Valvular Disorder Part 1 Flashcards
Why does the left side of heart typically have the most problems?
More pressure on that side of the heart
What are the two types of murmurs (valvular disorders)?
Stenosis (harsh, clicking sound)
Regurgitation (wissh, blowing)
What is the severity of valvular heart disease based on?
Symptoms and anatomic problems
Stage A and B of Valvular disease
Stage A - at risk for valvular heart disease
Stage B - mild/moderate² progressive valvular heart disease but asymptomatic
both asymptomatic
What changes from C1 to C2
Abnormal LV function in C2, causing backup of blood
What is stage D?
symptomatic patients due to valvular heart disease
Want to catch things at a lower stage
Is a murmur a symptom?
No it is a PE finding
What are congenital defects that lead to risk of (valvular VHD
Aortic stenosis
Pulmonic stenosis
Bicuspid aortic valve (MC) - there is less space to allow blood to go through (can lead to scarring)
Why does aging often lead to VHD?
Aging puts strain
Calcification (overtime)
Mediastinal radiation therapy (cancer that needs radiation can dmg the valves)
What illness/disease can increase risk of VHD?
Infective endocarditis (bacteria get onto heart valve)
Rheumatic fever (complication of strep)
What is the MC murmur?
Aortic stenosis
What is the MC congenital aortic stenosis?
Bicuspid (but can happen in unicuspid, or quadricuspid)
When aortic valve suposed to be open?
Systole, squeezing LV, but if the aortic valve is scarred, it will cause backup
What happens to the hearts response to aortic stenosis?
LVH d/t heart saying that there is not enough output
Where does blood back up in LVH aortic stenosis?
Left atria, lungs, right atrium, body
What are the risk factor of calcified AS?
HTN, HLD, Smoking
high ASCVD risk
What is the MC surgical valve lesion:
Aortic stenosis
What does a stenotic valve lead to?
Does not fully close
You might hear regurgitation during dystale because blood flows back (this is typically late stage)
What can help Aortic stenosis?
BB
in order to slow the heart down, because the pumping will actually make it worse and may lead to HF
What is the least concerning congenital valve?
Quadricuspid
Why do you see angina with aortic stenosis anatomically?
Angina: coronary arteries occluded (chest pain on exertion)
Why do you see syncope with aortic stenosis?
Not enough perfusion to the brain (everything else is dilated even more)
-peripheral vasodilation basically
Why does aortic stenosis lead to CHF?
Backup of blood
Once there are symptoms of aortic stenosis, what is the prognosis?
Bad :(
Once symptoms occur, prognosis drops to 2-5 yrs unless surgical correction is made
Why is aortic stenosis a midsystolic murmur?
first noise is
S1: MV and TC close
then
Why does the aortic stenosis lead to radiation of carotid?
Shooting blood
HARSH sound
What is an S4?
Atrial kick trying to push blood into the ventricle
What is the first thing you do if you hear a murmur?
Echocardiography
modality of choice
What might you see in CXR of aortic stenosis?
Could show enlarged cardiac silhouette, calcified aortic valve, dilated ascending aorta
What does a cardiac catheterization used for?
Confirms presence of severe AS and any CAD
open the carotids
What should you not do for surgery referal?
Should not do a stress chest
If you are symptomatic with aortic stenosis, what should you do?
Symptomatic patients with severe AS → surgery! (aortic valve replacement)
After replacing a valve, what often happens? What should you do as a result?
Might break off a piece of the valve, and need anticoagulant
If you have a mechanical valve, what therapy do you need to be on?
Warfarin :(
+/- asparin
How do you often treat congental AS?
Balloon valvuloplasty
What are a couple complications of surgery?
Stroke
AV node issues
How do patients with aortic regurg present?
Asymptomatic if slow process
What can infective endocarditis lead to?
Aortic regurg d/t putting more weight/stress on the leaflets
Why do you hear dyastolic murmur?
Early, because the valve is not closing (which is normally heard in S2)
Why do you not hear the noise for a aortic regurgitation?
2nd to 4th left interspaces, with radiation to the apex
Why is there a widened pulse pressure?
Systolic number is high
Dyastolic is low because blood is not actually going anywhere
170/60 is common
What is an Austin Flint murmur?
A low-pitched, diastolic mitral murmur, may be heard at the apex
As a result of the incomplete opening of the mitral leaflets due to increased LV pressures or impingement of the AR jet on the anterior mitral leaflet (not a mitral valve)
Diagnostic modality of choice for aortic regurg
Echocardiography (TTE)
Transthoracic echo
How do you manage edema with aortic regurg?
Diuretic
How do you cure aortic regurgitation?
Surgery of valve
Why is an acute aortic regurgitation (AAR) worse than chronic?
No compensation
EMERGENCY
If a patient has cardiogenic shock, what do you use?
BB
Pressors
What is the diagnostic of choice for AAR?
STAT echo
Mitral stenosis is heard during?
Diastole (mid)
What is the #1 cause of mitral stenosis (MS)?
Rheumatic fever
can also be from tumor
Who is MS MC in?
women with rheumatic fever when they were younger
Where does blood back up with a small mitral valve?
Left atria, lungs, right ventricle, to right atria
When does the right heart tend to fail?
After the left side has already failed
If the left ventricle does not get enough blood.
As the stenosis becomes severe, LV filling is impaired, reducing the stroke volume and cardiac output
What does mitral stenosis lead to?
Symptoms are related to pulmonary vascular congestion and RV failure
Fatigue, exertional dyspnea, orthopnea are most common presentations
Atrial fibrillation¹ is also common
Sudden hemoptysis due to rupture of the dilated bronchial veins
Blood-tinged sputum associated with pulmonary edema (heart failure)
What is a fib?
A. Fib occurs because there are a large number of atrial fibers located in the pulmonary veins that feed the left atria. As these veins sustain pressure from backed up blood, it can induce A. Fib.
What is ortner syndrome?
Compression of the left recurrent laryngeal nerve from a severely dilated LA may result in hoarseness
Where do you hear MS?
Low-pitched, rumbling, diastolic murmur best heard at the apex with patient in left lateral decubitus position
S1 is loud in early MS. S1 then softens as the leaflets become more calcified and immobile
like putting finger on a hose
What type of deformity do you see on an echo?
Hockey stick deformity
Stanant blood (LAE)
What is the dx of choice for MS?
TTE
What do you treat MS with?
BB
Diuretics
What is the definitive treatment for MS?
bioprosthetic or mechanical valve replacement
What happens during mitral regurg (MR)?
Mitral valve leaks from LV to LA
What can cause Mitral regurg?
MV prolapse
LV dilation (cardiomyopathy)
Posterior wall MI
Rheumatic fever
Endocarditis
How do most chronic MR patients present?
Asymptomatic
only symptoms from depressed LV systolic function
Fatigue
Dyspnea on exertion
Peripheral edema
Why is MR regurg holosystolic?
murmur best heard at the apex and radiates to the axilla and back
Mid-systolic click may be present if MVP present (because it is not held down by the papillary muscles)
When would you send a patient for coronary angiography for MR?
is recommended if male patient >40 or menopausal female w/ RF
What do you see in color flow in MR?
Mixing of oxygenated and deoxygenated blood
How do you treat a MR with drugs?
Vasoidlators (ACE or Hydralyzine)
Dierutics
What is the surgical treatment for MR?
Surgical intervention is definitive treatment
Timing is difficult
Surgery should be performed before irreversible myocyte damage and left ventricular remodeling occur
Patients with known MR should have at least annual echocardiograms to monitor LV size and function
Development of Afib or pulmonary HTN may also be an indication of surgical intervention regardless of LV size and function
MV repair is possible in many patients
Annuloplasty (a prosthetic ring is sewn in)
Preserves the mitral apparatus which helps maintain normal LV geometry and function
Not indicated if the MV is heavily calcified or disrupted secondary to papillary muscle disease or endocarditis
MV replacement is indicated when repair is not feasible
What does ACUTE mitral regurg lead to?
Cardiogenic shock
because there has not been enough time to compensate
What is the MC of acute mitral regurg? What are some others?
Acute MI is MC
Trauma
Endocarditis
Tachyarrhythmia in patient with chronic MR
MVP – papillary muscle / chordae tendineae dysfunction
Mitral valve prolapse common patient
Thin
Female
History of mitral valve prolapse
Connective tissue disorders
What is th pathophys of mitral valve prolapse (MVP)?
Defined as superior displacement in ventricular systole of one or both mitral valve leaflets across the plane of the mitral annulus toward the left atrium
May be associated with varying degrees of MR
What is the presentation of MVP?
Asymptomatic
Typically anxiety
Auscultation reveals a mid-systolic click, usually followed by a late-systolic murmur
Standing mimics
valsalva, needs to push harder and faster, you hear click
not heard during squatting
How do you treat MVP?
Replace valve, only if severe
