Valvular Disorders 1 Flashcards
What are the two types of valve disorders?
Regurgitation and stenosis
What does stenosis mean?
Valve is hard and closed off and doesn’t open properly
What does regurgitation mean?
Valve doesnt close properly
What are the clinical classification categories of valvular heart disease?
- Stage A: at risk for valvular heart disease
- Stage B: mild/moderate progressive valvular heart disease but asymptomatic
- Stage C: severe valvular heart disease but asymptomatic
- C1: severe valve lesion but asymptomatic with normal LV function
- C2: severe valve lesion but asymptomatic with abnormal LV function
- Stage D: symptomatic due to valvular heart disease
What are risk factors for valvular heart disease?
- Congenital defects: aortic stenosis, pulmonic stenosis, bicuspid aortic valve
- Infective endocarditis
- Rheumatic fever
- Aging: degenerative valve disease, valve calcification, mediastinal radiation therapy
radiation therapy due to cancer treatment
infective endocarditis: vegetation can grow on heart valve
rheumatic fever: due to strep
What are the 2 settings that aortic stenosis usually occurs?
Congenital and acquired
how can congenital aortic stenosis present?
`
unicuspid, bicuspid, or quadricuspid valve with symptoms before age 50
what are causes of acquired aortic stenosis? When does this usually present?
Rheumatic fever, valve calcification, degenerative stenosis
After age 50
Aortic stenosis leads to what happening to the valve leaflets? What does that lead to?
thickening or calcification
narrowed valve opening
What does aortic stenosis cause?
LVH, which leads to diastolic dysfunction, which leads to systolic dysfunction
What is the cause of degenerative or calcified aortic stenosis?
calcium deposition on valve leaflets
Which patients are more likely to get degenerative or calcified aortic stenosis?
- Elderly
- HTN
- HLD
- Smoking
This is the most common surgical valve lesion in developed countries
Degenerative or calcified aortic stenosis
What is the clinical presentation of aortic stenosis?
Most asymptomatic for years, despite severity
Cardinal symptoms: angina, syncope, CHF
Angina due to lack of blood going through coronary arteries
too much blood in left ventricle –> dilates blood vessel –> decreased perfusion
Syncope: increased LV pressure stimulates baroreceptors to induce peripheral vasodilation
Once symptoms of aortic stenosis occur, what is the prognosis?
2-5 years unless surgical correction is made
What are physical exam findings of aortic stenosis?
- Midsystolic murmur at right 2nd interspace, radiates to carotids
- Medium pitch, harsh quality, often loud with thrill
- Heard best sitting and leaning forward
- Laterally displaced, sustained apical impulse
- S4 gallop may be present
- EKG: may demonstrate LVH
S4 gallop due to atria contracting to try to get blood from left atria to left ventricle (just before S1) that is full of blood
Apical impulse moved due to LVH
What diagnostic studies can be done once the murmur is noticed?
CXR
Echocardiography: MODALITY OF CHOICE
Cardiac catheterization
What could be seen on CXR with aortic stenosis?
enlarged cardiac silhouette, calcified aortic valve, dilated ascending aorta
Why would cardiac catheterization be used in diagnosis of aortic stenosis?
Confirms presence of severe AS and any CAD
A lot of providers like to do stress tests prior to cardiac catheterization. Why would you not want to do this with aortic stenosis?
Stress test may lead to syncope
How is aortic stenosis managed?
- Severe AS with symptoms: surgery
- Poor candidates for open heart surgery: TAVI/TAVR
- Refer to cardiology
- Balloon valvuloplasty
TAVI: transcutaneous aortic valve implantation
How is surgery performed for aortic stenosis?
- Open AVR through sternotomy or TAVR
- Anticoagulation after
What anticoagulation needs to be used for a mechanical valve? TAVR?
- Mechanical: warfarin
- TAVR: plavix x 6 months, lifelong ASA
Cardiology will make this decision
When would balloon valvuloplasty be more useful? Less useful?
- More: congenital AS
- Less: degenerative AS due to complications and high restenosis rate
What medications can be added to help with aortic stenosis?
statins
Afterload reduction and volume reduction meds
What causes aortic regurgitation?
disease of the aortic leaflets, aortic root, or both
What are causes of aortic regurgitation?
- rheumatic fever
- congenital abnormalities
- infective endocarditis
- hypertension
what can cause aortic root disease leading to aortic regurgitation?
- aortic dissection
- root dilation
- Marfan’s
what does chronic aortic regurgitation lead to?
LVH and dilation due to need to accomodate additional regurgitant volume
What is the clinical presentation of aortic regurgitation?
- Asymptomatic for years
- Symptoms due to increase in LV filling pressures, leading to CHF
- Exertional dyspnea and fatigue (MC)
- Angina
Angina due to coronaries not getting enough perfusion d/t aortic insufficiency
What are physical exam findings of aortic regurgitation?
- Early diastolic murmur, decrescendo, blowing
- High pitched, best heard in the 2nd to 4th left interspaces, with radiation to the apex
- Best heard with patient sitting, leaning forward
- Widened pulse pressure
- S3 and S4 may be present
- Low pitched, diastolic mitral murmur may be heard at apex (Austin Flint murmur)
murmur over left ventricle because blood rushing back into ventricle from valve
widened pulse pressure due to high pressure in systolic to get blood out and not enough pressure in diastolic
What are diagnostic tests if you hear aortic regurgitation?
- Echocardiography diagnostic modality of choice
Helps monitor progression of disease to determine timing for surgery
How is aortic regurgitation treated?
- AVR surgery if symptomatic or with LV changes, if LV dilation >5 cm or reduction in EF to <50%
- Vasodilator therapy (does not slow progression)
Vasodilator therapy to unload the ventricle
Acute aortic regurgitation is a what???
Medical emergency!!!
What causes acute aortic regurgitation?
- Infective endocarditis
- Traumatic rupture of aortic leaflets
- aortic root dissection
- acute dysfunction of prosthetic aortic valve
What does acute aortic regurgitation result in?
- hemodynamic instability
why does acute aortic regurgitation result in hemodynamic instability?
- LV unable to accommodate increased diastolic volume
- increased LV size –> LA –> lung vasculature pressure –> pulmonary congestion –> pulmonary edema
What is the clinical presentation of acute aortic regurgitation?
- Cardiogenic shock
- pale, cool extremities
- weak, rapid pulse
- low pitched, early diastolic murmur
How is acute aortic regurgitation diagnosed?
- STAT echocardiography
what can you see on EKG with acute aortic regurgitation?
- moderate/severe LVH
what can you see on CXR with acute aortic regurgitation?
- cardiomegaly with LV prominence
What is treatment of acute aortic regurgitation?
- vasodilator therapy and diuretics if BP stable
- inotropic agents/vasopressors may be necessary
- TREATMENT OF CHOICE: urgent aortic valve replacement
What is mitral stenosis?
Thickening and immobility of the mitral leaflets impede flow from left atrium to left ventricle
what is the most common cause of mitral stenosis?
rheumatic fever
what can cause mitral stenosis?
- rheumatic fever (MC)
- congenital abnormalities
- connective tissue disorders
- left atrial tumors
2/3 of patients with mitral stenosis are in what population?
women
what is the pathophysiology of mitral stenosis?
- gradual change over many years before hemodynamically important
- fusion of leaflet commissures and thickening, fibrosis, and calcification of mitral leaflets and chordae
what are initial hemodynamic changes in mitral stenosis?
- elevated left atrial pressure –> LA enlargement
- transmitted to pulmonary venous system –> pulmonary congestion
what do chronic elevations in pulmonary venous pressures lead to in mitral stenosis?
- increase in pulmonary vascular resistance and pulmonary arterial pressures –> RV failure
What are LV filling pressures with mild to moderate MS? Severe? What does this lead to?
- mild to moderate: normal or low
- severe: LV filling impaired –> decreased stroke volume and cardiac output
what is the clinical presentation of mitral stenosis?
- 4th or 5th decade of life, 20-40 years after illness
- Pulmonary vascular congestion and RV failure
- Fatigue
- Exertional dyspnea
- Orthopnea
- Atrial fibrillation
- Sudden hemoptysis due to rupture of dilated bronchial veins
- Blood-tinged sputum asssociated with pulmonary edema
What are additional findings of mitral stenosis?
- Peripheral embolism from left atrial thrombus
- Peripheral edema
- Compression of left recurrent laryngeal nerve from severely dilated LA may result in hoarseness (Ortner syndrome)
What are physical exam findings of mitral stenosis?
- Low-pitched, rumbling, diastolic murmur
- best heard at the apex with patient in left lateral decubitus position
- S1 loud early on, softens as leaflets become more calcified and immobile
- opening snap following S2
- If elevated pulmonary artery pressures, palpable P2 at upper left sternal border associated with prominent pulmonic component of S2 on auscultation
What are EKG findings of mitral stenosis?
- LA abnormality
- A fib possible
- RV hypertrophy possible
What is the diagnostic tool of choice for mitral stenosis?
- Echocardiography
What is characteristic of mitral stenosis on echocardiography?
rheumatic doming “hockey stick” of anterior MV leaflet
What side of the stethoscope should we use to assess MS?
Bell
How is mitral stenosis diagnosed?
- EKG
- Echocardiography
- TTE to measure extent of valvular calcification and stenosis severity
- TEE may also be helpful
- Cardiac catheterization
why would cardiac catheterization be helpful for mitral stenosis?
allows for measurement of cardiac output and transvalvular gradient
what is treatment for mitral stenosis?
- Mild to moderate MS: medically managed for symptom control
- Beta blockers (HR control)
- Diuretics (pulmonary congestion and signs of RV failure
- Refer moderate to severe MS/severe symptoms for percutaneous or surgical intervention
Surgery = bioprosthetic or mechanical valve replacement
What patients is percutaneous balloon valvuloplasty for mitral stenosis recommended for?
- Patients with pliable, noncalcified leaflets and chords
- Minimal MR and
- No evidence of LA thrombus
Not a definitive treatment
what causes mitral regurgitation?
abnormalities of the mitral leaflets, annulus chordae, or papillary muscles due to
* MV prolapse
* LV dilation
* Posterior wall MI
* Rheumatic fever
* Endocarditis
What causes mitral regurgitation?
- abnormalities of the mitral leaflets, annulu, chordae, or papillary muscles
- MV prolapse
- LV dilation
- Posterior wall MI
- Rheumatic fever
- Endocarditis
what does mitral regurgitation result in?
Regurgitant blood flow from the LV to the LA during systole
What happens to the heart tissue in mitral regurgitation?
- LA and LV dilate to compensate for increased volume
- Mitral annulus stretches to prevent closure, leading to worsening MR and LV dilation
- LV dilation causes elevation in diastolic filling pressures and a reduction in LV systolic function
- LA pressures build and pulmonary venous pressures increase –> pulmonary congestion
- LA and LV dilate to compensate for the increased volume
What is the presentation of most mitral regurgitation patients?
asymptomatic and well-compensated
why do symptoms occur from mitral regurgitation patients?
LV systolic function
What are symptoms of depressed LV systolic function?
- Fatigue
- Dyspnea on exertion
- Peripheral edema
What is present on the physical exam with mitral regurgitation?
- Holosystolic murmur best heard at apex and radiates to axilla and back
- mid systolic click may be present if MVP
How is mitral regurgitation diagnosed?
- EKG
- Echocardiography
- Cardiac catheterization
What can be present on EKG with mitral regurgitation?
- LA abnormality
- LVH pattern
- Afib
Why would cardiac catheterization be used in mitral regurgitation?
to assess severity of MR and LV function
when would a coronary angiography be recommended?
- if male patient >40 or menopausal female with RF
how is mitral regurgitation treated?
- afterload reduction with vasodilators ie ACE inhibitors or hydralazine
- Diuretics to treat pulmonary congestion, pulmonary edema, excess volume
- Surgical treatment
what is the definitive treatment of mitral regurgitation?
surgical intervention
surgery for mitral regurg should be performed before what?
irreversible myocyte damage and left ventricular remodeling occur
patients with known mitral regurgitation should have at least what?
annual echocardiograms to monitor LV size and function
what may be indication of surgical intervention for mitral regurg regardless of LV size and function?
development of afib or pulmonary HTN
how is MV repair completed?
annuloplasty or MV replacement
what does annuloplasty do?
preserves mitral apparatus to maintain normal LV geometry and function
when would MV repair not be indicated?
if MV is heavily calcified or disrupted secondary to papillary muscle disease or endocarditis
life threatening condition that may result from abnormalities with the papillary muscles chordal structures or leaflets with the mitral valve
acute mitral regurgitation
what does acute mitral regurg do to the structure of the heart?
- LA does not dilate
- Results in abrupt increase in LA and pulmonary venous pressures —> pulmonary congestion
what are causes of acute mitral regurgitation?
- acute MI
- Trauma
- Endocarditis
- Tachyarrhythmia in patient with chronic MR
- MVP-papillary muscle/chordae tendineae dysfunction
what is the presentation of patients with acute mitral regurgitation?
signs of cardiogenic shock:
* hypotension
* tachycardia
* syncope
* pale
* diaphoretic
* SOB
MR murmur = soft, low-pitched sound in early systole
what is treatment of acute mitral regurgitation?
urgent valve replacement surgery
what population is MVP more common in?
women
how do you get MVP?
- autosomal dominant trait
- systemic or connective tissue disorders
definition of mitral valve prolapse?
- superior displacement in ventricular systole of one or both of mitral valve leaflets
- across plane of mitral annulus towards left atrum
- associated with varying degrees of MR
Clinical presentation of MVP?
most asymptomatic
symptoms of MVP when it does present?
- chest pain
- palpitations
- dizziness
- anxiety
- fatigue
MVP syndrome
What will be present on physical exam with MVP?
- Auscultation with mid-systolic click followed by late-systolic murmur
What is the diagnostic study of choice for MVP?
Echocardiogram
How is MVP managed?
- Mild prolapse–> asymptomatic –> no intervention
- If severe, MR, MV repair or replacement indicated
