stenosis following rheumatic fever, we can perform _
In patients who have mitral stenosis following rheumatic fever, we can perform percutaneous balloon mitral valvuloplasty
* This is most effective because it tears the commissural fusion
Name some causes of mitral regurgitation
Mitral regurgitation:
* Annular calcification
* LV cavity dilation
* Myxomatous degeneration (MVP)
* Rheumatic disease
* Endocarditis
* SAM
* Chordae tendineae rupture
* Papillary muscle rupture
Acute mitral regurgitation causes
Acute causes:
* Trauma
* Endocarditis
* MI (papillary rupture)
Chronic mitral regurgitation causes
Chronic causes:
* Valve degeneration
* Infective endocarditis
* Rheumatic heart disease
* Congenital heart disease
* Ventricular disease (cardiomyopathy)
What does mitral regurgitation look like on the PV loop?
Inferior, posterior STEMI
Acute mitral regurgitation will present with symptoms of _
Acute mitral regurgitation will present with symptoms of pulmonary edema
* From high LA pressure
How do we treat acute mitral regurgitation?
Presents with sx of pulmonary edema –> treat with diuretics to relieve the pulmonary edema –> vasodilators to reduce resistance to forward flow
* We can also put in an intra-aortic balloon pump to reduce afterload
* Treat it like a surgical emergency
Symtoms of chronic mitral regurgitation:
Symtoms of chronic mitral regurgitation:
* Low cardiac output
* LV contractile dysfunction
* Right sided heart failure
For asymptomatic chronic mitral regurgitation we tend to monitor; for symptomatic we fix the valve
Mitral valve prolapse occurs due to _ (either spontaneous or secondary to a connective tissue disorder)
Mitral valve prolapse occurs due to myxomatous degeneration (either spontaneous or secondary to a connective tissue disorder)
Myxomatous degeneration on histology looks like _
Myxomatous degeneration on histology looks like valve collagen and elastic fibers fragment –> remodeling –> makes the leaflets stretch and prolapse
During mitral valve prolapse, the weak mitral valve prolapses into the _
During mitral valve prolapse, the weak mitral valve prolapses into the left atrium during systole
What does mitral regurgitation sound like?
Mitral regurgitation is holosystolic
What does mitral valve prolapse sound like?
Late crescendo murmur with midsystolic click
Causes of aortic regurgitation:
Aortic regurgitation:
Syphilis is a possible cause of _
Syphilis is a possible cause of aortic regurgitation
* Increases the risk of thoracic aortic aneurysm –> can cause aortic dilation –> aortic regurgitation
Aortic regurgitation leads to _ hypertrophy of _ ventricle
Aortic regurgitation leads to eccentric hypertrophy of LV
Explain how aortic regurgitation can lead to wide pulse pressure
Aortic regurgitation causes LV volume overload –> eccentric hypertrophy –> increases LV compliance –> aortic diastolic pressure drops –> plus the aortic systolic pressure is raised due to higher volume with each beat
Explain the longer term consequence of aortic regurgitation
Gradual remodeling of LV –> eccentric hypertrophy –> systolic dysfunction –> blood takes path of least resistance and goes into the LA –> increases left atrial and pulmonary vascular pressures
What does aortic regurgitation sound like?
ARD fall- diastolic decrescendo
