Valvular Diseases Flashcards
What three conditions cause aortic stenosis in adults?
Dystrophic calcification
Bicuspid valve
Rheumatic heart disease
What is the normal relationship between LV and aortic pressures during systole?
Normally no pressure gradient
What are the hemodynamic effects of aortic stenosis?
Peripheral auto regulatory mechanisms maintain BP in aorta so LV pressure increases to maintain gradient and flow across valve
LV undergoes hypertrophy –> pulm congestion and SOB
What are the clinical manifestations of aortic stenosis and what is the average survival after the onset of each?
CHF - 2 years
Syncope - 3 yrs
Angina - 5 years
What are physical exam findings in aortic stenosis other than the murmur?
Pulsus parvus et tardus
Post stenotic dilation of aorta
Cardiomegaly
Pulm congestion
What tests can be used to diagnose aortic stenosis?
Echo is most useful noninvasive
Doppler echo can calculate pressure gradients
Cardiac cath - measures pressure gradient
What sizes of the aortic valve are constitute different types of stenosis?
1.5-2 cm squared - mild
1.0-1.5 cm squared - moderate
Less than 1 cm squared - severe
What are indications for surgery for aortic stenosis?
Recommended for symptomatic severe (.5 cm squared)
Asymptomatic patients even with critical AS by measurement should not have operation until symptoms develop
Symptoms are primary indicator - make sure not to miss any subtle ones
Not contraindicated in elderly patients
What kind of concomitant surgery increase the risk of valve surgery for all types of valve lesions?
CABG
What is the physiology of the mitral annulus?
Fibrous and semi rigid posteriorly
Thinner anteriorly and and continuous with aortic valve annulus
What is normal mitral valve area?
4-6 cm squared
What is the main cause of mitral valve stenosis?
Rheumatic heart disease
Avg time from disease to symptoms is 10-30 yrs
What are the hemodynamics of mitral valve stenosis?
Pressure gradient generally doesn’t occur until valve area less than 2 cm squared
Dilation of LA and a fib
Passive increases in pulm art pressure
Increased HR reduces time in diastole for filling and causes LA pressure to rise
What are clinical manifestations of mitral valve stenosis?
First develop symptoms during tachycardias
Mild respond well to beta blockers
Moderate to severe require surgery
SOB due to pulm congestion and fatigue due to low CO
LA thrombus and emoblization can lead to stroke
What are physical exam findings in patients with mitral valve stenosis other than the murmur?
Pulmonary hypertension and congestion
Echo is pathognomonic for MS with a hockey stick deformity of anterior mitral leaflet
Cardiac cath can measure and assess risk before surgery
What is the general treatment strategy for patients with mitral valve stenosis?
Alleviating symptoms and reducing risk of stroke
Beta blockers control tachycardia that provokes symptoms
Diuretics can relieve pulm congestion
Antiarrhythmics
Anticoagulants in all patients with a fib or with dilated LA or prior embolic events to reduce stroke risk
When should surgery for mitral valve stenosis be considered?
Symptomatic patients with mitral valve area <1.2 cm squared
Open commissurotomy is preferable to MVR
Balloon mitral valvuloplasty slightly superior to open commissurotomy - ideal patient has pliable leaflets, minimal thickening, and little involvement of subvalvular apparatus
What are contraindications to balloon mitral valvuloplasty?
Thrombus in LA appendage
More than mild mitral regurgitation
Why is significant acquired pulmonic valve disease uncommon in adults?
Exposed to lower pressures of right heart as opposed of aortic valve exposed to higher pressures of left
What is the etiology of pulmonic stenosis?
Majority is congenital and results from leaflet fusion during intrauterine development
Acquired can be causes by rheumatic heart disease, carcinoid syndrome, or tumors
When is pulmonic stenosis classified as mild?
If pressure gradient less than 80 mm Hg
What are the clinical manifestations of pulmonic valve stenosis?
Severe - exertion all dyspnea, fatigue, syncope, right sided heart failure, or mild cyanosis
Harsh systolic ejection murmur louder with inspiration
What is the treatment for pulmonic stenosis?
Procedure of choice is balloon valvuloplasty - indicated for relief of symptoms
Asymptomatic and mild don’t require balloon or surgery
What is the normal area of the tricuspid valve?
6-10 cm squared
What is the etiology of tricuspid stenosis?
Rare - almost always associated with rheumatic mitral stenosis
Large vegetations on valve, endomyocardial fibrosis or intracardiac tumors rare causes
What are the clinical manifestations of tricuspid stenosis?
JVD
Peripheral edema
Low CO
congestion of liver and ascites
What is the treatment for tricuspid stenosis?
Few data about timing of balloon or surgery
Commissurotomy can relieve stenosis but may result in regurgitation
What is a big difference between symptoms of stenotic lesions and symptoms of regurgitation lesions?
In regurgitant - symptoms usually occur later past window of successful intervention
What is the etiology of aortic regurgitation?
Leaflet abnormalities - endocarditis, rheumatic disease, bicuspid valves, SLE, ankylosing spondylitis, myxomatous degeneration, trauma
Aortic annulus - dilation, expansion or loss of support - HT, Marfans, dissection, osteogenesis imperfecta, takayasus, syphilis, giant cell arteritis
What are the hemodynamics of aortic regurgitation?
LV gradually dilates without increasing wall thickness - ventricle can maintain SV but increased after load
Chronic severe has wide pulse pressure - myocardial ischemia since heart perfumed during diastole
What are the clinical manifestations of acute severe AR?
Tachycardia Pulm edema Hypotension No s2 Need surgery!
What are the clinical manifestations of chronic severe AR?
Widened pulse pressure
Water hammer pulses
Traubes sign - pistol shot sounds over femoral artery
De mussets sign - head bobbing with each heartbeat
Mullers sign - uvula pulsations with each heartbeat
Quinckes pulses - capillary pulsations in fingernails
Duroziezs sign - systolic murmur over femoral artery when compressed proximally and diastolic when distally
What is an Austin flint murmur?
Mid late diastolic rumble heard in aortic regurgitation
What are the indications for surgery with aortic regurgitation?
Acute require immediate
Generally symptoms attributable to severe AR or progressive LV dilation in asymptomatic patients (surgery should be done before LVEF falls below 55% or end systolic dimension increases to 5.5cm)
What are the hemodynamics of acute severe MR?
Tachycardia, hypotension, severe pulm edema
LV function is supranormal due to increased preload and decreased after load
Forward SV into aorta still low
What are the hemodynamics of chronic severe MR?
Allows LV to dilate
LV function still preserved by increased preload and decreased after load = compensated phase
Further dilation - wall tension increases and raises afterload = decompensated phase
What are the indications for surgery in mitral regurgitation?
Shift toward earlier surgery
Preservation of posterior leaflet tendinae is good
Repair much better
Should be considered for chronic MR in patients with symptoms or asymptomatic patterns with severe and LVEF 4.5 cm
What is the etiology of pulmonic regurgitation?
Most common caus is dilation of annulus due to pulm HT
Also endocarditis, connective tissue diseases, congenital abnormalities, trauma, carcinoid syndrome, or syphillis
what are the hemodynamics of pulmonic regurgitation?
Volume overload of RV generally well tolerated
What are the clinical manifestations of pulmonic regurgitation?
Most asymptomatic
Can present with RHF
Soft decrescendo murmur that can increase with inspiration
Surgery almost never indicated except with endocarditis
What is the etiology of tricuspid regurgitation?
Usually functional or secondary to right ventricular dilation or pulm HT
Intrinsic diseases of leaflets
What are the hemodynamics of tricuspid regurgitation?
Volume overload on RV usually well tolerated
If severe and with pulm HT, can develop RHF
What are the indications for surgery for tricuspid regurgitation?
Replacement reserved for very severe cases
If due to dilation of annulus, can benefit from placement of annuloplasty ring
